Cost-effectiveness analysis of drug-coated therapies in the superficial femoral artery

Abstract

Objective: Drug-coated balloons (DCBs) may increase durability of endovascular treatment of superficial femoral artery (SFA) disease while avoiding stent-related risks. The purpose of this study was to use meta-analytic data of DCB studies to compare the cost-effectiveness of potential SFA treatments: DCB, drug-eluting stent (DES), plain old balloon angioplasty (POBA), or bare-metal stent (BMS).

Methods: A search for randomized controlled trials comparing DCB with POBA for treatment of SFA disease was performed. Hazard ratios were extracted to account for the time-to-event primary outcome of target lesion revascularization. Odds ratios were calculated for the secondary outcomes of primary patency (PP) and major amputation. Incorporating pooled data from the meta-analysis, cost-effectiveness analysis, assuming a payer perspective, used a decision model to simulate patency at 1 year and 2 years for each index treatment modality: POBA, BMS, DCB, or DES. Costs were based on current Medicare outpatient reimbursement rates.

Results: Eight studies (1352 patients) met inclusion criteria for meta-analysis. DCB outperformed POBA with respect to target lesion revascularization over time (pooled hazard ratio, 0.41; P < .001). Risk of major amputation at 12 months was not significantly different between groups. There was significantly improved 1-year PP in the DCB group compared with POBA (pooled odds ratio, 3.30; P < .001). In the decision model, the highest PP at 1 year was seen in the DES index therapy strategy (79%), followed by DCB (74%), BMS (71%), and POBA (64%). With a baseline cost of $9259.39 per patent limb at 1 year in the POBA-first group, the incremental cost per patent limb for each other strategy compared with POBA was calculated: $14,136.10/additional patent limb for DCB, $38,549.80/limb for DES, and $59,748,85/limb for BMS. The primary BMS option is dominated by being more expensive and less effective than DCB. Compared directly with DCB, DES costs $87,377.20 per additional patent limb at 1 year. Based on the projected PP at 1 year in the decision model, the number needed to treat for DES compared with DCB is 20. At current reimbursement, the use of more than two DCBs per procedure would no longer be cost-effective compared with DES. At 2 years, DCB emerges as the most cost-effective index strategy with the lowest overall cost and highest patency rates over that time horizon.

Conclusions: Current data and reimbursements support the use of DCB as a cost-effective strategy for endovascular intervention in the SFA; any additional effectiveness of DES comes at a high price. Use of more than one DCB per intervention significantly decreases cost-effectiveness.

Fig 1

Forest plot of target lesion revascularization (TLR) rates for drug-coated balloon (DCB) vs plain old balloon angioplasty (POBA) meta-analysis. Hazard ratio, 0.39; P < .001. CI, confidence interval; ES, effect size; ID, identifier.

Fig 2

Forest plot of primary patency (PP) rates for drug-coated balloon (DCB) vs plain old balloon angioplasty (POBA) at 1-year meta-analysis. Odds ratio (OR), 3.09; P = .001. CI, confidence interval; ID, identifier.

Fig 3

The initial decision for the decision analysis model was one of the following four possible interventions for superficial femoral artery (SFA)/popliteal artery disease: plain old balloon angioplasty (POBA) with bailout stenting, primary bare-metal stent (BMS), drug-coated balloon (DCB) with bailout stenting, and primary drug-eluting stent (DES).

Fig 4

Probabilistic sensitivity analysis was performed on the 2-year model, in which parameter values were simultaneously varied over distributions 1000 times. This showed that that drug-coated balloon (DCB) remained cost-effective (CE) over a range of parameter variations and willingness-to-pay thresholds. DES, Drug-eluting stent; POBA, plain old balloon angioplasty.