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

Objective. Transmyocardial laser revascularization (TMLR) is used to treat patients with refractory angina considered unsuitable for conventional form s of revascularization. Using patient specific data from a single centre UK randomised-controlled trial, we aimed to determine whether, from a UK Nati onal Health Service (NHS) perspective, TMLR plus standard medical managemen t is cost-effective when compared with standard medical management alone. M ethods: 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 managemen t alone (94). Costs to the UK NHS of TMLR (where appropriate), and all seco ndary 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 cos t per patient over the year from hospitalization for TMLR was pound 11,470 and for medical management alone was pound 2586, giving a cost difference o f pound 8901 (95% confidence interval (CI) pound 7502-pound 10,008: P < 0.0 001). 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 poun d 228,000. Analysis of stochastic uncertainty and of sensitivity to gross c hanges in key parameters consistently produces very high costs per QALY. Co nclusions: The policy implications are clear: for such patients TMLR is an inefficient use of UK health service resources. This conclusion would not b e changed by considerable improvements in effectiveness or reductions in co st. (C) 2001 Elsevier Science B.V. All rights reserved.