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.

J. Maxwell Chamberlain memorial paper. Sternal wound complications after isolated coronary artery bypass grafting: early and late mortality, morbidity, and cost of care

Of 6,504 consecutive patients who underwent isolated coronary bypass grafting in 1985 to 1987, 72 (1.1%) patients experienced sternal wound complications. Ten patients (14%) with wound complications died of multi-system failure. Only the patients with negative cultures fared well; of the bacterial culture categories, polymicrobial infection carried the worst prognosis. Effects of recurring infection were seen throughout the first year. Patients, grouped according to conduits received, experienced these wound complication rates: vein grafts only, 11/1,085 (1.0%); one internal thoracic artery, 38/4,073 (0.9%); and bilateral internal thoracic artery grafts, 23/1,346 (1.7%). There were no significant differences in wound complication rates between primary and reoperation patients or among conduit groups. By logistic regression analysis, the relative risk for patients with diabetes and bilateral internal thoracic artery grafting was 5.00 (95% confidence interval, 2.4 to 10.5). Operation time as a continuous variable increased the relative risk of wound complication 1.47 times per hour (1.3 to 1.7); obesity, 2.90 times (1.8 to 4.8); and blood units as continuous variable, 1.05 times per unit (1.01 to 1.10). Bilateral internal thoracic artery grafting in nondiabetic patients carried no greater risk of wound complication than that in patients with vein grafts only or with one internal thoracic artery graft.

Off-pump vs conventional coronary artery bypass grafting: early and 1-year graft patency, cost, and quality-of-life outcomes: a randomized trial

CONTEXT

Previous trials of off-pump coronary artery bypass (OPCAB) have enrolled selected patients and have not rigorously evaluated long-term graft patency. A preliminary report showed OPCAB achieved improved inhospital outcomes, similar completeness of revascularization, and shorter lengths of stay compared with conventional coronary artery bypass grafting (CABG).

OBJECTIVE

To assess graft patency, clinical and quality-of-life outcomes, and cost among patients while in the hospital and at 1-year follow-up.

DESIGN, SETTING, AND PATIENTS

Randomized controlled trial of patients unselected for coronary anatomy, ventricular function, or comorbidities between March 10, 2000, and August 20, 2001, at a US academic center. A total of 200 patients were enrolled; 3 patients were withdrawn after randomization for mitral valve repair or replacement. Follow-up was complete for 197 patients at 30 days; 185 at 1 year.

INTERVENTIONS

One surgical session consisting of elective OPCAB or CABG with cardiopulmonary bypass. The surgeon had extensive experience performing off-pump surgery; patients were subsequently managed by blinded protocols.

MAIN OUTCOME MEASURES

Coronary angiography documented graft patency prior to hospital discharge and at 1 year; health-related quality of life; and cost of the index and subsequent hospitalization(s).

RESULTS

Graft patency was similar for OPCAB and conventional CABG with cardiopulmonary bypass at 30 days (absolute difference, 1.3%; 95% confidence interval [CI], -0.66% to 3.31%; P =.19) and at 1 year (absolute difference, -2.2%; 95% CI, -6.1% to 1.7%; P =.27). Rates of death, stroke, myocardial infarction, angina, and reintervention were similar at 30 days and 1 year. There were no significant differences in health-related quality of life. Mean total hospitalization cost per patient at hospital discharge was 2272 dollars (95% CI, 755 dollars-3732 dollars) less for OPCAB (P =.002) and 1955 dollars (95% CI, -766 dollars to 4727 dollars) less at 1 year (P =.08).

CONCLUSIONS

In this randomized single-surgeon trial among unselected patients with angiographic follow-up, OPCAB achieved similar graft patency in the hospital and at 1 year. Cardiac outcomes and health-related quality of life at 30 days and 1 year were similar and patients incurred a lower cost. OPCAB may provide complete revascularization that is durable and cost-effective.

Economics of coronary artery bypass grafting

To decide whether the number of operations for coronary artery bypass grafting should be increased, maintained at the present levels, or decreased we need to know how cost effective they are relative to other claimants on the resources of the National Health Service. For this purpose effectiveness is taken to be the effect on life expectancy adjusted for the quality of life. In an assessment of the cost per quality adjusted life year gained coronary artery bypass grafting rates well for cases of severe angina and extensive coronary artery disease. The cost, however, rises sharply for less severe cases. Bypass grafting seems to compare favourably with valve replacement for aortic stenosis and implantation of pacemakers for heart block; it is distinctly better than heart transplantation and the treatment of end stage renal failure but is probably less cost effective than hip replacement. If the number of operations for coronary artery bypass grafting were to increase it would be a fairly strong claimant only if restricted to the most severe cases. The data on which these judgments are based are crude and in need of refinement. The methodology is powerful, far reaching, and open to comment.

