The association of timing of coronary artery bypass grafting for non-ST-elevation myocardial infarction and clinical outcomes in the contemporary United States

BACKGROUND

In contrast to the timing of coronary angiography and percutaneous coronary intervention, the optimal timing of coronary artery bypass grafting (CABG) in non-ST-elevation myocardial infarction (NSTEMI) has not been determined. Therefore, we compared in-hospital outcomes according to different time intervals to CABG surgery in a contemporary NSTEMI population in the USA.

METHODS

We identified all NSTEMI hospitalizations from 2016 to 2020 where revascularization was performed with CABG. We excluded NSTEMI with high-risk features using prespecified criteria. CABG was stratified into ≤24 h, 24-72 h, 72-120 h, and >120 h from admission. Outcomes of interest included in-hospital mortality, perioperative complications, length of stay (LOS), and hospital cost.

RESULTS

A total of 147 170 NSTEMI hospitalizations where CABG was performed were assessed. A greater percentage of females, Blacks, and Hispanics experienced delays to CABG surgery. No difference in in-hospital mortality was observed, but CABG at 72-120 h and at >120 h was associated with higher odds of non-home discharge and acute kidney injury compared with CABG at ≤24 h from admission. In addition to these differences, CABG at >120 h was associated with higher odds of gastrointestinal hemorrhage and need for blood transfusion. All 3 groups with CABG delayed >24 h had longer LOS and hospital-associated costs compared with hospitalizations where CABG was performed at ≤24 h.

CONCLUSION

CABG delays in patients with NSTEMI are more frequently experienced by women and minority populations and are associated with an increased burden of complications and healthcare cost.

Differences in Treatment Patterns and Outcomes of Acute Myocardial Infarction for Low- and High-Income Patients in 6 Countries

Importance

Differences in the organization and financing of health systems may produce more or less equitable outcomes for advantaged vs disadvantaged populations. We compared treatments and outcomes of older high- and low-income patients across 6 countries.

Objective

To determine whether treatment patterns and outcomes for patients presenting with acute myocardial infarction differ for low- vs high-income individuals across 6 countries.

Design, Setting, and Participants

Serial cross-sectional cohort study of all adults aged 66 years or older hospitalized with acute myocardial infarction from 2013 through 2018 in the US, Canada, England, the Netherlands, Taiwan, and Israel using population-representative administrative data.

Exposures

Being in the top and bottom quintile of income within and across countries.

Main Outcomes and Measures

Thirty-day and 1-year mortality; secondary outcomes included rates of cardiac catheterization and revascularization, length of stay, and readmission rates.

Results

We studied 289 376 patients hospitalized with ST-segment elevation myocardial infarction (STEMI) and 843 046 hospitalized with non-STEMI (NSTEMI). Adjusted 30-day mortality generally was 1 to 3 percentage points lower for high-income patients. For instance, 30-day mortality among patients admitted with STEMI in the Netherlands was 10.2% for those with high income vs 13.1% for those with low income (difference, -2.8 percentage points [95% CI, -4.1 to -1.5]). One-year mortality differences for STEMI were even larger than 30-day mortality, with the highest difference in Israel (16.2% vs 25.3%; difference, -9.1 percentage points [95% CI, -16.7 to -1.6]). In all countries, rates of cardiac catheterization and percutaneous coronary intervention were higher among high- vs low-income populations, with absolute differences ranging from 1 to 6 percentage points (eg, 73.6% vs 67.4%; difference, 6.1 percentage points [95% CI, 1.2 to 11.0] for percutaneous intervention in England for STEMI). Rates of coronary artery bypass graft surgery for patients with STEMI in low- vs high-income strata were similar but for NSTEMI were generally 1 to 2 percentage points higher among high-income patients (eg, 12.5% vs 11.0% in the US; difference, 1.5 percentage points [95% CI, 1.3 to 1.8 ]). Thirty-day readmission rates generally also were 1 to 3 percentage points lower and hospital length of stay generally was 0.2 to 0.5 days shorter for high-income patients.

