Cost-effectiveness analysis in heart disease, Part III: Ischemia, congestive heart failure, and arrhythmias

Cost-effectiveness analyses were reviewed in the following diagnostic and treatment categories: acute myocardial infarction (MI) and diagnostic strategies for coronary artery disease (CAD), coronary artery bypass graft (CABG) surgery, percutaneous transluminal coronary angioplasty (PTCA), congestive heart failure (CHF), and arrhythmias. In the case of acute MI, coronary care units, as presently used, are rather expensive but could be made much more efficient with more effective triage and resource utilization; reperfusion via thrombolysis is cost-effective, as are beta-blockers and angiotensin-converting enzyme (ACE) inhibitors post-MI in appropriate patients. Cost-effectiveness of CAD screening tests depends strongly on the prevalence of disease in the population studied. Cost-effectiveness of CABG surgery depends on targeting; eg, it is highly effective for such conditions as left-main and three-vessel disease but not for lesser disease. PTCA appears to be cost-effective in situations where there is clinical consensus for its use, eg, severe ischemia and one-vessel disease, but requires further analysis based on randomized data; coronary stents also appear to be cost-effective. In preliminary analysis, ACE inhibition for CHF dominates, ie, saves both money and lives. Cardiac transplant appears to be cost-effective but requires further study. For arrhythmias, implantable cardioverter defibrillators are cost-effective, especially the transvenous device, in life-threatening situations; radiofrequency ablation is also cost-effective in patients with Wolff-Parkinson-White syndrome apart from asymptomatic individuals; and pacemakers have not been analyzed except in the case of biofascicular block, where results were variable depending on the situation and preceding tests.

The New Zealand priority criteria project. Part 2: Coronary artery bypass graft surgery

Priority criteria developed during a national project were used to conduct an audit of all 662 patients on waiting lists for coronary artery bypass surgery in New Zealand during spring 1996. Based on the observed distribution of priority scores, the cost of providing surgery to all patients down to various levels of priority was estimated. Descriptions incorporating life expectancy and quality of life implications of surgery were developed of the kinds of patients who would or would not receive surgery at each of several possible funding levels. Cardiologists and cardiac surgeons agreed that a threshold of 25 points was a reasonable clinical goal but to work with a threshold of 35, which can be sustained with current levels of funding. All agree that the gap between these clinically preferred and currently afforded thresholds is a subject for wider societal dialogue and decision. The ability to measure the size of the gap between clinical desirability and financial sustainability provides a new transparency to the problem of healthcare resource allocation.

Effect of surgical training on outcome and hospital costs in coronary surgery

BACKGROUND

There is a perceived conflict between the need for service provision and surgical training within the National Health Service (NHS). Trainee surgeons tend to be slower (thereby reducing theatre throughput), and may have more complications (increasing hospital stay and costs).

OBJECTIVE

To quantify the effect of training on outcome and costs.

DESIGN

Data on 2740 consecutive isolated coronary artery bypass (CABG) operations were analysed retrospectively. Redo and emergency procedures were excluded. The seniority of the operating surgeon was related to operating times, risk stratified outcome, and overall hospital costs.

SETTING

Regional cardiothoracic surgery unit.

MAIN OUTCOME MEASURES

Postoperative mortality; hospital costs.

RESULTS

Consultants, senior trainees, intermediate trainees, and junior trainees performed 1524, 759, 434, and 23 procedures, respectively. Trainees at the three different levels were directly supervised by a consultant in 55%, 95%, and 100% of cases. The unadjusted mortalities were 3.2%, 2.0%, 2.3%, and 4.3%, respectively (NS). There were no significant differences between the groups with respect to time in the intensive care unit and length of hospital stay. The mean cost per patient was pound6619, pound6572, pound6494, and pound6404 (NS).

CONCLUSIONS

Trainees performed 44.4% of all CABG operations. There was no detrimental effect on patient outcome, length of hospital stay, or overall hospital costs. There need be little conflict between service and training needs, even in hospitals with extensive training programmes.

Clinical effectiveness and cost-effectiveness of immediate angioplasty for acute myocardial infarction: systematic review and economic evaluation

OBJECTIVES

To review the clinical evidence comparing immediate angioplasty with thrombolysis, and to consider whether it would be cost-effective.

DATA SOURCES

Electronic databases. Experts in the field.