Does off-pump coronary artery bypass reduce mortality, morbidity, and resource utilization when compared with conventional coronary artery bypass? A meta-analysis of randomized trials

The authors undertook a meta-analysis of 37 randomized trials (3369 patients) of off-pump coronary artery bypass surgery versus conventional coronary artery bypass surgery. No significant differences were found for 30-day mortality (odds ratio [OR], 1.02; 95% confidence interval [CI], 0.58-1.80), myocardial infarction (OR, 0.77; 95%CI, 0.48-1.26), stroke (OR, 0.68; 95%CI, 0.33-1.40), renal dysfunction, intraaortic balloon pump, wound infection, rethoracotomy, or reintervention. However, off-pump coronary artery bypass surgery significantly decreased atrial fibrillation (OR, 0.58; 95%CI, 0.44-0.77), transfusion (OR, 0.43; 95%CI, 0.29-0.65), inotrope requirements (OR, 0.48; 95%CI, 0.32-0.73), respiratory infections (OR, 0.41; 95%CI, 0.23-0.74), ventilation time (weighted mean difference, -3.4 h; 95%CI, -5.1 to -1.7 h), intensive care unit stay (weighted mean difference, -0.3 days; 95%CI -0.6 to -0.1 days), and hospital stay (weighted mean difference, -1.0 days; 95%CI -1.5 to -0.5 days). Patency and neurocognitive function results were inconclusive. In-hospital and 1-yr direct costs were generally higher for conventional coronary artery bypass surgery versus off-pump coronary artery bypass surgery. Therefore, this meta-analysis demonstrates that mortality, stroke, myocardial infarction, and renal failure were not reduced in off-pump coronary artery bypass surgery surgery; however, selected short-term and mid-term clinical and resource outcomes were improved compared with conventional coronary artery bypass surgery.

A comparison of on-pump and off-pump coronary bypass surgery in low-risk patients

BACKGROUND

The performance of coronary bypass surgery without cardiopulmonary bypass ("off pump") may reduce perioperative morbidity and costs, but it is uncertain whether the outcome is similar to that involving the use of cardiopulmonary bypass ("on pump").

METHODS

In a multicenter, randomized trial, we randomly assigned 139 patients with predominantly single- or double-vessel coronary disease to on-pump surgery and 142 to off-pump surgery. Cardiac outcome and cost effectiveness were determined one year after surgery. The uncertainty surrounding the cost-effectiveness ratio (cost differences per quality-adjusted year of life gained) was addressed by bootstrapping.

RESULTS

At one year, the rate of freedom from death, stroke, myocardial infarction, and coronary reintervention was 90.6 percent after on-pump surgery and 88.0 percent after off-pump surgery (absolute difference, 2.6 percent; 95 percent confidence interval, - 4.6 to 9.8). Graft patency in a randomized subgroup of patients was 93 percent after on-pump surgery and 91 percent after off-pump surgery (absolute difference, 2.0 percent; 95 percent confidence interval, - 6.5 to 10.4). On-pump surgery was associated with $1,839 in additional direct costs per patient ($14,908 vs. $13,069--a difference of 14.1 percent) and an increase in quality-adjusted years of life of 0.83 as compared with 0.82 (difference, 0.01 year; 95 percent confidence interval, - 0.03 to 0.04). Off-pump surgery was more cost effective than on-pump surgery in 95 percent of bootstrap estimates.

CONCLUSIONS

In low-risk patients, there was no difference in cardiac outcome at one year between those who underwent on-pump bypass surgery and those who underwent off-pump surgery. Off-pump surgery was more cost effective.

Five-Year Outcomes after Off-Pump or On-Pump Coronary-Artery Bypass Grafting

BACKGROUND

We previously reported that there was no significant difference at 30 days or at 1 year in the rate of the composite outcome of death, stroke, myocardial infarction, or renal failure between patients who underwent coronary-artery bypass grafting (CABG) performed with a beating-heart technique (off-pump) and those who underwent CABG performed with cardiopulmonary bypass (on-pump). We now report the results at 5 years (the end of the trial).

METHODS

A total of 4752 patients (from 19 countries) who had coronary artery disease were randomly assigned to undergo off-pump or on-pump CABG. For this report, we analyzed a composite outcome of death, stroke, myocardial infarction, renal failure, or repeat coronary revascularization (either CABG or percutaneous coronary intervention). The mean follow-up period was 4.8 years.

RESULTS

There were no significant differences between the off-pump group and the on-pump group in the rate of the composite outcome (23.1% and 23.6%, respectively; hazard ratio with off-pump CABG, 0.98; 95% confidence interval [CI], 0.87 to 1.10; P=0.72) or in the rates of the components of the outcome, including repeat coronary revascularization, which was performed in 2.8% of the patients in the off-pump group and in 2.3% of the patients in the on-pump group (hazard ratio, 1.21; 95% CI, 0.85 to 1.73; P=0.29). The secondary outcome for the overall period of the trial - the mean cost in U.S. dollars per patient - also did not differ significantly between the off-pump group and the on-pump group ($15,107 and $14,992, respectively; between-group difference, $115; 95% CI, -$697 to $927). There were no significant between-group differences in quality-of-life measures.