Conclusions and Relevance

High-income individuals had substantially better survival and were more likely to receive lifesaving revascularization and had shorter hospital lengths of stay and fewer readmissions across almost all countries. Our results suggest that income-based disparities were present even in countries with universal health insurance and robust social safety net systems.

Cost-Effectiveness of Coronary Artery Bypass Grafting and Percutaneous Coronary Intervention in Patients With Chronic Kidney Disease and Acute Coronary Syndromes in the US Medicare Program

Background Coronary revascularization provides important long-term clinical benefits to patients with high-risk presentations of coronary artery disease, including those with chronic kidney disease. The cost-effectiveness of coronary interventions in this setting is not known. Methods and Results We developed a Markov cohort simulation model to assess the cost-effectiveness of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in patients with chronic kidney disease who were hospitalized with acute myocardial infarction or unstable angina. Model inputs were primarily drawn from a sample of 14 300 patients identified using the Medicare 20% sample. Survival, quality-adjusted life-years, costs, and cost-effectiveness were projected over a 20-year time horizon. Multivariable models indicated higher 30-day mortality and end-stage renal disease with both PCI and CABG, and higher stroke with CABG, relative to medical therapy. However, the model projected long-term gains of 0.72 quality-adjusted life-years (0.97 life-years) for PCI compared with medical therapy, and 0.93 quality-adjusted life-years (1.32 life-years) for CABG compared with PCI. Incorporation of long-term costs resulted in incremental cost-effectiveness ratios of $65 326 per quality-adjusted life-year gained for PCI versus medical therapy, and $101 565 for CABG versus PCI. Results were robust to changes in input parameters but strongly influenced by the background costs of the population, and the time horizon. Conclusions For patients with chronic kidney disease and high-risk coronary artery disease presentations, PCI and CABG were both associated with markedly increased costs as well as gains in quality-adjusted life expectancy, with incremental cost-effectiveness ratios indicating intermediate value in health economic terms.

Minimally Invasive vs Open Coronary Surgery: A Multi-Institutional Analysis of Cost and Outcomes

BACKGROUND

Limited multi-institutional data evaluating minimally invasive cardiac surgery (MICS) coronary artery bypass surgery (CABG) outcomes have raised concern for increased resource utilization compared with standard sternotomy. The purpose of this study was to assess short-term outcomes and resource utilization with MICS CABG in a propensity-matched regional cohort.

METHODS

Isolated CABG patients (2012-2019) were extracted from a regional Society of Thoracic Surgeons database. Patients were stratified by MICS CABG vs open CABG via sternotomy, propensity-score matched 1:2 to balance baseline differences, and compared by univariate analysis.

RESULTS

Of 26,255 isolated coronary artery bypass graft patients, 139 MICS CABG and 278 open CABG patients were well balanced after matching. There was no difference in the operative mortality rate (2.2% open vs 0.7% MICS CABG, P = .383) or major morbidity (7.9% open vs 7.2% MICS CABG, P = .795). However, open CABG patients received more blood products (22.2% vs 12.2%, P = .013), and had longer intensive care unit (45 vs 30 hours, P = .049) as well as hospital lengths of stay (7 vs 6 days, P = .005). Finally, median hospital cost was significantly higher in the open CABG group ($35,011 vs $27,906, P < .001) compared with MICS CABG.

CONCLUSIONS

Open CABG via sternotomy and MICS CABG approaches are associated with similar, excellent perioperative outcomes. However, MICS CABG was associated with fewer transfusions, shorter length of stay, and ∼$7000 lower hospital cost, a superior resource utilization profile that improves patient care and lowers cost.

Coronary Artery Bypass Grafting in Cancer Patients: Prevalence and Outcomes in the United States

OBJECTIVE

To characterize the contemporary efficacy and utilization patterns of coronary artery bypass grafting (CABG) in specific cancer types.

METHODS

We leveraged the data from the National Inpatient Sample and plotted trends of utilization and outcomes of isolated CABG (with no other additional surgeries during the same hospitalization) procedures from January 1, 2003, through September 1, 2015. Propensity score matching was used to assess for potential differences in outcomes by type of cancer status among contemporary (2012-2015) patients.

