Comparison of costs of percutaneous transluminal coronary angioplasty and coronary bypass surgery for patients with angina pectoris

One year cost effectiveness of sirolimus eluting stents compared with bare metal stents in the treatment of single native de novo coronary lesions: an analysis from the RAVEL trial

OBJECTIVE

To assess the balance between costs and effects of the sirolimus eluting stent in the treatment of single native de novo coronary lesions in the RAVEL (randomised study with the sirolimus eluting Bx Velocity balloon expandable stent in the treatment of patients with de novo native coronary artery lesions) study.

DESIGN

Multicentre, double blind, randomised trial.

SETTING

Percutaneous coronary intervention for single de novo coronary lesions.

PATIENTS

238 patients with stable or unstable angina.

INTERVENTIONS

Randomisation to sirolimus eluting stent or bare stent implantation.

MAIN OUTCOME MEASURES

Patients were followed up to one year and the treatment effects were expressed as one year survival free of major adverse cardiac events (MACE). Costs were estimated as the product of resource utilisation and Dutch unit costs.

RESULTS

At one year, the absolute difference in MACE-free survival was 23% in favour of the sirolimus eluting stent group. At the index procedure, sirolimus eluting stent implantation had an estimated additional procedural cost of 1286. At one year, however, the estimated additional cost difference had decreased to 54 because of the reduction in the need for repeat revascularisations in the sirolimus group (0.8% v 23.6%; p < 0.01). After adjustment of actual results for the consequences of angiographic follow up (correction based on data from the BENESTENT (Belgium Netherlands stent) II study), the difference in MACE-free survival was estimated at 11.1% and the additional one year costs at 166.

CONCLUSIONS

The one year data from RAVEL suggest an attractive balance between costs and effects for sirolimus eluting stents in the treatment of single native de novo coronary lesions. The cost effectiveness of drug eluting stents in more complex lesion subsets remains to be determined.

Comparison of coronary-artery bypass surgery and stenting for the treatment of multivessel disease

BACKGROUND

The recent recognition that coronary-artery stenting has improved the short- and long-term outcomes of patients treated with angioplasty has made it necessary to reevaluate the relative benefits of bypass surgery and percutaneous interventions in patients with multivessel disease.

METHODS

A total of 1205 patients were randomly assigned to undergo stent implantation or bypass surgery when a cardiac surgeon and an interventional cardiologist agreed that the same extent of revascularization could be achieved by either technique. The primary clinical end point was freedom from major adverse cardiac and cerebrovascular events at one year. The costs of hospital resources used were also determined.

RESULTS

At one year, there was no significant difference between the two groups in terms of the rates of death, stroke, or myocardial infarction. Among patients who survived without a stroke or a myocardial infarction, 16.8 percent of those in the stenting group underwent a second revascularization, as compared with 3.5 percent of those in the surgery group. The rate of event-free survival at one year was 73.8 percent among the patients who received stents and 87.8 percent among those who underwent bypass surgery (P<0.001 by the log-rank test). The costs for the initial procedure were $4,212 less for patients assigned to stenting than for those assigned to bypass surgery, but this difference was reduced during follow-up because of the increased need for repeated revascularization; after one year, the net difference in favor of stenting was estimated to be $2,973 per patient.

CONCLUSION

As measured one year after the procedure, coronary stenting for multivessel disease is less expensive than bypass surgery and offers the same degree of protection against death, stroke, and myocardial infarction. However, stenting is associated with a greater need for repeated revascularization.

Spatial analysis of Percutaneous Transluminal Coronary Angioplasty (PTCA) in Austria

STUDY OBJECTIVES

To investigate the geographical distribution of Percutaneous Transluminal Coronary Angioplasty (PTCA) and morbidity for coronary heart disease, angina pectoris and myocardial infarction by spatial analysis of the standardized morbidity rates (SMR) on district level. To identify clusters by Moran's I Statistic and the Regional Spatial Autocorrelation Coefficient (RSAC) of Munasinghe and Morris. To investigate demand factor morbidity and supply factor health care infrastructure on the district level as reasons for geographical disparity. To describe characteristics of the cluster population and intervention centres.

