Long-Term Cost-Effectiveness of Fractional Flow Reserve–Based Percutaneous Coronary Intervention in Stable and Unstable Angina

Background: There are limited studies on the cost-effectiveness of fractional flow reserve (FFR)-based percutaneous coronary intervention (PCI) over angiography-based PCI. Objectives: The current study sought to evaluate long-term cost-effectiveness of FFR-based PCI compared to angiography-based PCI. Methods: A cost-effectiveness analysis was conducted using a nationwide cohort that consisted of patients with stable or unstable angina from the National Health Insurance Service (NHIS) and Health Insurance Review and Assessment (HIRA) database in Korea. The cost-effectiveness analysis was also performed by using a decision and Markov model with key values from the United States and the United Kingdom health care systems. Incremental cost-effectiveness ratio (ICER), an indicator of incremental cost on additional quality-adjusted life-years gained by FFR-based PCI, was evaluated. Results: In the NHIS-HIRA data, FFR-based PCI was used during the index PCI in 5,116 patients (3.8%) among 134,613 eligible patients. FFR-based PCI showed significantly lower risk of all-cause death (5.8% vs 7.7%, P = 0.001) and spontaneous myocardial infarction (1.6% vs 2.2%, P = 0.022) than the angiography-based PCI at 4 years. In the NHIS-HIRA data, FFR-based PCI gained 0.039 quality-adjusted life-years at a lower cost ($303) than angiography-based PCI, yielding an ICER of −$7,748 during the 4-year follow-up. FFR-based PCI was dominant in the health care system of Korea (ICER = −$7,309), United States (ICER = −$31,267), and United Kingdom (ICER = −$1,341) during a 10-year time horizon. These results were consistently shown in probabilistic sensitivity analyses. Conclusions: In the current cohort, FFR-based PCI was associated with higher quality of life at a lower cost than angiography-based PCI. FFR-based PCI was cost-effective in patients with stable or unstable angina undergoing PCI.