CONCLUSIONS

In our trial, the rate of the composite outcome of death, stroke, myocardial infarction, renal failure, or repeat revascularization at 5 years of follow-up was similar among patients who underwent off-pump CABG and those who underwent on-pump CABG. (Funded by the Canadian Institutes of Health Research; CORONARY ClinicalTrials.gov number, NCT00463294 .).

Early tracheal extubation after coronary artery bypass graft surgery reduces costs and improves resource use. A prospective, randomized, controlled trial

BACKGROUND

Economics has caused the trend of early tracheal extubation after cardiac surgery, yet no prospective randomized study has directly validated that early tracheal extubation anesthetic management decreases costs when compared with late extubation after cardiac surgery.

METHODS

This prospective, randomized, controlled clinical trial was designed to evaluate the cost savings of early (1-6 h) versus late tracheal extubation (12-22 h) in patients after coronary artery bypass graft (CABG) surgery. The total cost for the services provided for each patient was determined for both the early and late groups from hospital admission to discharge home. All costs applicable to each of the services were classified into direct variables, direct fixed costs, and overhead (an indirect cost). Physician fees and heart catheterization costs were included. The total service cost was the sum of unit workload and overhead costs.

RESULTS

One hundred patients having elective CABG who were younger than 75 yr were studied. Including all complications, early extubation (n = 50) significantly reduced cardiovascular intensive care unit (CVICU) costs by 53% (P < 0.026) and the total CABG surgery cost by 25% (P < 0.019) when compared with late extubation (n = 50). Forty-one patients (82%) in each group were tracheally extubated within the defined period. In the early extubation group, the actual departmental cost savings in CVICU nursing and supplies was 23% (P < 0.005), in ward nursing and supplies was 11% (P < 0.05), and in respiratory therapy was 12% (P < 0.05). The total cost savings per patient having CABG was 9% (P < 0.001). Further cost savings using discharge criteria were 51% for CVICU nursing and supplies (P < 0.001), 9% for ward nursing and supplies (P < 0.05), and 29% for respiratory therapy (P < 0.001), for a total cost savings per patient of 13% (P < 0.001). Early extubation also reduced elective case cancellations (P < 0.002) without any increase in the number of postoperative complications and readmissions.

CONCLUSIONS

Early tracheal extubation anesthetic management reduces total costs per CABG surgery by 25%, predominantly in nursing and in CVICU costs. Early extubation reduces CVICU and hospital length of stay but does not increase the rate or costs of complications when compared with patients in the late extubation group. It shifts the high CVICU costs to the lower ward costs. Early extubation also improves resource use after cardiac surgery when compared with late extubation.

Clinical and economic impact of diabetes mellitus on percutaneous and surgical treatment of multivessel coronary disease patients: insights from the Arterial Revascularization Therapy Study (ARTS) trial

BACKGROUND

Our aims were to compare coronary artery bypass grafting (CABG) and stenting for the treatment of diabetic patients with multivessel coronary disease enrolled in the Arterial Revascularization Therapy Study (ARTS) trial and to determine the costs of these 2 treatment strategies.

METHODS AND RESULTS

Patients (n=1205) were randomly assigned to stent implantation (n=600; diabetic, 112) or CABG (n=605; diabetic, 96). Costs per patient were calculated as the product of each patient's use of resources and the corresponding unit costs. Baseline characteristics were similar between the groups. At 1 year, diabetic patients treated with stenting had the lowest event-free survival rate (63.4%) because of a higher incidence of repeat revascularization compared with both diabetic patients treated with CABG (84.4%, P<0.001) and nondiabetic patients treated with stents (76.2%, P=0.04). Conversely, diabetic and nondiabetic patients experienced similar 1-year event-free survival rates when treated with CABG (84.4% and 88.4%). The total 1-year costs for stenting and CABG in diabetic patients were $12 855 and $16 585 (P<0.001) and in the nondiabetic groups, $10 164 for stenting and $13 082 for surgery.

CONCLUSIONS

Multivessel diabetic patients treated with stenting had a worse 1-year outcome than patients assigned to CABG or nondiabetics treated with stenting. The strategy of stenting was less costly than CABG, however, regardless of diabetic status.

Medical care costs and quality of life after randomization to coronary angioplasty or coronary bypass surgery. Bypass Angioplasty Revascularization Investigation (BARI) Investigators

BACKGROUND

Randomized trials comparing coronary angioplasty with bypass surgery in patients with multivessel coronary disease have shown no significant differences in overall rates of death and myocardial infarction. We compared quality of life, employment, and medical care costs during five years of follow-up among patients treated with angioplasty or bypass surgery.