RESULTS

Overall, the utilization of CABG decreased over time (250,677 in 2003 vs 134,534 in 2015, P<.001). However, the proportion of those with comorbid cancer increased (7.0% vs 12.6%, P<.001). Over time, in-hospital mortality associated with CABG use in cancer remained unchanged (.9% vs 1.0%, P=.72); yet, cancer patients saw an increase in associated major bleeding (4.5% vs 15.3%, P<.001) and rate of stroke (.9% vs 1.5%, P<.001) over time. In-hospital cost-of-care associated with CABG-use in cancer also increased over time ($29,963 vs $33,636, P<.001). When stratified by cancer types, in-hospital mortality was not higher in breast, lung, prostate, colon cancer, or lymphoma versus non-cancer CABG patients (all P>.05). However, there was a significantly higher prevalence of major bleeding but not stroke in patients with breast and prostate cancer only compared with non-cancer CABG patients (P<.01). Discharge dispositions were not found to be different between cancer sub-groups and non-cancer patients (P>.05), except for breast cancer patients who had lower home care, but higher skilled care disposition (P<.001).

CONCLUSION

Among those undergoing CABG, the prevalence of comorbid cancer has steadily increased. Outside of major bleeding, these patients appear to share similar outcomes to those without cancer indicating that CABG utilization should be not be declined in cancer patients when otherwise indicated. Further research into the factors underlying the decision to pursue CABG in specific cancer sub-groups is needed.

Federal Payments for Coronary Revascularization Procedures Among Dual Enrollees in Medicare Advantage and the Veterans Affairs Health Care System

IMPORTANCE

More than 1 million US veterans are dually enrolled in a Medicare Advantage (MA) plan and in the Veterans Affairs (VA) health care system. The federal government prepays private MA plans to cover veterans; if a dually enrolled veteran receives an MA-covered service at the VA, the government is making 2 payments for the same service. It is not clear what proportion of veterans dually enrolled in VA and MA are undergoing coronary revascularization at VA vs non-VA hospitals.

OBJECTIVE

To describe where veterans who are enrolled in both VA and MA undergo coronary revascularization and the associated costs.

DESIGN, SETTINGS, AND PARTICIPANTS

This is a cohort study consisting of US veterans dually enrolled in VA and MA from January 1, 2010, to December 31, 2013, who had at least 1 VA encounter and underwent coronary revascularization during the study period. Data were analyzed from April 2019 to September 2019.

MAIN OUTCOMES AND MEASURES

Number of coronary artery bypass graft (CABG) operations and percutaneous coronary interventions (PCIs) performed through the VA and through MA during years 2010 to 2013, and the associated VA costs of coronary revascularization. In addition, multivariable logistic regression was performed to assess patient factors associated with receiving care through the VA.

RESULTS

A total of 18 874 VA users with concurrent MA enrollment who underwent coronary revascularization during 2010 to 2013 were identified (mean [SD] age, 75.3 [8.8] years; 18 739 men [99.0%]). Enrollees were predominantly white (17 457 patients [92.0%]). Among patients, 4115 (22.0%) underwent either CABG or PCI through the VA only, 14 281 (75.0%) did so through MA only, and 478 (2.5%) underwent coronary revascularization procedures through both payers. From 2010 to 2013, these veterans underwent 4764 coronary revascularization procedures (721 CABGs and 3043 PCIs) that cost the VA $214.7 million ($115.8 million for CABGs and $99.0 million for PCIs). In multivariable analysis, nonwhite patients were more likely than white patients to undergo coronary revascularization through the VA (odds ratio, 1.73; 95% CI, 1.52-1.96; P < .001), and for each year of age, veterans were less likely to undergo coronary revascularization through the VA (odds ratio, 0.95; 95% CI, 0.94-0.95; P < .001). There was no statistically significant association between undergoing coronary vascularization through the VA and distance in miles to the nearest VA hospital (odds ratio, 1.00; 95% CI, 0.99-1.00; P = .30).

CONCLUSIONS AND RELEVANCE

A substantial share of VA users concurrently enrolled in an MA plan underwent coronary revascularization procedures through the VA, incurring significant duplicative federal health care spending. Given the financial pressures facing both Medicare and the VA, government officials should consider policy solutions to mitigate redundant spending.