STUDY DESIGN

Retrospective record linkage study.

SETTING

All hospitals and cardiological centres in Austria (n = 150) which performed the Minimum Basic Data Set (MBDS).

PATIENTS

All Austrian residents who were diagnosed for myocardial infarction, coronary heart disease or angina pectoris in 1995 (n = 87,174).

MEASUREMENTS AND MAIN RESULTS

One 'positive' PTCA cluster (all SMRs > or =0.96) and one 'negative' PTCA cluster (all SMRs < or =0.59) were identified. They differed significantly in morbidity rate, intervention rate and available cardiological beds. The tendency to inverse relation between PTCA utilization and morbidity in the 'negative' cluster supported the thesis of 'inverse care law'. Austrianwide no significant correlation was found between the SMR of PTCA-application and both demand factor and supply factors. Nevertheless, differences between the clusters concerning number and capacity of intervention centres and density of specialists pointed to supply factors as reasons for geographical disparity. The ongoing trend of steady expansion of existing intervention centres and establishment of new ones will reduce the extent of geographical variation in future.

Randomised comparison of implantation of heparin-coated stents with balloon angioplasty in selected patients with coronary artery disease (Benestent II)

BACKGROUND

The multicentre, randomised Benestent-II study investigated a strategy of implantation of a heparin-coated Palmar-Schatz stent plus antiplatelet drugs compared with the use of balloon angioplasty in selected patients with stable or stabilised unstable angina, with one or more de-novo lesions, less than 18 mm long, in vessels of diameter 3 mm or more.

METHODS

827 patients were randomly assigned stent implantation (414 patients) or standard balloon angioplasty (413 patients). The primary clinical endpoint was event-free survival at 6 months, including death, myocardial infarction, and the need for revascularisation. The secondary endpoints were the restenosis rate at 6 months and the cost-effectiveness at 12 months. There was also one-to-one subrandomisation to either clinical and angiographic follow-up or clinical follow-up alone. Analyses were by intention to treat.

FINDINGS

Four patients (one stent group, three angioplasty group) were excluded from analysis since no lesion was found. At 6 months, a primary clinical endpoint had occurred in 53 (12.8%) of 413 patients in the stent group and 79 (19.3%) of 410 in the angioplasty group (p=0.013). This significant difference in clinical outcome was maintained at 12 months. In the subgroup assigned angiographic follow-up, the mean minimum lumen diameter was greater in the stent group than in the balloon-angioplasty group, (1.89 [SD 0.65] vs 1.66 [0.57] mm, p=0.0002), which corresponds to restenosis rates (diameter stenosis > or =50%) of 16% and 31% (p=0.0008). In the group assigned clinical follow-up alone, event-free survival rate at 12 months was higher in the stent group than the balloon-angioplasty group (0.89 vs 0.79, p=0.004) at a cost of an additional 2085 Dutch guilders (US$1020) per patient.

INTERPRETATION

Over 12-month follow-up, a strategy of elective stenting with heparin-coated stents is more effective but also more costly than balloon angioplasty.

Comparison of percutaneous transluminal coronary angioplasty outcome and hospital costs for low-volume and high-volume operators

Whether higher operator case volume is associated with improved percutaneous transluminal coronary angioplasty (PTCA) clinical and cost outcomes is the subject of this study. Hospital volume-related improvement in clinical outcomes has been shown for coronary artery bypass grafting (CABG) and PTCA. Physician case volume-related differences in clinical outcomes have not been clearly demonstrated, and differences in hospital costs have not been examined. For clinical and cost outcomes, risk-adjusted analysis of differences in PTCA outcomes has not been reported. In addition, controversy exists about the appropriate annual case volume considered adequate to maintain skills and achieve optimal clinical outcomes in performing PTCA procedures. We studied 2,350 PTCAs performed between March 1, 1991, and February 28, 1994. Physicians were divided into 2 volume groups: high (>50 cases/year) and low (<50 cases/year). The rate of emergency CABG after PTCA was 2.1% for high- and 3.9% for low-volume operators (p = 0.009). Hospital morbidity associated with PTCA was lower in high-than in low-volume operators (6.46% vs 10.73%, p <0.001). The risk-adjusted ratios for emergency CABG and morbidity were 2.05 (p = 0.005) and 1.79 (p <0.001), respectively. The length of stay averaged 4.07 +/- 4.54 days for high- and 4.49 +/- 4.33 days for low-volume operators (p = 0.003). Hospital costs averaged $7,977 +/-$7,269 for high- and $8,278 +/- $6,289 for low-volume operators (p = 0.065). The risk adjusted ratio was 1.091 (p = 0.004) for length of stay and 1.050 (p = 0.029) for cost. Thus, PTCA performed by high-volume operators is significantly less likely to require emergency CABG and is also significantly associated with lower hospital morbidity, shorter hospital length of stay, and lower hospital costs.