REVIEW METHODS

For clinical effectiveness, a comprehensive review of randomised control trials (RCTs) was used for efficacy, and a selection of observational studies such as case series or audit data used for effectiveness in routine practice. RCTs of thrombolysis were used to assess the relative value of prehospital and hospital thrombolysis. Observational studies were used to assess the representativeness of patients in the RCTs, and to determine whether different groups have different capacity to benefit. Clinical effectiveness was synthesised through a narrative review with full tabulation of results of all included studies and a meta-analysis to provide a precise estimate of absolute clinical benefit. Consideration was given to the effect of the growing use of stents. The economic modelling adopted an NHS perspective to develop a decision-analytical model of cost-effectiveness focusing on opportunity costs over the short term (6 months).

RESULTS

The results were consistent in showing an advantage of immediate angioplasty over hospital thrombolysis. The updated meta-analysis showed that mortality is reduced by about one-third, from 7.6% to 4.9% in the first 6 months, and by about the same in studies of up to 24 months. Reinfarction is reduced by over half, from 7.6% to 3.1%. Stroke is reduced by about two-thirds, from 2.3% with thrombolysis to 0.7% with percutaneous coronary intervention (PCI), with the difference being due to haemorrhagic stroke. The need for coronary artery bypass graft is reduced by about one-third, from 13.2% to 8.4%. Caution is needed in interpreting some of the older trials, as changes such as an increase in stenting and the use of the glycoprotein IIb/IIa inhibitors may improve the results of PCI. There is little evidence comparing prehospital thrombolysis with immediate PCI. Research on thrombolysis followed by PCI, known as 'facilitated PCI', is underway, but results are not yet available. Trials may be done in select centres and results may not be as good in lower volume centres, or out of normal working hours. In addition, much of the marginal mortality benefit of PCI over hospital thrombolysis may be lost if door-to-balloon time were more than an hour longer than door-to-needle time. Conversely, within the initial 6 hours, the later patients present, the greater the relative advantage of PCI. Results suggest that PCI is more cost-effective than thrombolysis, providing additional benefits in health status at some extra cost. In the longer term, the cost difference is expected to be reduced because of higher recurrence and reintervention rates among those who had thrombolysis.

CONCLUSIONS

If both interventions were routinely available, the economic analysis favours PCI, given the assumptions of the model. However, very few units in England could offer a routine immediate PCI service at present, and there would be considerable resource implications of setting up such services. Without a detailed survey of existing provision, it is not possible to quantify the implications, but they include both capital and revenue: an increase in catheter laboratory provision and running costs. The greatest problem would be staffing, and that would take some years to resolve. A gradual incrementalist approach based on clinical networks, with transfer to centres able to offer PCI, may be used. In rural areas, one option may be to promote an increase in prehospital thrombolysis, with PCI for thrombolysis failures. There is a need for data on the long-term consequences of treatment, the quality of life of patients after treatment, and the effects of PCI following thrombolysis failure.

Relative cost of coronary angioplasty and bypass surgery in a one-vessel disease model

A national study was carried out to determine the relative costs of PTCA and CABG. Baseline clinical criteria for the 2 groups were similar. Data were collected in 186 sets for the PTCA group and 175 sets for the CABG group. Male patients make up 81% of the PTCA group and 80% of the CABG group. Mean hospital stay was 12 +/- 5 days in the CABG group, compared with 4 +/- 2 days in the PTCA group (p less than 0.001). The base charges for hospital and professional components of the CABG procedure were $15,580 +/- $2,159, whereas the same charges for the PTCA procedure were $5,315 +/- $2,159 (p less than 0.001). With an 80% primary success rate, which was the group mean success rate, the average dollar savings per PTCA procedure would be $7,149, or $7,149,000 per 1,000 cases. Thus, PTCA for revascularization in 1-vessel CAD is significantly more cost-effective than CABG in the short term.

Mechanisms to reduce hospital stays

BACKGROUND

The present era of medicine is concerned to a large measure with cost containment and the advent of managed care. For these reasons the concept of reducing hospital stays with a concomitant reduction in hospital cost is very attractive. The role of fast track is to ensure that we are not placing the patient at any additional risk and in fact are improving recovery and patient well-being.

METHODS

Fast track is based on a specific protocol that is followed for each patient. Intensive preoperative education of patient and family familarize them with early discharge. Anesthetic technique is modified to effect early (4 to 8 hours) postoperative extubation. Steroids are administered perioperatively to improve myocardial function and reduce the release of inflammatory mediators. Digoxin is given prophylactically as are the bowel-mediating drugs metoclopramide, docusate, and ranitidine. The fast-track protocol is associated with aggressive ambulation of the patients and cardiac rehabilitation, so that the patient is out of bed the first day after operation, walking in the hall the second day, and up a flight of stairs the third day.