Variation in expenditure for common, high cost surgical procedures in a working age population: implications for reimbursement reform

BACKGROUND

In the move toward value-based care, bundled payments are believed to reduce waste and improve coordination. Some commercial insurers have addressed this through the use of bundled payment, the provision of one fee for all care associated with a given index procedure. This system was pioneered by Medicare, using a population generally over 65 years of age, and despite its adoption by mainstream insurers, little is known of bundled payments' ability to reduce variation or cost in a working-age population. This study uses a universally-insured, nationally-representative population of adults aged 18-65 to examine the effect of bundled payments for five high-cost surgical procedures which are known to vary widely in Medicare reimbursement: hip replacement, knee replacement, coronary artery bypass grafting (CABG), lumbar spinal fusion, and colectomy.

METHODS

Five procedures conducted on adults aged 18-65 were identified from the TRICARE database from 2011 to 2014. A 90-day period from index procedure was used to determine episodes of associated post-acute care. Data was sorted by Zip code into hospital referral regions (HRR). Payments were determined from TRICARE reimbursement records, they were subsequently price standardized and adjusted for patient and surgical characteristics. Variation was assessed by stratifying the HRR into quintiles by spending for each index procedure.

RESULTS

After adjusting for case mix, significant inter-quintile variation was observed for all procedures, with knee replacement showing the greatest variation in both index surgery (107%) and total cost of care (75%). Readmission was a driver of variation for colectomy and CABG, with absolute cost variation of $17,257 and $13,289 respectively. Other post-acute care spending was low overall (≤$1606, for CABG).

CONCLUSIONS

This study demonstrates significant regional variation in total spending for these procedures, but much lower spending for post-acute care than previously demonstrated by similar procedures in Medicare. Targeting post-acute care spending, a common approach taken by providers in bundled payment arrangements with Medicare, may be less fruitful in working aged populations.

Who Will be the Costliest Patients? Using Recent Claims to Predict Expensive Surgical Episodes

INTRODUCTION

Surgery accounts for almost half of inpatient spending, much of which is concentrated in a subset of high-cost patients. To study the effects of surgeon and hospital characteristics on surgical expenditures, a way to adjust for patient characteristics is essential.

DESIGN

Using 100% Medicare claims data, we identified patients aged 66-99 undergoing elective inpatient surgery (coronary artery bypass grafting, colectomy, and total hip/knee replacement) in 2014. We calculated price-standardized Medicare payments for the surgical episode from admission through 30 days after discharge (episode payments). On the basis of predictor variables from 2013, that is, Elixhauser comorbidities, hierarchical condition categories, Medicare's Chronic Conditions Warehouse (CCW), and total spending, we constructed models to predict the costs of surgical episodes in 2014.

RESULTS

All sources of comorbidity data performed well in predicting the costliest cases (Spearman correlation 0.86-0.98). Models on the basis of hierarchical condition categories had slightly superior performance. The costliest quintile of patients as predicted by the model captured 35%-45% of the patients in each procedure's actual costliest quintile. For example, in hip replacement, 44% of the costliest quintile was predicted by the model's costliest quintile.

CONCLUSIONS

A significant proportion of surgical spending can be predicted using patient factors on the basis of readily available claims data. By adjusting for patient factors, this will facilitate future research on unwarranted variation in episode payments driven by surgeons, hospitals, or other market forces.

Factors associated with switching between low and super utilization in the surgical population: A study in medicare expenditure

BACKGROUND

Considered the top 5% of healthcare utilizers, "super-utilizers" are estimated to consume as much as 40-55% of all healthcare costs. The aim of this study was to identify factors associated with switching between low- and super-utilization.

METHODS

Low and super-utilizers who underwent abdominal aortic aneurysm (AAA) repair, coronary artery bypass graft (CABG), colectomy, total hip arthroplasty (THA), total knee arthroplasty (TKA), or lung resection between 2013 and 2015 were identified from 100% Medicare Inpatient Standard Analytic Files.