METHODS

A total of 934 of the 1829 patients enrolled in the randomized Bypass Angioplasty Revascularization Investigation participated in this study. Detailed data on quality of life were collected annually, and economic data were collected quarterly.

RESULTS

During the first three years of follow-up, functional-status scores on the Duke Activity Status Index, which measures the ability to perform common activities of daily living, improved more in patients assigned to surgery than in those assigned to angioplasty (P<0.05). Other measures of quality of life improved equally in both groups throughout the follow-up period. Patients in the angioplasty group returned to work five weeks sooner than did patients in the surgery group (P<0.001). The initial mean cost of angioplasty was 65 percent that of surgery ($21,113 vs. $32,347, P<0.001), but after five years the total medical cost of angioplasty was 95 percent that of surgery ($56,225 vs. $58,889), a difference of $2,664 (P = 0.047). The five-year cost of angioplasty was significantly lower than that of surgery among patients with two-vessel disease ($52,930 vs. $58,498, P<0.05), but not among patients with three-vessel disease ($60,918 vs. $59,430). After five years of follow-up, surgery had an overall cost-effectiveness ratio of $26,117 per year of life added, but unacceptable ratios of $100,000 or more per year of life added could not be excluded (P=0.13). Surgery appeared particularly cost effective in treating diabetic patients because of their significantly improved survival.

CONCLUSIONS

In patients with multivessel coronary disease, coronary-artery bypass surgery is associated with a better quality of life for three years than coronary angioplasty, after the initial morbidity caused by the procedure. Coronary angioplasty has a lower five-year cost than bypass surgery only in patients with two-vessel coronary disease.

Changes in transfusion therapy and reexploration rate after institution of a blood management program in cardiac surgical patients

A retrospective study was performed to determine the impact of a coagulation and transfusion management program on blood utilization in 1,079 sequential patients for myocardial revascularization and open ventricle or combined procedures. Four hundred and eighty-eight patients (group 1) before, and 591 patients (group 2) after institution of thromboelastography (TEG)-guided coagulation were studied and compared for transfusion requirements, donor exposure, and the incidence of reoperation for hemorrhage. Group 2 patients had a significantly lower incidence of overall transfusion (78.5% v 86.3%) during hospitalization and in total transfusion in the operating room (57.9% v 66.4%). The incidence of each transfusion subtype was also significantly lower in group 2 patients. Actual total median donor exposure was 8 in group 1 patients and 6 exposures in group 2 patients. Mediastinal reexploration for hemorrhage was 5.7% before institution of TEG-based coagulation monitoring and 1.5% in TEG-monitored patients. Use of TEG monitoring before reexploration has decreased the cost and potential risk for patients undergoing CABG surgery.

Argentine randomized trial of percutaneous transluminal coronary angioplasty versus coronary artery bypass surgery in multivessel disease (ERACI): in-hospital results and 1-year follow-up. ERACI Group

OBJECTIVES

This study was designed to compare freedom from combined cardiac events (death, angina, myocardial infarction) at 1-, 3- and 5-year follow-up in patients with multivessel disease randomized to either percutaneous transluminal coronary angioplasty or coronary artery bypass graft surgery.

BACKGROUND

Percutaneous transluminal coronary angioplasty has been an effective approach in patients with coronary artery disease, but its role in patients with multivessel coronary artery disease is still controversial.

METHODS

One-hundred twenty-seven patients with multivessel disease and lesions suitable for either form of therapy were randomized to either coronary artery bypass grafting (n = 64) or coronary angioplasty (n = 63). In this study we report the immediate results and freedom from combined cardiac events at 1-year follow-up.

RESULTS

Demographic, clinical and angiographic characteristics were similar in both groups. There were no differences in in-hospital deaths, frequency of periprocedure myocardial infarction or need for emergency revascularization procedures between the two groups. At 1-year follow-up, there were no differences in mortality or in the incidence of myocardial infarction between the groups. However, patients treated with coronary artery bypass grafting were more frequently free of angina, reinterventions and combined cardiac events than were patients treated with coronary angioplasty (83.5% vs. 63.7%, p < 0.005). In-hospital cost and cumulative cost at 1-year follow-up were greater for the coronary artery bypass grafting than for the coronary angioplasty group.

CONCLUSIONS

No significant differences were found in major in-hospital complications between patients treated with coronary artery bypass grafting or coronary angioplasty. Although at 1-year follow-up there were no differences in survival and freedom from myocardial infarction, patients in the coronary artery bypass grafting group were more frequently free from angina, reinterventions and combined events than were patients in the coronary angioplasty group.

Outcomes and perioperative hyperglycemia in patients with or without diabetes mellitus undergoing coronary artery bypass grafting

BACKGROUND

The association between perioperative hyperglycemia and outcomes in patients with and without diabetes mellitus undergoing coronary artery bypass grafting is not well defined. We measured the association between perioperative hyperglycemia and outcomes among patients undergoing coronary artery bypass grafting.