RESULTS

A shift to fast track in 1992 permitted comparison between 282 non-fast-track patients and 280 fast-track patients undergoing coronary artery bypass grafting. The results showed no adverse consequences of fast track. Forty-eight percent of fast-track patients were discharged at 3 to 5 days compared with 26% of non-fast-track patients. No significant differences were found between the two groups with respect to infection (1%), operative mortality (approximately 4%), and 30-day hospital readmission (7% non-fast-track and 8% fast-track). A postdischarge questionnaire addressed issues of patient and family satisfaction. The early discharge patient had a 77% comfort level, whereas their family members felt satisfied with a 3- to 5-day hospital stay in only 54% of cases. These data suggest the need for better communication, education, and additional postdischarge support systems.

CONCLUSIONS

A fast-track protocol allows faster recovery and earlier discharge from both the intensive care unit and the hospital without apparent increased risk. Complicated patients can also be fast tracked, and the desire to do so may actually expedite recovery.

The effect of cost-containment policies on rates of coronary revascularization in California

BACKGROUND

Lower rates of use of resources have been reported for the treatment of hospitalized patients covered by Medicaid than for privately insured patients. Cost-containment policies may exacerbate such differences in the use of hospital resources. We studied patients with ischemic heart disease who received care at nonfederal hospitals in California in 1983 (the year a Medicaid cost-containment program was implemented), in 1985, or in 1988. Within this sample of patients, we compared the rates of coronary revascularization (coronary-artery bypass surgery or coronary angioplasty) among patients covered by Medicaid, patients with private insurance covering fee-for-service care, and patients enrolled in a health maintenance organization (HMO).

METHODS

Logistic-regression models were used to determine adjusted odds ratios for the use of coronary revascularization procedures in patients with different types of insurance, with control for demographic, clinical, and hospital characteristics. The study samples were made up of 49,167 patients in 1983, 47,809 in 1985, and 44,631 in 1988.

RESULTS

The frequency of revascularization increased in all three insurance groups from 1983 to 1988, but it did so much faster in the fee-for-service and HMO groups than in the Medicaid group. Patients with private fee-for-service insurance were 1.66 times as likely as Medicaid patients to undergo revascularization in 1983 (P < 0.01), 2.01 times as likely in 1985 (P < 0.01) and 2.33 times as likely in 1988 (P < 0.01). Patients enrolled in HMOs were 0.96 times as likely as Medicaid patients to undergo revascularization in 1983 (P < 0.05), 1.23 times as likely in 1985 (P < 0.01), and 1.53 times as likely in 1988 (P < 0.01).

CONCLUSIONS

The frequency of coronary revascularization in California in 1983 was nearly twice as high for patients with private fee-for-service insurance as for patients enrolled in HMOs or for Medicaid recipients. The implementation that year of stringent cost-control measures by Medicaid may explain the slower increase in the frequency of revascularization over five year among Medicaid recipients as compared with patients in the fee-for-service and HMO groups. Different incentives in fee-for-service and HMO practice may explain the lower frequency of revascularization among patients enrolled in HMOs, although the rates of increase for these two groups were about the same from 1983 to 1988.

Physician response to Medicare fee reductions: changes in the volume of coronary artery bypass graft (CABG) surgeries in the Medicare and private sectors

The demand inducement hypothesis predicts that physicians will respond to reductions in their income by increasing the volume of their services when the income effect is strong and negative. I test for such inducement in the market for coronary artery bypass grafting (CABG), using a longitudinal panel of physicians in New York and Washington states. The results show that physicians whose incomes were reduced the most by Medicare fee cuts performed higher volumes of CABGs, and they did so in both the Medicare and private markets.

Outcomes and cost of coronary artery bypass graft surgery in the United States and Canada

BACKGROUND

We sought to determine whether there is a difference in in-hospital outcomes and costs for coronary artery bypass graft surgery (CABG) between the United States and Canada.

METHODS

We compared the outcomes and costs of treating 12 017 consecutive patients (4698 US and 7319 Canadian patients) undergoing CABG at 5 US and 4 Canadian hospitals. Participating hospitals used the same cost accounting system to provide patient-level clinical, resource utilization, and cost-of-treatment data (excluding physicians' fees). Canadian costs were converted to US dollars using purchasing power parities.

RESULTS

Compared with Canadian patients, US patients were older (mean +/- SD age, 68.0 +/- 10.4 vs 63.7 +/- 9.8 years [P<.001]), more likely to be female (27.4% vs 21.8% [P<.001]), and discharged from the hospital sooner (mean +/- SD length of stay, 8.7 +/- 0.1 vs 9.5 +/- 0.1 days [P<.001]). In-hospital costs of treatment were substantially higher in the United States than in Canada (mean +/- SD cost, dollar 20,673 +/- dollar 241 vs dollar 10,373 +/- dollar 123 [P<.001]; median, dollar 16,036 vs dollar 7880). After controlling for demographic and clinical differences, length of stay in Canada was 16.8% longer than in the United States; there was no difference in in-hospital mortality; and the cost in the United States was 82.5% higher than in Canada (P<.001).