RESULTS

Among 1,049,160 patients, 788,488 (75.1%) and 21,700 (2.1%) patients were low- or super-utilizers prior to surgery, respectively. Among patients who were super-utilizers before surgery, 23% remained super-utilizers post-operatively, yet 26.8% patients became low-utilizers after surgery. Factors associated with moving from low-to super-utilization in the pre-versus post-operative setting included AAA repair, higher Charlson, and pulmonary failure. In contrast, pre-operative super-utilizers who became low-utilizers in the post-operative setting were less likely to be African American or have undergone CABG.

CONCLUSION

While 3% of pre-operative low-utilizers became super-utilizers likely due to complications, nearly one quarter of all pre-operative super-utilizers became low-utilizers following surgery suggesting success of the surgery to resolve underlying conditions associated with preoperative super-utilization.

Five-year costs from a randomised comparison of bilateral and single internal thoracic artery grafts

BACKGROUND

The use of bilateral internal thoracic arteries (BITA) for coronary artery bypass grafting (CABG) may improve survival compared with CABG using single internal thoracic arteries (SITA). We assessed the long-term costs of BITA compared with SITA.

METHODS

Between June 2004 and December 2007, 3102 patients from 28 hospitals in seven countries were randomised to CABG surgery using BITA (n=1548) or SITA (n=1554). Detailed resource use data were collected from the initial hospital episode and annually up to 5 years. The associated costs of this resource use were assessed from a UK perspective with 5 year totals calculated for each trial arm and pre-selected patient subgroups.

RESULTS

Total costs increased by approximately £1000 annually in each arm, with no significant annual difference between trial arms. Cumulative costs per patient at 5-year follow-up remained significantly higher in the BITA group (£18 629) compared with the SITA group (£17 480; mean cost difference £1149, 95% CI £330 to £1968, p=0.006) due to the higher costs of the initial procedure. There were no significant differences between the trial arms in the cost associated with healthcare contacts, medication use or serious adverse events.

CONCLUSIONS

Higher index costs for BITA were still present at 5-year follow-up mainly driven by the higher initial cost with no subsequent difference emerging between 1 year and 5 years of follow-up. The overall cost-effectiveness of the two procedures, to be assessed at the primary endpoint of the 10-year follow-up, will depend on composite differences in costs and quality-adjusted survival.

TRIAL REGISTRATION NUMBER

ISRCTN46552265.

Cost-effectiveness of coronary artery bypass grafting plus mitral valve repair versus coronary artery bypass grafting alone for moderate ischemic mitral regurgitation

OBJECTIVE

The Cardiothoracic Surgical Trials Network reported that left ventricular reverse remodeling at 2 years did not differ between patients with moderate ischemic mitral regurgitation randomized to coronary artery bypass grafting plus mitral valve repair (n = 150) or coronary artery bypass grafting alone (n = 151). To address health resource use implications, we compared costs and quality-adjusted survival.

METHODS

We used individual patient data from the Cardiothoracic Surgical Trials Network trial on survival, hospitalizations, quality of life, and US hospitalization costs to estimate cumulative costs and quality-adjusted life years. A microsimulation model was developed to extrapolate to 10 years. Bootstrap and deterministic sensitivity analyses were performed to address uncertainty.

RESULTS

In-hospital costs were $59,745 for coronary artery bypass grafting plus mitral valve repair versus $51,326 for coronary artery bypass grafting alone (difference $8419; 95% uncertainty interval, 2259-18,757). Two-year costs were $81,263 versus $67,341 (difference 13,922 [2370 to 28,888]), and quality-adjusted life years were 1.35 versus 1.30 (difference 0.05; -0.04 to 0.14), resulting in an incremental cost-effectiveness ratio of $308,343/quality-adjusted life year for coronary artery bypass grafting plus mitral valve repair. At 10 years, its costs remained higher ($107,733 vs $88,583, difference 19,150 [-3866 to 56,826]) and quality-adjusted life years showed no difference (-0.92 to 0.87), with 5.08 versus 5.08. The likelihood that coronary artery bypass grafting plus mitral valve repair would be considered cost-effective at 10 years based on a cost-effectiveness threshold of $100K/quality-adjusted life year did not exceed 37%. Only when this procedure reduces the death rate by a relative 5% will the incremental cost-effectiveness ratio fall below $100K/quality-adjusted life year.