In-hospital and one-year economic outcomes after coronary stenting or balloon angioplasty. Results from a randomized clinical trial. Stent Restenosis Study Investigators

BACKGROUND

Coronary stenting has been shown to improve initial success, reduce angiographic restenosis, and reduce the need for repeat revascularization compared with conventional balloon angioplasty (PTCA). Although previous studies have demonstrated that initial hospital costs for stenting are considerably higher than those for conventional PTCA, the impact of coronary stenting on long-term medical care costs remains unknown.

METHODS AND RESULTS

Between January 1991 and June 1993, 207 consecutive patients with symptomatic coronary disease requiring revascularization of a single coronary lesion were randomized to receive initial treatment by either PTCA (n = 105) or Palmaz-Schatz coronary stent implantation (n = 102) in the multicenter STRESS trial. Detailed resource utilization and cost data were collected for each patient's initial hospitalization and for any subsequent hospital visits for 1 year after randomization. Compared with conventional angioplasty, coronary stenting resulted in additional catheterization laboratory costs, increased vascular complications, and longer length of stay. Initial hospital costs were thus approximately $2200 higher for stenting than for PTCA ($9738 +/- 3248 versus $7505 +/- 5015; P < .001). Over the first year of follow-up, however, patients assigned to initial stenting were less likely to require rehospitalization for a cardiac condition and underwent fewer subsequent revascularization procedures. Follow-up medical care costs thus tended to be lower for stenting than for conventional angioplasty ($1918 +/- 4841 versus $3359 +/- 7100, P = .21). Nonetheless, cumulative 1-year medical care costs remained higher for patients undergoing initial stenting ($11,656 +/- 5674 versus $10,865 +/- 9073, P < .001). Even after adjustment for the higher incidence of vascular complications in the stent group, total 1-year costs were $300 higher for stenting than for balloon angioplasty.

CONCLUSIONS

Elective coronary stenting, as performed in the randomized STRESS trial, increased total 1-year medical care costs by approximately $800 per patient compared with conventional angioplasty. Future studies will be necessary to determine whether ongoing refinements in stent design, implantation techniques, and anticoagulation regimens can narrow this cost difference further by reducing stent-related vascular complications or length of stay.

Coronary angioplasty versus bypass grafting. Cost-benefit considerations

Both PTCA and CABG are effective strategies for coronary revascularization. The initial cost of PTCA is 60% to 75% less than that of CABG. PTCA patients, however, often require repeat procedures secondary to restenosis and incomplete revascularization. Despite this, the cost of PTCA is still approximately half that of CABG at 1 year but approaches that of CABG at 3 years. The BARI SEQOL trial will be available in 1996 and will analyze cost differences as well as quality of life for PTCA versus CABG up to 5 years after revascularization. Patients with single-vessel disease can be treated effectively with PTCA or medications. Although PTCA is more expensive, patients have less angina and better exercise tolerance. Many patients with single-vessel disease are now treated with PTCA, who in the past would have been treated medically. Undoubtedly, this change has added to the increasing cost of health care. Although certain patient groups, such as those with three-vessel disease and low ejection fraction and left-main disease, have a significant mortality advantage when revascularized surgically, many patients with symptomatic two-vessel and three-vessel disease can be treated either with CABG or PTCA with no difference in mortality and MI. To reach this equivalent outcome, however, PTCA patients require more interventional procedures. As a result, at 3 years, there is no cost savings with PTCA. Physicians in the United States have been able to choose the mode of revascularization for patients based on clinical judgment and preference, which has been financed by third-party payers. Given the escalating costs of health care in a country with limited resources, physicians failing to consider costs and benefits may find their choices limited secondary to lack of funding and restrictive policies. Future treatment of CAD will most likely be influenced by aggressive lipid-lowering therapy to prevent secondary cardiac events and possibly by gene therapy to prevent restenosis.