CONCLUSIONS

The in-hospital cost of CABG in the United States is substantially higher than in Canada. This difference is due to higher direct and overhead costs in US hospitals, is not explained by demographic or clinical differences, and does not lead to superior clinical outcomes.

Cost reduction by combined carotid endarterectomy and coronary artery bypass grafting

A significant cost reduction is likely if patients who require coronary artery bypass grafting with significant carotid stenosis have simultaneous carotid endarterectomy and bypass grafting, provided risk is not increased. To investigate this issue, we retrospectively identified cases from February 1977 to May 1994 with first-time isolated carotid endarterectomy, coronary bypass, or combined procedures. In the isolated carotid endarterectomy population, median age was 69 years and 58% (85/146) were male, as compared with 68 years and 68% (68/100) male in the combined group; median age of the coronary bypass cohort was 65 years and 76% (381/500) male. A significantly higher percentage of patients in the coronary bypass versus combined group were in New York Heart Association functional class IV. In the combined group there was a significantly higher incidence of older age, diabetes, hypertension, hyperlipidemia, renal failure, and congestive heart failure. There was no difference among the three groups with respect to hospital mortality (0%, 3.4%, and 4.0%, respectively) and permanent stroke (0.7%, 1.2%, and 0%, respectively). Hospital costs were $4,896, $10,959 and $11,089, respectively, with a savings of $4,766 (30%), and Medicare hospital reimbursement was $8,575, $23,071, and $23,071, respectively, with a savings of $10,077 (25.3%). Thus, in appropriate patients, a combined procedure is cost effective, eliminating a second surgical procedure and the cost of the postoperative stay (3.7 +/- 2.4 days) associated with isolated carotid endarterectomy. Risk of permanent stroke or death is not increased.

A multi-centre randomised controlled trial of minimally invasive direct coronary bypass grafting versus percutaneous transluminal coronary angioplasty with stenting for proximal stenosis of the left anterior descending coronary artery

OBJECTIVES

To compare the clinical- and cost-effectiveness of minimally invasive direct coronary artery bypass grafting (MIDCAB) and percutaneous transluminal coronary angioplasty (PTCA) with or without stenting in patients with single-vessel disease of the left anterior descending coronary artery (LAD).

DESIGN

Multi-centre randomised trial without blinding. The computer-generated sequence of randomised assignments was stratified by centre, allocated participants in blocks and was concealed using a centralised telephone facility.

SETTING

Four tertiary cardiothoracic surgery centres in England.

PARTICIPANTS

Patients with ischaemic heart disease with at least 50% proximal stenosis of the LAD, suitable for either PTCA or MIDCAB, and with no significant disease in another vessel.

INTERVENTIONS

Patients randomised to PTCA had local anaesthetic and underwent PTCA according to the method preferred by the operator carrying out the procedure. Patients randomised to MIDCAB had general anaesthetic. The chest was opened through an 8-10-cm left anterior thoracotomy. The ribs were retracted and the left internal thoracic artery (LITA) harvested. The pericardium was opened in the line of the LAD to confirm the feasibility of operation. The distal LITA was anastomosed end-to-side to an arteriotomy in the LAD. All operators were experienced in carrying out MIDCAB.

MAIN OUTCOME MEASURES

The primary outcome measure was survival free from cardiac-related events. Relevant events were death, myocardial infarction, repeat coronary revascularisation and recurrence of symptomatic angina or clinical signs of ischaemia during an exercise tolerance test at annual follow-up. Secondary outcome measures were complications, functional outcome, disease-specific and generic quality of life, health and social services resource use and their costs.

RESULTS

A total of 12,828 consecutive patients undergoing an angiogram were logged at participating centres from November 1999 to December 2001. Of the 1091 patients with proximal stenosis of the LAD, 127 were eligible and consented to take part; 100 were randomised and the remaining 27 consented to follow-up. All randomised participants were included in an intention-to-treat analysis of survival free from cardiac-related events, which found a non-significant benefit from MIDCAB. Cumulative hazard rates at 12 months were estimated to be 7.1 and 9.2% for MIDCAB and PTCA, respectively. There were no important differences between MIDCAB and PTCA with respect to angina symptoms or disease-specific or generic quality of life. The total NHS procedure costs were 1648 British pounds and 946 British pounds for MIDCAB and PTCA, respectively. The costs of resources used during 1 year of follow-up were 1033 British pounds and 843 British pounds, respectively.