METHODS

We report a historic cohort study of 1574 patients who had undergone coronary artery bypass grafting between 1998 and 1999, 545 (34.6%) with diabetes. Perioperative blood glucose level was defined as the average of all blood glucose tests obtained on the day of and the day after surgery. Outcomes were 30-day mortality, infection rates (sternum, harvest site, sepsis, pneumonia, urinary tract), and resource utilization.

RESULTS

After adjusting for diabetes status and calculated preoperative mortality or mediastinitis risk scores, each 50 mg/dL (2.78 mmol/L) blood glucose increase was not statistically associated with higher mortality (odds ratio 1.37; 95% confidence interval, 0.98 to 1.92; p = 0.07), or higher infection rate (odds ratio 1.23, 95% confidence interval 0.94 to 1.60; p = 0.14). Each 50 mg/dL blood glucose increase was associated with longer postoperative days by 0.76 days (95% confidence interval 0.36 to 1.17 days; p < 0.001), increased hospitalization charges by 2824 dollars (95% confidence interval 1599 dollars to 4049 dollars; p < 0.001), and increased hospitalization cost by 1769 dollars (95% confidence interval 928 dollars to 2610 dollars; p < 0.001). In the unadjusted analysis, infections occurred more frequently in patients with diabetes (6.6% vs 4.1%, p = 0.03).

CONCLUSIONS

Perioperative hyperglycemia is associated with increased resource utilization in patients undergoing coronary artery bypass grafting with and without diabetes.

Clinical outcomes, angiographic patency, and resource utilization in 200 consecutive off-pump coronary bypass patients

BACKGROUND

This retrospective study compared clinical outcomes and resource utilization in patients having off-pump coronary artery bypass grafting (OPCAB) versus conventional coronary artery bypass grafting (CABG). Angiographic patency was documented in the OPCAB group.

METHODS

From April 1997 through November 1999, OPCAB was performed in 200 consecutive patients, and the results were compared with those in a contemporaneous matched control group of 1,000 patients undergoing CABG. Patients were matched according to age, sex, preexisting disease (renal failure, diabetes, pulmonary disease, stroke, hypertension, peripheral vascular disease, previous myocardial infarction, and primary or redo status. Follow-up in the OPCAB patients was 93% and averaged 13.4 months.

RESULTS

Hospital death (1.0%), postoperative stroke (1.5%), myocardial infarction (1.0%), and re-entry for bleeding (1.5%) occurred infrequently in the OPCAB group. There were reductions in the rates of transfusion (33.0% versus 70.0%; p < 0.001) and deep sternal wound infection (0% versus 2.2%; p = 0.067) in the OPCAB group compared with the CABG group. Angiographic assessment of 421 grafted arteries was performed in 167 OPCAB patients (83.5%) prior to hospital discharge. All but five were patent (98.8%) (93.3% FitzGibbon A, 5.5% FitzGibbon B, 1.2% FitzGibbon O). All 163 internal mammary artery grafts were patent. Off-pump coronary artery bypass grafting reduced postoperative hospital stay from 5.7 +/- 5.3 days in the CABG group to 3.9 +/- 2.6 days (p < 0.001), with a decrease in hospital cost of 15.0% (p < 0.001).

CONCLUSIONS

Off-pump coronary artery bypass grafting reduces hospital cost, postoperative length of stay, and morbidity compared with CABG on cardiopulmonary bypass. Off-pump coronary bypass grafting is safe, cost effective, and associated with excellent graft patency and clinical outcomes.

Risk index for perioperative renal dysfunction/failure: critical dependence on pulse pressure hypertension

BACKGROUND

An acute renal event after coronary bypass graft surgery is associated with high mortality and substantial additive cost.

METHODS AND RESULTS

This prospective and descriptive study of 4801 patients having coronary bypass graft surgery with cardiopulmonary bypass from November 1996 to June 2000 at 70 centers in 16 countries established associations between predictor variables and postoperative renal composite (renal dysfunction and/or renal failure) from a cohort of 2381 patients and developed a risk index assessed in a validation cohort of 2420 patients. Postoperative renal composite occurred in 231 patients (4.8%). Independent and significant risk factors were age >75 years (odds ratio [OR], 2.04; 95% confidence interval [CI], 1.23 to 3.37; P=0.006), preoperative congestive heart failure (OR, 2.38; CI, 1.55 to 3.64; P<0.001), prior myocardial infarction (OR, 1.75; CI, 1.08 to 2.83; P=0.023), preexisting renal disease (OR, 3.71; CI, 2.41 to 5.70; P<0.001), intraoperative multiple inotrope use (OR, 2.75; CI, 1.75 to 4.31; P<0.001), intraoperative intra-aortic balloon pump insertion (OR, 4.41; CI, 2.21 to 8.80; P<0.001), cardiopulmonary bypass >2 hours (OR, 1.78; CI, 1.15 to 2.74; P=0.01), and preoperative pulse pressure such that for every additional 20-mm Hg increment in pulse pressure >40 mm Hg, there was an OR of 1.49 (CI, 1.17 to 1.89; P=0.001). Patients with pulse pressure hypertension >80 mm Hg were 3 times more likely to die a renal-related death compared with those without (3.7% versus 1.1%).

