A cost analysis of coronary stenting without anticoagulation versus stenting with anticoagulation using warfarin

Predictors of length of stay after coronary stenting

BACKGROUND

Postprocedure length of stay (LOS) remains an important determinant of medical costs after coronary stenting. Variables that predict LOS in this setting have not been well characterized.

METHODS

We evaluated 359 consecutive patients who underwent coronary stenting with antiplatelet therapy. Sequential multiple linear regression (MLR) models were constructed with use of 4 types of variables to predict log-transformed LOS: preprocedure, intraprocedure, and postprocedure factors and adverse outcomes.

RESULTS

Preprocedure factors alone explained more than one third of the variability in postprocedure LOS (adjusted R(2) = 0.37). The addition of procedural variables added little to the model (adjusted R(2) = 0.39). Entering nonoutcome postprocedure variables significantly enhanced the predictive capacity of the model, explaining more than half the variability in postprocedure LOS (adjusted R(2) = 0.54). In the final model, addition of outcome variables increased its predictive capacity only slightly (adjusted R(2) = 0.61). In this model, significant preprocedure factors included: myocardial infarction (MI) within 24 hours, MI within 1 to 30 days, women with peripheral vascular disease, intravenous heparin, and chronic atrial fibrillation. High-risk intervention was the only significant intraprocedure variable. Significant postprocedure factors included periprocedure ischemia; cerebrovascular accident or transient ischemic attack; treatment with intravenous heparin or nitroglycerin or intra-aortic balloon pump; and need for blood transfusion. Significant adverse outcomes included contrast nephropathy, gastrointestinal bleeding, arrhythmia, vascular complication, and repeat angiography.

CONCLUSION

This prediction model identifies a number of potentially reversible factors responsible for prolonging LOS and may enable the development of more accurate risk-adjusted methods with which to improve or compare care.

Failure to monitor ticlopidine: the case for clopidogrel

AIM: Ticlopidine remains unlicensed for use in coronary artery stenting. Haematological monitoring at two-weekly intervals of all patients taking ticlopidine is recommended because of the risk of neutropaenia. The authors assessed their ability to monitor a two-week course of ticlopidine given to patients undergoing coronary stenting procedures. METHODS AND RESULTS: One hundred and forty-one unselected consecutive patients undergoing coronary stenting procedures were prescribed ticlopidine 250 mg twice daily for two weeks, in addition to aspirin. Prior to discharge home they and their GPs were given written information outlining the side-effects of ticlopidine and the monitoring procedures required. One hundred and thirty-three patients (94%) completed the full two-week course of ticlopidine; three (2.4%) developed significant neutropaenia (neutrophil count <0.5 x 10(9)/mm(3)). Patient compliance with full blood count monitoring was 85% at two weeks and 80% at four weeks. Two patients (1.4%) suffered subacute stent thrombosis. At six months, there were no deaths, one (0.7%) myocardial infarction and nine patients (6%) requiring target vessel revascularization. CONCLUSION: A two-week course of ticlopidine is well tolerated and does not appear to be associated with an increase in adverse cardiac events. However, even with a dedicated monitoring team, adequate haematological follow-up was achieved in only 80% of patients. The need for a licensed antiplatelet agent which has a lower side-effect profile and does not require haematological monitoring is obvious.

One-year clinical outcomes and relative costs of primary infarct artery stenting versus angioplasty following systemic thrombolysis for acute myocardial infarction

We investigated the clinical effectiveness and relative cost of two different infarct artery revascularization strategies in patients following systemic thrombolysis for acute myocardial infarction. The clinical efficacy and relative cost of stenting and angioplasty have not been investigated in patients requiring infarct artery revascularization after systemic thrombolysis for myocardial infarction. We prospectively enrolled 220 consecutive patients who received thrombolytic therapy for acute myocardial infarction and were subsequently treated with either angioplasty or primary stenting of the infarct artery. In-hospital and 1-year clinical outcomes, including death, myocardial infarction, and repeat revascularization, and total hospital costs over the 1-year study period were assessed. Compared to angioplasty, primary stenting resulted in lower in-hospital mortality (4% vs. 0%; P = 0.01) and reduced rates of repeat percutaneous or surgical revascularization (7% vs. 0%; P = 0.0009). At 1-year follow-up, stenting was associated with a lower death rate (6.25% vs. 0%; P = 0.002) and reduced repeat infarct artery revascularization (11% vs. 27%; P = 0. 001). Initial hospitalization costs were higher in the stent group ($11,818 +/- $3,377 vs. $9,723 +/- $8,661; P = 0.014) due primarily to catheterization laboratory-related expenditures ($7,346 +/- $2, 395 vs. $3,567 +/- $1,212; P = 0.0001). However, the cumulative 1-year medical cost difference between the two groups was not significant ($13,938 +/- $5,939 vs. $12,914 +/- $9,308; P = 0.33). Following thrombolytic therapy, primary infarct artery stenting reduced in-hospital and 1-year mortality and revascularization rates compared to angioplasty. Stenting was associated with higher initial hospital costs, which were off-set by lower revascularization rates, resulting in comparable total hospitalization costs after 1 year. These findings have important clinical and economic implications in an increasingly cost-conscious health care environment. Cathet. Cardiovasc. Intervent. 49:135-141, 2000.