CONCLUSIONS

The study found no evidence that MIDCAB was more effective than PTCA. The procedure costs of MIDCAB were observed to be considerably higher than those of PTCA. Given these findings, it is unlikely that MIDCAB represents a cost-effective use of resources in the reference population. Recent advances in cardiac surgery mean that surgeons now tend to carry out off-pump bypass grafting via a sternotomy instead of MIDCAB. At the same time, cardiologists are treating more patients with multi-vessel disease by PTCA. Future primary research should focus on this comparison. Other small trials of PTCA versus MIDCAB have now finished and a more conclusive answer to the original objective could be provided by a systematic review.

U.S. Trends In CABG Hospital Volume: The Effect Of Adding Cardiac Surgery Programs

Hospital coronary artery bypass graft (CABG) volume is inversely related to mortality--with low-volume hospitals having the highest mortality. Medicare data (1992-2003) show that the number of CABG procedures increased from 158,000 in 1992 to a peak of 190,000 in 1996 and then fell to 152,000 in 2003, while the number of hospitals performing CABG increased steadily. Predictably, the proportion of CABG procedures performed at low-volume hospitals increased, and the proportion in high-volume hospitals declined. An unintended consequence of starting new cardiac surgery programs is declining CABG hospital volume--a side effect that might increase mortality.

Mortality, morbidity, and cost-accounting related to coronary artery bypass graft surgery in the elderly

The purpose of this study was to document early mortality, perioperative complication rate, duration of hospitalization, and costs related to coronary artery bypass graft (CABG) surgery in the elderly. Arbitrarily, elderly patients were defined by age greater than or equal to 65 years; younger patients were less than or equal to 60 years old. A detailed list of specific perioperative complications was analyzed. Early (30-day) mortality was similar between groups, while 120-day mortality was higher among elderly compared with younger patients (7.6% versus 1.3%; p = 0.05). The number of elderly patients with 1 or more complications was also higher than among the younger patients (62% versus 43%; p = 0.05). When the incidences of atrial arrhythmias and transient psychoses were considered minor complications and excluded from consideration, the incidence of major complications was higher in the elderly: 41 major events among 76 younger surviving patients compared with 89 major complications in 61 older surviving patients (p = 0.001). Time spent in the intensive care unit and the duration of postoperative hospitalization were also greater in the elderly (p = 0.01 and p = 0.001, respectively). Finally, the elderly group incurred greater costs than the younger patients (p = 0.03). The likelihood of increased perioperative morbidity in elderly patients is documented in this study. Also, it appears that the increased frequency of complications in elderly patients is associated with a longer hospital stay and greater financial expense. Consequently, the careful preoperative evaluation of these patients, including cautious patient selection, assumes greater importance. After CABG procedures, the highly symptomatic elderly patient may experience dramatic relief of symptoms.(ABSTRACT TRUNCATED AT 250 WORDS)

Economic analysis of treatments reducing coronary heart disease mortality in England and Wales, 2000-2010

BACKGROUND

Coronary heart disease (CHD) in the UK affects approximately 3 million people, with >100,000 deaths annually. Mortality rates have halved since the 1980s, but annual NHS treatment costs for CHD exceed 2 billion pounds.

AIM

To examine the cost-effectiveness of specific CHD treatments in England and Wales.

METHODS

The IMPACT CHD model was used to calculate the number of life-years gained (LYG) from specific cardiological interventions from 2000 to 2010. Cost-effectiveness ratios (costs per LYG) were generated for each specific intervention, stratified by age and sex. The robustness of the results was tested using sensitivity analyses.

RESULTS

In 2000, medical and surgical treatments together prevented or postponed approximately 25,888 deaths in CHD patients aged 25-84 years, thus generating approximately 194,929 extra life-years between 2000 and 2010 (range 143,131-260,167). Aspirin and beta-blockers for secondary prevention following myocardial infarction or revascularisation, for angina and heart failure were highly cost-effective (< 1000 pounds per LYG). Other secondary prevention therapies, including cardiac rehabilitation, ACE inhibitors and statins, were reasonably cost-effective (1957 pounds, 3398 pounds and 4246 pounds per LYG, respectively), as were CABG surgery (3239 pounds-4601 pounds per LYG) and angioplasty (3845 pounds-5889 pounds per LYG). Primary angioplasty for myocardial infarction was intermediate (6054 pounds-12,057 pounds per LYG, according to age), and statins in primary prevention were much less cost-effective (27,828 pounds per LYG, reaching 69,373 pounds per LYG in men aged 35-44). Results were relatively consistent across a wide range of sensitivity analyses.