CONCLUSIONS

The addition of mitral valve repair to coronary artery bypass grafting for patients with moderate ischemic mitral regurgitation is unlikely to be cost-effective. Only if late mortality benefits can be demonstrated will it meet commonly used cost-effectiveness criteria.

The Real-World Cost-Effectiveness of Coronary Artery Bypass Surgery Versus Stenting in High-Risk Patients: Propensity Score-Matched Analysis of a Single-Centre Experience

BACKGROUND

There are limited economic evaluations comparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for multi-vessel coronary artery disease (MVCAD) in contemporary, routine clinical practice.

OBJECTIVE

The aim was to perform a cost-effectiveness analysis comparing CABG and PCI in patients with MVCAD, from the perspective of the Australian public hospital payer, using observational data sources.

METHODS

Clinical data from the Melbourne Interventional Group (MIG) and the Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) registries were analysed for 1022 CABG (treatment) and 978 PCI (comparator) procedures performed between June 2009 and December 2013. Clinical records were linked to same-hospital admissions and national death index (NDI) data. The incremental cost-effectiveness ratios (ICERs) per major adverse cardiac and cerebrovascular event (MACCE) avoided were evaluated. The propensity score bin bootstrap (PSBB) approach was used to validate base-case results.

RESULTS

At mean follow-up of 2.7 years, CABG compared with PCI was associated with increased costs and greater all-cause mortality, but a significantly lower rate of MACCE. An ICER of $55,255 (Australian dollars)/MACCE avoided was observed for the overall cohort. The ICER varied across comparisons against bare metal stents (ICER $25,815/MACCE avoided), all drug-eluting stents (DES) ($56,861), second-generation DES ($42,925), and third-generation of DES ($88,535). Moderate-to-low ICERs were apparent for high-risk subgroups, including those with chronic kidney disease ($62,299), diabetes ($42,819), history of myocardial infarction ($30,431), left main coronary artery disease ($38,864), and heart failure ($36,966).

CONCLUSIONS

At early follow-up, high-risk subgroups had lower ICERs than the overall cohort when CABG was compared with PCI. A personalised, multidisciplinary approach to treatment of patients may enhance cost containment, as well as improving clinical outcomes following revascularisation strategies.

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.

Economies of scale: body mass index and costs of cardiac surgery in Ontario, Canada

An obesity paradox has been described, whereby obese patients have better health outcomes than normal weight patients in certain clinical situations, including cardiac surgery. However, the relationship between body mass index (BMI) and resource utilization and costs in patients undergoing coronary artery bypass graft (CABG) surgery is largely unknown. We examined resource utilization and cost data for 53,224 patients undergoing CABG in Ontario, Canada over a 10-year period between 2002 and 2011. Data for costs during hospital admission and for a 1-year follow-up period were derived from the Institute for Clinical Evaluative Sciences, and analyzed according to pre-defined BMI categories using analysis of variance and multivariate models. BMI independently influenced healthcare costs. Underweight patients had the highest per patient costs ($50,124 ± $36,495), with the next highest costs incurred by morbidly obese ($43,770 ± $31,747) and normal weight patients ($42,564 ± $30,630). Obese and overweight patients had the lowest per patient costs ($40,760 ± $30,664 and $39,960 ± $25,422, respectively). Conversely, at the population level, overweight and obese patients were responsible for the highest total yearly population costs to the healthcare system ($92 million and $50 million, respectively, compared to $4.2 million for underweight patients). This is most likely due to the high proportion of CABG patients falling into the overweight and obese BMI groups. In the future, preoperative risk stratification and preparation based on BMI may assist in reducing surgical costs, and may inform health policy measures aimed at the management of weight extremes in the population.