In-hospital cost of percutaneous coronary revascularization. Critical determinants and implications

BACKGROUND

Hospital charges associated with percutaneous transluminal coronary revascularization (PTCR) in the United States exceeded $6 billion in 1994 and are likely to be constrained in some manner in the near future. Despite this high cost to the public, little is known about the major determinants and sources of variability of PTCR.

METHODS AND RESULTS

From a consecutive series of 1258 procedures with attempted PTCR at a single tertiary referral center, we analyzed 65 clinical, angiographic, physician, and outcome variables as potential correlates of total (hospital and physician) cost. Direct and indirect costs, both hospital and physician, were determined on the basis of resource utilization using "top-down" methodology and were available for 1237 procedures (1086 patients) (98.3%). Mean (+/- SD) patient age was 62 +/- 11 years, 76% were male, 3% had acute myocardial infarction, 71% had unstable angina, 58% had multivessel disease, left ventricular ejection fraction was 54 +/- 12%, 26% had use of at least one nonballoon revascularization device, and median length of stay was 4.4 days. Procedural success was obtained in 89%, and major complications (death, bypass surgery, or Q-wave myocardial infarction) occurred in 3.8%. The median cost was $9176, but it was asymmetrically distributed, and the interquartile and total ranges were wide ($7333 to $13,845 and $3422 to $193,474, respectively). Analyses of independent correlates of cost and loge(cost) were performed using multivariate linear regression in training and test populations. Modeling found 15 independent preprocedural correlates of loge(cost) (R2 = .37) and 23 overall correlates (R2 = .65), excluding length of stay per se. Additional of length of stay to the model increased the explanatory power of the model to R2 = .82. Preprocedural variables most predictive of loge(cost) included presentation with acute myocardial infarction, decision delay (> 48 hours between admission and diagnostic angiography and/or > 24 hours between angiography and intervention), weekend delay, use of intra-aortic balloon counterpulsation, intention to stent, creatinine > or = 2.0 mg%, and lesion complexity (modified American College of Cardiology/American Heart Association score) (all P < .001). In the model that included postprocedural variables as well, length of stay, noncardiac death, urgent bypass surgery, use of the Rotablator, Q-wave myocardial infarction, rise in creatinine > or = 1.0%, and blood product transfusion were all strong independent correlates of loge(cost) (P < .001).

CONCLUSIONS

The range of total hospital costs associated with percutaneous intervention is extraordinarily wide. Baseline patient characteristics account for nearly half of the explained variance, but procedural complications and system delays account for much of the remainder. Quantification of the determinants of cost may promote more economically efficient care in the future.

The invasive management of angina: issues for consumers and commissioners

OBJECTIVE

To review, from the purchaser's perspective, the current state of knowledge of techniques for investigation and treating coronary artery disease. The study was based on evidence from past and continuing randomised controlled trials (RCTs). CRITERIA FOR INCLUSION OF REPORTS: Articles listed on Medline (1990-3) with the keywords coronary disease, angina, and unstable angina (combined with surgery, economics, therapy, or drug therapy) and percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG) were included. Articles published before 1990 were obtained from two comprehensive literature reviews published by the Rand organisation in 1991 and from the papers obtained using the Medline search. A hand search of relevant journals published between July 1993 and June 1994 was also undertaken. Results from more recently published RCTs are included.