DISCUSSION

The cost-effectiveness ratios for standard CHD treatments varied by over 100-fold. Large amounts of NHS funding are being spent on relatively less cost-effective interventions, such as statins for primary prevention, angioplasty and CABG surgery. This merits debate.

Resource utilization for minimally invasive direct and standard coronary artery bypass grafting

BACKGROUND

Minimally invasive direct coronary artery bypass grafting (MIDCABG) has been recently reintroduced into the cardiac surgical armamentarium for selected patients with suitable coronary anatomy. We hypothesized that MIDCABG had the potential for similar immediate results with decreased perioperative morbidity and decreased resource utilization compared with standard coronary artery bypass grafting (CABG).

METHODS

From January 1996 to August 1996, 17 MIDCABG patients were compared with 33 patients with left ventricular ejection fraction greater than 0.50 who underwent CABG with standard technique. No significant differences were observed between the two groups for preoperative variables that are known to affect cost and resource utilization. Length of stay in the hospital was 2.5 +/- 0.8 days for MIDCABG and 5.9 +/- 2 days for CABG (p < 0.0001); length of stay in the intensive care unit was 12.3 +/- 3.3 hours for MIDCABG compared to 32.3 +/- 12.6 hours for the CABG group (p < 0.0001).

RESULTS

Forty-one percent of MIDCABG patients were extubated in the operating room and 59% were discharged home on the first or second postoperative day versus none in the CABG group (p < 0.0001). Significantly less morbidity was observed in the MIDCABG group compared with CABG. Total ratio of cost-to-charge was $12,885 +/- $1,511 for MIDCABG and $21,260 +/- $5,497 for CABG (p < 0.0001), with an average savings of $8,375.

CONCLUSIONS

Minimally invasive CABG is associated with significant reduction of resource utilization and morbidity related to inital hospitalization compared with CABG.

Cost-effectiveness of coronary artery bypass surgery in octogenarians

OBJECTIVE

The objective of this retrospective cohort study was to determine whether coronary artery bypass graft (CABG) surgery is effective and cost-effective relative to medical management of coronary artery disease (CAD) in the elderly.

SUMMARY BACKGROUND DATA

The aging of the U.S population and the improvements in surgical techniques have resulted in increasing numbers of elderly patients who undergo this surgery. The three randomized, controlled trials (RCTs) that established the efficacy of CABG surgery completed patient enrollment from 19 to 24 years ago excluded patients older than 65 years. Although information regarding outcomes of CABG in this population is mainly available in case series, a major lacuna exists with respect to information on quality of life and cost effectiveness of surgery as compared with medical management.

METHODS

The authors retrospectively formed surgical and medically managed cohorts of octogenarians with significant multivessel CAD. More than 600 medical records of patients older than 80 years who underwent angiography at our institution were reviewed to identify 48 patients who were considered reasonable surgical candidates but had not undergone surgery. This cohort was compared with 176 patients who underwent surgery.

RESULTS

The cost per quality-adjusted life year saved was $10,424. At 3 years, survival in the surgical group was 80% as compared with 64% in the entire medical cohort and 50% in a smaller subset of the medical cohort. Quality of life in patients who underwent surgery was measurably better than that of the medical cohort with utility index scores, as measured by the EuroQoL, (a seven-item quality of life questionnaire) of 0.84, 0.61, and 0.74, respectively.

CONCLUSIONS

Performing CABG surgery in octogenarians is highly cost-effective. The quality of life of the elderly who elect to undergo CABG surgery is greater than that of their cohorts and equal to that of an average 55-year-old person in the general population.

Surgery for aortic stenosis in severely symptomatic patients older than 80 years: experience in a single UK centre

OBJECTIVE

To ascertain the surgical risk and long term outcome of patients over 80 years old undergoing aortic valve replacement (AVR).

DESIGN

Consecutive cases with respective case note audit and a telephone questionnaire.

SETTING

Single UK cardiothoracic surgical centre.

PATIENTS

103 (48 male) patients over 80 years old undergoing AVR. The median age was 82 years (80-95 years) and 95 of 103 patients were in New York Heart Association (NYHA) class III or IV.

METHOD AND RESULTS

Preoperative characteristics, operative course, cost, and outcome measures were ascertained. Mean bypass time was 56 minutes and 25 patients had simultaneous coronary artery bypass grafting. Overall mortality was 19 of 103. Univariate analysis of pertinent variables found that impaired renal function and peripheral vascular disease were significantly associated with early postoperative death. 10 of 12 patients requiring ventilation for more than 24 hours died. The 50% actuarial survival was 62 months. Late complications were uncommon with 92% of patients in NYHA class I or II at follow up.

