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Eur J Cardiothorac Surg 2001;20:312-318
© 2001 Elsevier Science NL

A UK trial-based cost–utility analysis of transmyocardial laser revascularization compared to continued medical therapy for treatment of refractory angina pectoris

^a Health Economics Research Group, Brunel University, Uxbridge, Middlesex UB8 3PH, UK
^b Papworth Hospital NHS Trust, Papworth Everard, Cambridge CB3 8RE, UK
^c MRC Biostatistics Unit, Institute of Public Health, University Forvie Site, Cambridge CB2 2SR, UK

Received 30 November 2000; received in revised form 26 February 2001; accepted 12 May 2001.

Corresponding author. Tel.: +44-1895-203331; fax: +44-1895-203330
e-mail: martin.buxton{at}brunel.ac.uk

Objective: Transmyocardial laser revascularization (TMLR) is used to treat patients with refractory angina considered unsuitable for conventional forms of revascularization. Using patient specific data from a single centre UK randomised-controlled trial, we aimed to determine whether, from a UK National Health Service (NHS) perspective, TMLR plus standard medical management is cost-effective when compared with standard medical management alone. Methods: One hundred and eighty-eight patients assessed as having refractory angina, and not suitable for conventional forms of revascularization were randomized to receive TMLR and medical management (94) or medical management alone (94). Costs to the UK NHS of TMLR (where appropriate), and all secondary sector health care contacts and cardiac-related medication in the 12 months following randomization, were collected. Patient utility as measured using the EuroQol EQ-5D questionnaire was combined with 12-month survival data to generate quality adjusted life years (QALYs). Results: The mean cost per patient over the year from hospitalization for TMLR was £11,470 and for medical management alone was £2586, giving a cost difference of £8901 (95% confidence interval (CI) £7502–£10,008: P<0.0001). The mean QALY difference, in favour of TMLR was 0.039 (95% CI -0.033 to 0.113: P=0.268). This gives an incremental cost per QALY of over £228,000. Analysis of stochastic uncertainty and of sensitivity to gross changes in key parameters consistently produces very high costs per QALY. Conclusions: The policy implications are clear: for such patients TMLR is an inefficient use of UK health service resources. This conclusion would not be changed by considerable improvements in effectiveness or reductions in cost.

Key Words: Transmyocardial laser revascularization • Randomized-controlled trial • Cost • Quality adjusted life year • Cost–utility analysis

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