Hospitalization costs and clinical outcomes in CABG patients treated with intensive insulin therapy

BACKGROUND

The financial impact of intensive (blood glucose [BG] 100-140mg/dl [5.5-7.8mM] vs. conservative (141-180mg/dl (7.9-10.0mM) glucose control in the ICU in patients, with and without diabetes, undergoing coronary artery bypass graft (CABG) surgery is not known.

METHODS

This post-hoc cost analysis determined differences in hospitalization costs, resource utilization and perioperative complications in 288 CABG patients with diabetes (n=143) and without diabetes (n=145), randomized to intensive (n=143) and conservative (n=145) glucose control.

RESULTS

Intensive glucose control resulted in lower BG (131.4±14mg/dl-(7.2±0.8mM) vs. 151.6±17mg/dl (8.4±0.8mM, p<0.001), a nonsignificant reduction in the median length of stay (LOS, 7.9 vs. 8.5days, p=0.17) and in a composite of perioperative complications including wound infection, bacteremia, acute renal and respiratory failure, major cardiovascular events (42% vs 52%, p=0.10) compared to conservative control. Median hospitalization costs were lower in the intensive group ($39,366 vs. $42,141, p=0.040), with a total cost savings of $3654 (95% CI: $1780-$3723), than conservative control. Resource utilization for radiology (p=0.008), laboratory (p=0.014), consultation service (p=0.013), and ICU utilization (p=0.007) were also lower in the intensive group. Compared to patients without perioperative complications, those with complications had longer hospital length of stay (10.7days vs. 6.7days, p<0.001), higher total hospitalization cost ($48,299 vs. $32,675, p<0.001), and higher resource utilization units (2745 vs. 1710, p<0.001).

CONCLUSION

Intensive glycemic control [BG 100-140mg/dl (5.5-7.8mM)] in patients undergoing CABG resulted in significant reductions in hospitalization costs and resource utilization compared to patients treated with conservative [BG 141-180mg/dl (7.9-10.0mM)] glucose control.

Medicare Program; Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR). Final rule

This final rule implements three new Medicare Parts A and B episode payment models, a Cardiac Rehabilitation (CR) Incentive Payment model and modifications to the existing Comprehensive Care for Joint Replacement model under section 1115A of the Social Security Act. Acute care hospitals in certain selected geographic areas will participate in retrospective episode payment models targeting care for Medicare fee-forservice beneficiaries receiving services during acute myocardial infarction, coronary artery bypass graft, and surgical hip/femur fracture treatment episodes. All related care within 90 days of hospital discharge will be included in the episode of care. We believe these models will further our goals of improving the efficiency and quality of care for Medicare beneficiaries receiving care for these common clinical conditions and procedures.

Beating Heart Versus Conventional Cardiopulmonary Bypass: The Octopus Experience: A Randomized Comparison of 281 Patients Undergoing Coronary Artery Bypass Surgery With or Without Cardiopulmonary Bypass

In the Octopus Study, 281 coronary artery bypass surgery patients were randomized to surgery with or without cardiopulmonary bypass. The primary objective was to compare cognitive outcome between off-pump and on-pump coronary artery bypass surgery. Before and after surgery, psychologists administered a battery of 10 neuropsychological tests to the patients. Cognitive decline was defined as a decrease in an individual’s performance of at least 20% from baseline, in at least 20% of the main variables. According to this definition, cognitive decline was present in 21% in the off-pump group and 29% in the on-pump group, 3 months after the procedure ( P = .15). At 12 months, cognitive decline was present in 31% in the off-pump group and 34% in the on-pump group ( P = .69). These results indicated that patients undergoing coronary artery bypass surgery without cardiopulmonary bypass had improved cognitive outcomes 3 months after the procedure, but the effects were limited and became negligible at 12 months. The same definition of cognitive decline was also applied to 112 volunteers not undergoing surgery. The definition labeled 28% of the control subjects as suffering from cognitive decline, 3 months after their first assessment. This suggests that the natural fluctuations in performance during repeated neuropsychological testing should be included in the statistical analysis of cognitive decline. Using an alternative definition of cognitive decline that takes these natural fluctuations in performance into account, the proportions of coronary artery bypass surgery patients displaying cognitive decline were substantially lower. This indicates that the incidence of cognitive decline after coronary artery bypass surgery has been overestimated.