Acute and long-term cost implications of coronary stenting

OBJECTIVES

We compared the acute and one year medical costs and outcomes of coronary stenting with those for balloon angioplasty (percutaneous transluminal coronary angioplasty) in contemporary clinical practice.

BACKGROUND

While coronary stent implantation reduces the need for repeat revascularization, it has been associated with significantly higher acute costs compared with coronary angioplasty.

METHODS

We studied patients treated at Duke University between September 1995 and June 1996 who received either coronary stent (n = 384) or coronary angioplasty (n = 159) and met eligibility criteria. Detailed cost data were collected initially and up to one year following the procedure. Our primary analyses compared six and 12 month cumulative costs for coronary angioplasty- and stent-treated cohorts. We also compared treatment costs after excluding nontarget vessel interventions; after limiting analysis to those without prior revascularization; and after risk-adjusting cumulative cost estimates.

RESULTS

Baseline clinical characteristics were generally similar between the two treatment groups. The mean in-hospital cost for stent patients was $3,268 higher than for those receiving coronary angioplasty ($14,802 vs. $11,534, p < 0.001). However, stent patients were less likely to be rehospitalized (22% vs. 34%, p = 0.002) or to undergo repeat revascularization (9% vs. 26%, p = 0.001) than coronary angioplasty patients within six months of the procedure. As such, mean cumulative costs at 6 months ($19,598 vs. $19,820, p = 0.18) and one year ($22,140 vs. $22,571, p = 0.26) were similar for the two treatments. Adjusting for baseline predictors of cost and selectively examining target vessel revascularization, or those without prior coronary intervention yielded similar conclusions.

CONCLUSIONS

In contemporary practice, coronary stenting provides equivalent or better one-year patient outcomes without increasing cumulative health care costs.

Impact of an aggressive stenting strategy on initial and one-year follow-up costs in patients undergoing coronary angioplasty

BACKGROUND

Although stents have been shown in randomised trials to reduce restenosis rates compared with balloon angioplasty, there are concerns regarding the cost-effectiveness of an aggressive stenting strategy. Stents were shown to increase medical costs over 12 months in the early trials.

AIM

Our aim was to determine the economic impact of an aggressive stenting strategy using current stenting techniques compared with a conservative stenting strategy.

METHODS

Initial and one year follow-up costs were determined in all patients who underwent successful revascularisation during June to December 1996 (aggressive stenting, n = 401), and compared to all patients treated in the corresponding months in 1995 (conservative stenting, n = 347). All patients had clinical follow-up for one year.

RESULTS

The proportion of patients receiving a stent increased from 22.5% in 1995 to 66.1% in 1996 (p < 0.0001). Requirement for repeat procedures in the 1995 group compared with 1996 was coronary angiography in 31% vs 16% (p < 0.001), coronary angioplasty in 11% vs 6% (p = 0.0044) and bypass surgery in 4.8% vs 2.5% (p = 0.054). The mean initial cost of the procedure was higher in the aggressive stenting group ($4319 +/- 1276 in 1995 vs $5131 +/- 1491 in 1996, p < 0.0001), but after 12 months follow-up, total medical costs were equivalent ($5975 +/- 4143 in 1995 vs $5994 +/- 3476 in 1996, p = NS).

CONCLUSION

An aggressive coronary stenting strategy is associated with higher initial costs compared with a conservative strategy, but lower costs during follow-up due to reduced need for repeat procedures, resulting in equivalent one year total medical costs.

Antithrombotic Therapy for Percutaneous Transluminal Coronary Angioplasty

The use of adjunctive pharmacologic therapy in the setting of coronary angioplasty has evolved in recent years with the introduction of new antithrombotics and better understanding of the pharmacologic properties of the drugs. This manuscript reviews the various antithrombotic agents currently in use and their impact on the outcomes of patients receiving them.