CONCLUSIONS

Beside established risk factors, pulse pressure is independently and significantly associated with increased renal composite.

Long-term results of RITA-1 trial: clinical and cost comparisons of coronary angioplasty and coronary-artery bypass grafting. Randomised Intervention Treatment of Angina

BACKGROUND

Percutaneous transluminal coronary angioplasty (PTCA) and coronary-artery bypass grafting (CABG) are both effective intervention strategies for patients with coronary heart disease. We report comparative long-term clinical and health-service cost findings for these interventions in the first Randomised Intervention Treatment of Angina (RITA-1) trial.

METHODS

1011 patients with coronary heart disease (45% single-vessel, 55% multivessel) were randomly assigned initial treatment strategies of PTCA or CABG. Information on clinical events, subsequent intervention, symptomatic status, exercise testing, and use of health-care resources is available for a median 6.5 years of follow-up. Analyses were by intention to treat.

FINDINGS

The predefined primary endpoint of death or nonfatal myocardial infarction occurred in 87 (17%) PTCA-group patients and 80 (16%) CABG-group patients (p=0.64). Similarly, there was no significant treatment difference in deaths alone (39 PTCA, 45 CABG), of which 46% were cardiac related. In both groups, the risk of cardiac death or myocardial infarction was more than five times higher in the first year than in subsequent years of follow-up. 26% of patients assigned PTCA subsequently also had CABG, and a further 19% required additional nonrandomised PTCA. Most of these reinterventions occurred within a year of randomisation, and from 3 years onwards the reintervention rate averaged 4% per year. In the CABG group the reintervention rate averaged 2% per year. The prevalence of angina was consistently higher in the PTCA group, with an absolute average 10% excess compared with the CABG group (p<0.001). Total health-service costs over 5 years showed no significant difference between initial strategies of PTCA and CABG (mean difference pounds sterling 426 [95% Cl -pounds sterling 383 to pounds sterling 1235]; p=0.30). The clinical and cost comparisons showed similar patterns for patients with single-vessel and multivessel disease.

INTERPRETATION

Initial strategies of PTCA and CABG led to similar long-term results in terms of survival and avoidance of myocardial infarction and to similar long-term health-care costs. Choice of approach, therefore, rests on weighing the more invasive nature of CABG against the greater risk of recurrent angina and reintervention over many years after PTCA.

Reduced postoperative blood loss and transfusion requirement after beating-heart coronary operations: a prospective randomized study

OBJECTIVE

Coronary artery bypass grafting on the beating heart through median sternotomy is a relatively new treatment, which allows multiple revascularization without the use of cardiopulmonary bypass. A prospective randomized study was designed to investigate the effect of coronary bypass with or without cardiopulmonary bypass on postoperative blood loss and transfusion requirement.

METHODS

Two hundred patients with coronary artery disease were prospectively randomized to (1) on-pump treatment with conventional cardiopulmonary bypass and cardioplegic arrest and (2) off-pump treatment on the beating heart. Postoperative blood loss identified as total chest tube drainage, transfusion requirement, and related costs together with hematologic indices and clotting profiles were analyzed.

RESULTS

There was no difference between the groups with respect to preoperative and intraoperative patient variables. The mean ratio of postoperative blood loss and 95% confidence interval between groups was 1.64 and 1.39 to 1.94, respectively, suggesting on average a postoperative blood loss 1.6 times higher in the on-pump group compared with the off-pump group. Seventy-seven patients in the off-pump group required no blood transfusion compared with only 48 in the on-pump group (P <.01). Furthermore, less than 5% of patients in the on-pump group required fresh frozen plasma and platelet transfusion compared with 30% and 25%, respectively, in the on-pump group (both P <.05). Mean transfusion cost per patient was higher in the on-pump compared with that in the off-pump group ($184.8 +/- $35.2 vs $21.47 +/- $6.9, P <.01).

CONCLUSIONS

Coronary artery bypass grafting on the beating heart is associated with a significant reduction in postoperative blood loss, transfusion requirement, and transfusion-related cost when compared with conventional revascularization with cardiopulmonary bypass and cardioplegic arrest.

Determinants of hospital charges for coronary artery bypass surgery: the economic consequences of postoperative complications

This is a prospective study of 500 consecutive patients having coronary artery bypass surgery; mean hospital charge from time of surgery to discharge was +11,900 +/- 12,700. Multiple regression analysis was performed using preoperative variables and postoperative complications. No preoperative clinical feature was a significant predictor of higher average charge. Sternal wound infection (p = 0.0001), respiratory failure (p = 0.0001) and left ventricular failure (p = 0.017) were associated with higher average hospital charge. The absence of any complication predicted a lower average charge, and postoperative death (4.4 +/- 4.5 days after surgery) was also associated with lower average charge. A cost equation was developed: hospital charge equalled $11,217 + $41,559 of sternal wound infection, + $28,756 for respiratory failure, + $5,186 for left ventricular failure, - $1,798 for no complication and - $6,019 for death. Recognition of the influence of complications on charges suggests that low average charges can only be achieved by surgical programs with a low complication rate.