RESULTS

CABG provides improved angina relief compared with drug treatment and may prolong life in patients with more severe illness. PTCA is also better than drug treatment, but less so than CABG, and its cost advantages over CABG decrease with time. Repeat intervention for return of symptoms is more frequently required after PTCA, but increasing numbers of patients are also undergoing second and third repeat CABG for graft occlusion in the years after the original operation. Newer PTCA techniques are not, as yet, fully evaluated. One technique, atherectomy, has been shown to be no more effective, and more expensive, than conventional balloon angioplasty. In the short term intracoronary stents reduce the problems associated with vessel occlusion after PTCA and therefore reduce the need for further intervention. PTCA should not be performed without ready access to cardiothoracic support. There is an increasing trend towards the development of coronary catheterisation units at peripheral sites. This may lead to increasing, inappropriate use of this investigation in suboptimal circumstances.

CONCLUSIONS

Ischaemic heart disease is an important cause of morbidity and mortality and invasive management techniques are developing rapidly; some service expansion is occurring without trial evidence. More research is required to determine the optimum balance of PTCA, CABG, and angiography and population requirements for these procedures. In the meantime, in the absence of firm long term evidence of the superior cost effectiveness of PTCA compared with CABG, the rapid expansion of this procedure should be limited. Patients should be fully informed of the benefits and disadvantages of CABG and PTCA, where either procedure is indicated, to enable them to make fully informed choices.

Health service costs of coronary angioplasty and coronary artery bypass surgery: the Randomised Intervention Treatment of Angina (RITA) trial

For some patients with coronary artery disease, percutaneous transluminal coronary angioplasty (PTCA) is an alternative to coronary artery bypass grafting (CABG). We report comparative health service costs of these interventions within the Randomised Intervention Treatment of Angina (RITA) trial. Medications were costed at published UK prices; other resource use was costed with a set of unit costs estimated at two recruiting centres to the RITA trial, one in London and one outside. Over 2-year follow-up of 1011 patients, the estimated mean additional cost for those randomised to CABG compared with PTCA was 1050 pounds (95% CI 621 pounds-1479 pounds), with unit costs from the non-London centre, and 1823 pounds (1202 pounds-2444 pounds), with unit costs from the London centre. The initial average cost of treating a patient randomised to PTCA is about 52% of that of CABG, but after 2 years this increased to about 80% because of the greater need for subsequent interventions. The balance of advantage between PTCA and CABG may change after several years: funding has been obtained to continue RITA follow-up for 10 years. However, on the basis of patients' status at 2 years, the cost advantages of PTCA cannot be ignored. Further research is necessary to assess whether the advantage of PTCA in terms of cost is translated into one of cost-effectiveness.

Perspectives on invasive cardiology: the 24th Louis F. Bishop Lecture

The fast growing and complex field of invasive cardiology offers a host of opportunities and challenges for the clinician. Scientific and technical advances ranging from molecular biology to microtechnology are changing how physicians make decisions concerning treatment of coronary artery disease, myocardial infarction, unstable angina and electrophysiologic dysfunction. The economic impact and ethical implications presented by these developments contribute to the difficulty of achieving optimal therapeutic solutions for individual patients.

The dynamics of technological change in medicine

This paper contrasts a dynamic and interactive view of technological change with the linear model of medical innovation that is still so deeply ingrained in many policy discussions. In particular, it focuses on the role of feedback mechanisms between the users and the developers of medical technology and the demand and supply forces (including competition among medical specialties) determining this feedback. It explores three distinct mechanisms by which technological change may contribute to rising health care spending: intensity of use of existing technology, introduction of new technologies, and expanded application of these new technologies.

Coronary angioplasty. Statewide experience in California

BACKGROUND

This report describes the in-hospital experience with percutaneous transluminal coronary angioplasty (PTCA) for the state of California in 1989. Data are derived from the statewide hospital discharge abstracts.