CONCLUSIONS

AVR in patients over 80 years old has a significant risk. However, those patients who survive experience significant benefit with good long term prospects for general health and social independence.

Drivers of Payment Variation in 90-Day Coronary Artery Bypass Grafting Episodes

Importance

Coronary artery bypass grafting (CABG) is scheduled to become a mandatory Medicare bundled payment program in January 2018. A contemporary understanding of 90-day CABG episode payments and their drivers is necessary to inform health policy, hospital strategy, and clinical quality improvement activities. Furthermore, insight into current CABG payments and their variation is important for understanding the potential effects of bundled payment models in cardiac care.

Objective

To examine CABG payment variation and its drivers.

Design, Setting, and Participants

This retrospective cohort study used Medicare and private payer claims to identify patients who underwent nonemergent CABG surgery from January 1, 2012, through October 31, 2015. Ninety-day price-standardized, risk-adjusted, total episode payments were calculated for each patient, and hospitals were divided into quartiles based on the mean total episode payments of their patients. Payments were then subdivided into 4 components (index hospitalization, professional, postacute care, and readmission payments) and compared across hospital quartiles. Seventy-six hospitals in Michigan representing a diverse set of geographies and practice environments were included.

Main Outcomes and Measures

Ninety-day CABG episode payments.

Results

A total of 5910 patients undergoing nonemergent CABG surgery were identified at 33 of the 76 hospitals; of these, 4344 (73.5%) were men and mean (SD) age was 68.0 (9.3) years. At the patient level, risk-adjusted, 90-day total episode payments for CABG varied from $11 723 to $356 850. At the hospital level, the highest payment quartile of hospitals had a mean total episode payment of $54 399 compared with $45 487 for the lowest payment quartile (16.4% difference, P < .001). The highest payment quartile hospitals compared with the lowest payment quartile hospitals had 14.6% higher index hospitalization payments ($34 992 vs $30 531, P < .001), 33.9% higher professional payments ($8060 vs $6021, P < .001), 29.6% higher postacute care payments ($7663 vs $5912, P < .001), and 35.1% higher readmission payments ($3576 vs $2646, P = .06). The drivers of this variation are diagnosis related group distribution, increased inpatient evaluation and management services, higher utilization of inpatient rehabilitation, and patients with multiple readmissions.

Conclusions and Relevance

Wide variation exists in 90-day CABG episode payments for Medicare and private payer patients in Michigan. Hospitals and clinicians entering bundled payment programs for CABG should work to understand local sources of variation, with a focus on patients with multiple readmissions, inpatient evaluation and management services, and postdischarge outpatient rehabilitation care.

Con: beating-heart surgery for coronary revascularization: is it the most important development since the introduction of the heart-lung machine?

Contrary to what the media tend to suggest, beating-heart coronary artery bypass grafting (BHCABG) is not a new technique. It has been performed since the advent of coronary revascularization but, until recently, was largely abandoned in favor of cardiopulmonary bypass (CPB) and cardioplegic techniques. However, with the introduction of minimally invasive coronary surgery and mechanical methods for target-artery stabilization, interest in BHCABG has been renewed. In carefully selected cases, this approach has the advantages of simplicity, avoidance of the inflammatory response caused by CPB, and a decreased need for blood transfusion. Nevertheless, BHCABG may be technically difficult in some patients, and it involves a steep learning curve. Potential risks include incomplete revascularization, ischemia during temporary target-artery occlusion, and suboptimal anastomoses. Because of the need for special equipment, BHCABG can be expensive and time consuming. It may benefit older or sicker patients who are poor candidates for CPB, especially those with left anterior descending or right coronary artery lesions, but it should be used with discretion and not be considered for all coronary patients.

Will the use of low-molecular-weight heparin (enoxaparin) in patients with acute coronary syndrome save costs in Canada?

BACKGROUND

One-year follow-up data from the Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q-Wave Coronary Events (ESSENCE) trial show that use of low-molecular-weight heparin (enoxaparin) compared with unfractionated heparin in patients hospitalized with unstable angina or non-Q-wave myocardial infarction is associated with a 10% reduction in the cumulative 1-year risk of death, myocardial infarction, or recurrent angina. Given the higher acquisition cost of enoxaparin relative to unfractionated heparin, we assessed whether the reduced use of revascularization procedures and related care makes enoxaparin a cost-saving therapy in Canada.