Cardiac rehabilitation participation predicts lower rehospitalization costs

The effect of participation in cardiac rehabilitation on medical costs was determined by measuring hospitalization charges for cardiac admissions over a 3-year period in 580 post-coronary event patients (58% after coronary bypass surgery, 42% after myocardial infarction), of whom 230 entered a cardiac rehabilitation program and 350 did not. Baseline left ventricular ejection fraction was similar in entrants and nonentrants (59.9% vs 59.5%). Over the 1 to 46-month follow-up period (mean 21 months), per capita hospitalization charges for participants in cardiac rehabilitation were $739 lower than charges for nonparticipants ($1197 +/- 3911 vs $1936 +/- 5459, p = 0.022). This was due to both a lower incidence of hospitalizations and lower charges per hospitalization. Inasmuch as groups differed with regard to age, sex, diagnostic category, and smoking status, data were adjusted for these baseline differences by means of analysis of covariance. Rehospitalization charges remained significantly higher in nonparticipants (p = 0.015). Because physician charges were not measured, the cost differential between groups is underestimated. Results of this study show an association between participation in comprehensive cardiac rehabilitation and lowered cardiac rehospitalization costs in the years after an acute coronary event.

Economic outcome of off-pump coronary artery bypass surgery: a prospective randomized study

BACKGROUND

Emphasis on cost containment in coronary artery bypass surgery is becoming increasingly important in modern hospital management. The revival of interest in off-pump (beating heart) coronary artery bypass surgery may influence the economic outcome. This study examines these effects.

METHODS

Two hundred patients undergoing first-time coronary artery bypass surgery were prospectively randomized to either conventional cardiopulmonary bypass and cardioplegic arrest or off-pump surgery. Variable and fixed direct costs were obtained for each group during operative and postoperative care. The data were analyzed using parametric methods.

RESULTS

There was no difference between the groups with respect to pre- and intraoperative patient variables. Off-pump surgery was significantly less costly than conventional on-pump surgery with respect to operating materials, bed occupancy, and transfusion requirements (total mean cost per patient: on pump, $3,731.6+/-1,169.7 vs off-pump, $2,615.13+/-953.6; p < 0.001). Morbidity was significantly higher in the on-pump group, which was reflected in an increased cost.

CONCLUSIONS

Off-pump revascularization offers a safe, cost-effective alternative to conventional coronary revascularization with cardiopulmonary bypass and cardioplegic arrest.

Off-pump surgery decreases postoperative complications and resource utilization in the elderly

BACKGROUND

Bypass surgery in the elderly (age >70 years) has increased mortality and morbidity, which may be a consequence of cardiopulmonary bypass. We compare the outcomes of a cohort of elderly off-pump coronary artery bypass (OPCAB) patients with elderly conventional coronary artery bypass grafting (CABG) patients.

METHODS

Chart and provincial cardiac care registry data were reviewed for 30 consecutive elderly OPCAB patients (age 74.7 +/- 4.2 years) and 60 consecutive CABG patients (age 74.9 +/- 4.1 years, p = 0.82) with similar risk factor profiles: Parsonnet score 17.2 +/- 8.1 (OPCAB) versus 15.6 +/- 6.5 (CABG), p = 0.31; and Ontario provincial acuity index 4.5 +/- 1.9 (OPCAB) versus 4.3 +/- 2.0 (CABG), p = 0.65.

RESULTS

Mean hospital stay was 6.3 +/- 1.8 days for OPCAB patients and 7.7 +/- 3.9 days for CABG patients (p < 0.05). Average intensive care unit stay was 24.0 +/- 10.9 h for OPCAB patients versus 36.6 +/- 33.5 h for CABG patients (p < 0.05). Atrial fibrillation occurred in 10.0% of OPCAB patients and 28.3% of CABG patients (p < 0.05). Low output syndrome was observed in 10% of OPCAB patients and 31.7% of CABG patients (p < 0.05). Cost was reduced by $1,082 (Canadian) per patient in the OPCAB group. Postoperative OPCAB graft analysis showed 100% patency.

CONCLUSIONS

OPCAB is safe in the geriatric population and significantly reduces postoperative morbidity and cost.

Three-Year Outcome After Coronary Stenting Versus Bypass Surgery for the Treatment of Multivessel Disease

Background— The primary results of Arterial Revascularization Therapy Study reported a greater need for repeated revascularization after percutaneous coronary intervention with stenting (PCI). However, PCI was less expensive than coronary artery bypass grafting (CABG) and offered the same degree of protection against death, stroke, and myocardial infarction.