METHODS AND RESULTS

A total of 24,883 PTCAs were performed; most patients (70%) were men and most procedures were single vessel (87%). About one fifth (19%) of patients had a principal diagnosis of acute myocardial infarction (AMI). Overall mortality was 1.4% and was higher in the AMI group (4.2%) versus the non-AMI group (0.8%, P = .0001). Mortality was higher for AMI patients having PTCA on the day of or day after admission (5.5%) versus those treated later (2.6%, P = .0001). Five percent of patients had coronary artery bypass surgery (CABG) after PTCA; CABG was performed on the same day as PTCA in 61.7% of cases. Patients presenting with AMI were more likely to have CABG (7.1%) than non-AMI patients (4.5%, P = .0001). Mortality associated with CABG was 7.3% and was higher in the AMI group (12.0%) than in the non-AMI group (5.5%, P = .0001). Factors predictive of increased mortality by bivariate analysis included age > 63 years (2.1% mortality versus 0.8% < or = 63, P = .01), female sex (1.9% versus 1.2% for men, P < .01), and the presence of diabetes (1.9% versus 1.3% for nondiabetics, P < .05). Multiple logistic regression showed that timings of PTCA with respect to admission (P = .004) and age (P = .05) were predictors of mortality, but female sex was predictive only in the non-AMI group (P = .03). Mean hospital charges were $19,597 (+/- SD, $18,213). Forty-two percent of the 110 hospitals performed more than the recommended minimum of 200 cases per year. The requirement for CABG during the same admission or the combined adverse outcome of CABG and/or death was increased in the lower-volume centers for both AMI and non-AMI patients (P < .001), although mortality alone was not.

CONCLUSIONS

The mortality and need for CABG surgery in the statewide California PTCA experience is higher than that generally reported in the literature. In patients with an admitting diagnosis of AMI, the overall mortality was higher, as was the need for CABG and the associated CABG mortality. Most hospitals performed fewer than 200 PTCAs per year. Rates of CABG surgery and the combination of CABG and/or mortality, adjusted only for the presence or absence of AMI, were increased at the low-volume institutions.

Economics of elective coronary revascularization. Comparison of costs and charges for conventional angioplasty, directional atherectomy, stenting and bypass surgery

OBJECTIVES

This study was designed to evaluate more closely the true in-hospital costs of elective revascularization by directional coronary atherectomy and intracoronary stenting and to compare these costs with those of the traditional revascularization alternatives (i.e., conventional balloon angioplasty and coronary artery bypass surgery).

BACKGROUND

Previous studies have suggested that total hospital charges for directional coronary atherectomy or intracoronary stenting are significantly higher than those for conventional angioplasty. However, hospital charges do not necessarily reflect true economic costs, and their use may provide misleading data with regard to cost-effectiveness.

METHODS

We analyzed in-hospital charges from the itemized hospital accounts of 300 patients undergoing elective angioplasty, directional atherectomy, Palmaz-Schatz coronary stenting or bypass surgery between January 1, 1990 and December 31, 1991. Costs were then derived by adjusting itemized patient accounts for department-specific cost/charge ratios. Catheterization laboratory costs were based on actual resource consumption, and daily room costs were adjusted for the intensity of nursing services provided.

RESULTS

Length of hospital stay was similar for atherectomy (2.3 +/- 1.5 days) and conventional angioplasty (2.6 +/- 1.7 days) but significantly longer for stenting (5.5 +/- 2.6 days, p < 0.05). Total costs were also significantly higher for coronary stenting ($7,878 +/- $3,270, median $6,699, p < 0.05) than for angioplasty ($5,396 +/- $2,829, median $4,753) or atherectomy ($5,726 +/- $2,716, median $4,986). However, length of stay, resource consumption (laboratory and radiologic testing, drugs, blood products, for example) and total costs for bypass surgery were still greater than for any of the percutaneous interventional procedures.

CONCLUSIONS

In contrast to previous studies utilizing only hospital charges, the in-hospital costs of angioplasty and directional coronary atherectomy were similar. Although the cost of coronary stenting was approximately $2,500 higher than that of conventional angioplasty, the magnitude of this difference was smaller than the $6,300 increment previously suggested on the basis of analysis of hospital charges. These findings reflect the inherent discrepancies between cost-based and charge-based methodologies and may have important implications for future studies evaluating the relative cost-effectiveness of newer coronary interventions.