METHODS AND RESULTS

We analyzed cumulative 1-year resource use data on the 1259 ESSENCE patients enrolled in Canadian centers (40% of the total ESSENCE sample). Patient-specific data on use of drugs, diagnostic cardiac catheterization, percutaneous transluminal coronary angioplasty, coronary artery bypass grafting, and hospital days were available from the initial hospital stay and cumulative to 1 year. Hospital resources were costed with the use of data from a teaching hospital in southern Ontario that is a participant in the Ontario Case Costing Project. During the initial hospital stay, use of enoxaparin was associated with reduced use of diagnostic catheterization and revascularization procedures, with the largest effect being reduced use of percutaneous transluminal coronary angioplasty (15.0% vs 10.6%; P =.03). At 1 year, the reduced risk and costs of revascularization more than offset increased drug costs for enoxaparin, producing a cost-saving per patient of $1485 (95% confidence interval $-93 to $3167; P =.06). Sensitivity analysis with lower hospital per diem costs from a community hospital in Ontario still predicts cost savings of $1075 per patient over a period of 1 year.

CONCLUSIONS

The acquisition and administration cost of enoxaparin is higher than for unfractionated heparin ($101 vs $39), but in patients with acute coronary syndrome, the reduced need for hospitalization and revascularization over a period of 1 year more than offsets this initial difference in cost. Evidence from this Canadian substudy of ESSENCE supports the view that enoxaparin is less costly and more effective than unfractionated heparin in this indication.

Cost-effectiveness of bypass surgery versus stenting in patients with multivessel coronary artery disease

PURPOSE

To compare the cost-effectiveness of surgical and angioplasty-based coronary artery revascularization techniques, in particular, angioplasty with primary stenting.

METHODS

We used data from the Study of Economics and Quality of Life, a substudy of the Bypass Angioplasty Revascularization Investigation (BARI), to measure the outcomes and costs of angioplasty and bypass surgery in patients with multivessel coronary artery disease who had not undergone prior coronary artery revascularization. Using a Markov decision model, we updated the outcomes and costs to reflect technology changes since the time of enrollment in BARI, and projected the lifetime costs and quality-adjusted life-years (QALYs) for the two procedures from the time of initial treatment through death. We accounted for the effects of improved procedural safety and efficiency, and prolonged therapeutic effects of both surgery and stenting. This study was conducted from a societal perspective.

RESULTS

Surgical revascularization was less costly and resulted in better outcomes than catheter-based intervention including stenting. It remained the preferred strategy after adjusting the stent outcomes to eliminate the costs and events associated with target lesion restenosis. Among angioplasty-based strategies, primary stent use cost an additional 189,000 US dollars per QALY gained compared with a strategy that reserved stent use for treatment of suboptimal balloon angioplasty results.

CONCLUSION

Bypass surgery results in better outcomes than angioplasty in patients with multivessel disease, and at a lower cost.

Research related to surgical treatment of coronary artery disease

In the past 20 years, basic and clinical research have provided new information on coronary artery surgery. For example, several studies have shown that coronary artery bypass grafting is more effective than medical treatment in relieving the symptoms of chronic disabling angina pectoris. However, we still do not have definitive answers to many questions. What factors in the patient, in the operation and in the care after operation determine success in surgical treatment? Does the operation prolong useful life? Is the operation affordable? These questions are difficult. Further research is needed to solve complex problems relating to surgical vs medical treatment of coronary artery disease.

How did the recent increase in the supply of coronary operations in Finland affect socioeconomic and gender equity in their use?

STUDY OBJECTIVE

To explore how the increased supply of coronary bypass operations and angioplasties from 1988 to 1996 influenced socioeconomic and gender equity in their use.

DESIGN

Register based linkage study; information on coronary procedures from the Finnish Hospital Discharge Register in 1988 and 1996 was individually linked to national population censuses in 1970-1995 to obtain patients' socioeconomic data. Data on both hospitalisations and mortality attributable to coronary heart disease obtained from similar linkage schemes were used to approximate the relative need of procedures in socioeconomic groups.

SETTING

Finland, 2,094,846 inhabitants in 1988 and 2,401,027 in 1996 aged 40 years and older, and Discharge Register data from all Finnish hospitals offering coronary procedures in 1988 and 1996.

MAIN RESULTS

The overall rate of coronary revascularisations in Finland increased by about 140% for men and 250% for women from 1988 to 1996. Over the same period, socioeconomic and gender disparities in operation rates diminished, as did the influence of regional supply of procedures on the extent of these differences. However, men, and better off groups in terms of occupation, education, and family income, continued to receive more operations than women and the worse off with the same level of need.

CONCLUSIONS

Although revascularisations in Finland increased 2.5-fold overall, some socioeconomic and gender inequities persisted in the use of cardiac operations relative to need. To improve equity, a further increase of resources may be needed, and practices taking socioeconomic and gender equity into account should be developed for the referral of coronary heart disease patients to hospital investigations.