Methods and Results— Patients with multivessel disease (n=1205) were randomly assigned to either CABG or PCI and followed up for up to 3 years. Survival rates without stroke or myocardial infarction were similar in each group at 1 year and 3 years (90.5% versus 91.4% for PCI versus CABG at 1 year and 87.2% versus 88.4% for PCI versus CABG at 3 years). However, the respective repeat revascularization rates were 21.2% and 26.7% at 1 and 3 years in patients allocated to PCI, compared with 3.8% and 6.6% in patients allocated to CABG ( P <0.0001). Diabetes ( P <0.0009) and maximal pressure for stent deployment ( P <0.002) are the strongest independent predictors of events at 3 years after PCI, whereas left anterior descending coronary artery grafting ( P <0.006) is the best predictor of event-free survival at 3 years after CABG. The incremental cost of surgery compared with PCI for an event-free patient was 19 257 at 1 year but decreased to 10 492 at 3 years. It remained at 142 391 at 3 years when revascularization procedures were excluded in the efficacy end point, however.

Conclusions— Three-year survival rates without stroke and myocardial infarction are identical in both groups, and the cost/benefit ratio of stenting is determined primarily by the increasing need for revascularization in the PCI group.

Quality of care information makes a difference: an analysis of market share and price changes after publication of the New York State Cardiac Surgery Mortality Reports

OBJECTIVES

Quality report cards are becoming increasingly more common and receive much publicity. They can have significant impact on competition among providers, costs, and quality of health care. The authors test the hypotheses that hospitals and surgeons with better outcomes reported in the NYS Cardiac Surgery Reports experience a relative increase in their market share and prices.

METHODS

Information from the New York State Cardiac Surgery Reports was linked with physicians' claims submitted to Medicare and was used to calculate market shares and average prices for hospitals and physicians performing CABG surgeries. Regression models were estimated to test hypotheses. All 30 hospitals offering coronary artery bypass graft (CABG) were studied as well as a majority of surgeons (114 or approximately 80%) performing CABG surgery in New York State during the 1990-1993 period.

RESULTS

Findings indicate that hospitals and physicians with better outcomes experienced higher rates of growth in market shares. Physicians with better outcomes also had higher rates of growth in charges for this procedure.

CONCLUSIONS

Patients (and referring physicians) seem to respond to information about quality of individual surgeons and hospitals as expected. The magnitude of the association between reported mortality and market shares varies geographically, potentially reflecting differences in sociodemographic characteristics. The association tends to decline over time, suggesting that it is primarily due to "new" information.

Nationwide volume and mortality after elective surgery in cirrhotic patients

BACKGROUND

The outcomes after elective surgery in patients with cirrhosis have not been well studied.

STUDY DESIGN

We used the Nationwide Inpatient Sample (NIS) to identify all patients undergoing elective surgery for four index operations (cholecystectomy, colectomy, abdominal aortic aneurysm repair, and coronary artery bypass grafting) from 1998 to 2005. Elixhauser comorbidity measures were used to characterize patients' disease burden. Three distinct groups were created based on severity of liver disease: patients without cirrhosis (NON-CIRR), those with cirrhosis (CIRR), and patients with cirrhosis complicated by portal hypertension (PHTN). In-hospital mortality was the primary endpoint.

RESULTS

There were 22,569 patients with cirrhosis (of whom 4,214 had PHTN) who underwent 1 of the 4 index operations compared with approximately 2.8 million patients without cirrhosis having these operations. Patients with CIRR or PHTN were more likely to be women (49.5% versus 44.0%, p < 0.0001) and were less likely to be treated in a large hospital (62.8% versus 67.6%, p < 0.0001) than NON-CIRR patients. Length of hospital stay and total charges per hospitalization increased with severity of liver disease for all operations (p < 0.001, respectively). Adjusted mortality rates increased with increasing liver disease for each operation (cholecystectomy: CIRR hazard ratio [HR] 3.4, 95% CI 2.3 to 5.0; PHTN HR 12.3, 95% CI 7.6 to 19.9; colectomy: CIRR HR 3.7, 95% CI 2.6 to 5.2; PHTN HR 14.3, 95% CI 9.7 to 21.0; coronary artery bypass grafting: CIRR HR 8.0, 95% CI 5.0 to 13.0, PHTN HR 22.7, 95% CI 10.0 to 53.8; abdominal aortic aneurysm: CIRR HR 5.0, 95% CI 2.6 to 9.8, PHTN HR 7.8, 95% CI 2.3 to 26.5).

CONCLUSIONS

In-hospital mortality, length of stay, and total hospital charges are significantly higher after elective surgery in cirrhotic patients, even in the absence of portal hypertension. Careful decision-making about surgery in these patients is critical as the nationwide increase in hepatitis C and cirrhosis continues.