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 .).

Costs, Clinical Outcomes, and Health-Related Quality of Life of Off-Pump vs. On-Pump Coronary Bypass Surgery

BACKGROUND

Off-pump coronary bypass surgery avoids the potential complications of cardiopulmonary bypass. However, its acceptance depends on medical and economic outcome. The aim of this prospective non-randomised study was to compare functional and economic outcome of off-pump and on-pump surgery at 1-year follow-up.

METHODS

102 patients (pts) treated with either off-pump (60pts) or on-pump surgery (42pts) were studied. Pts with left ventricular dysfunction, recent myocardial infarction (<1 month), renal impairment, valve surgery, previous stroke or coagulopathy were excluded. Variable and fixed costs were obtained for each treatment group during operative and postoperative care. In-hospital endpoints included all-cause mortality and complications (defined as excessive bleeding [>6 units blood transfusion], peri-operative myocardial infarction, atrial fibrillation, stroke, and infection). All cause mortality; cost-effectiveness and quality of life were assessed 1 year after surgery.

RESULTS

The in-hospital mortality was similar in the two treatment groups. Off-pump group had significantly fewer postoperative complication rate (off-pump 41% vs. on-pump 72%, p=0.001). The mean in-hospital cost was lower for off-pump surgery (off-pump 6.515+/-926 euro vs. on-pump 9.872+/-1.299 euro, p<0.0001) as well as the mean length of hospital stay (off-pump 4.93+/-0.93 days vs. on-pump 6.58+/-1.04 days, p<0.0001). At 1 year, all cause mortality, quality of life indices, return to work rate and treatment satisfaction was similar in both groups.

CONCLUSION

Off-pump myocardial revascularization maintains the advantages of conventional surgery in terms of survival and freedom from cardiac events while reducing the in-hospital cost.

Free to Choose? Reform, Choice, and Consideration Sets in the English National Health Service

Choice in public services is controversial. We exploit a reform in the English National Health Service to assess the effect of removing constraints on patient choice. We estimate a demand model that explicitly captures the removal of the choice constraints imposed on patients. We find that, post-removal, patients became more responsive to clinical quality. This led to a modest reduction in mortality and a substantial increase in patient welfare. The elasticity of demand faced by hospitals increased substantially post- reform and we find evidence that hospitals responded to the enhanced incentives by improving quality. This suggests greater choice can raise quality.

Penetration, Completeness, and Representativeness of The Society of Thoracic Surgeons Adult Cardiac Surgery Database

BACKGROUND

The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (ACSD) has been successfully linked to the Centers for Medicare and Medicaid (CMS) Medicare database, thereby facilitating comparative effectiveness research and providing information about long-term follow-up and cost. The present study uses this link to determine contemporary completeness, penetration, and representativeness of the STS ACSD.

METHODS

Using variables common to both STS and CMS databases, STS operations were linked to CMS data for all CMS coronary artery bypass graft (CABG) surgery hospitalizations discharged between 2000 and 2012, inclusive. For each CMS CABG hospitalization, it was determined whether a matching STS record existed.

RESULTS

Center-level penetration (number of CMS sites with at least one matched STS participant divided by the total number of CMS CABG sites) increased from 45% in 2000 to 90% in 2012. In 2012, 973 of 1,081 CMS CABG sites (90%) were linked to an STS site. Patient-level penetration (number of CMS CABG hospitalizations done at STS sites divided by the total number of CMS CABG hospitalizations) increased from 51% in 2000 to 94% in 2012. In 2012, 71,634 of 76,072 CMS CABG hospitalizations (94%) occurred at an STS site. Completeness of case inclusion at STS sites (number of CMS CABG cases at STS sites linked to STS records divided by the total number of CMS CABG cases at STS sites) increased from 88% in 2000 to 98% in 2012. In 2012, 69,213 of 70,932 CMS CABG hospitalizations at STS sites (98%) were linked to an STS record.

CONCLUSIONS

Linkage of STS and CMS databases demonstrates high and increasing penetration and completeness of the STS database. Linking STS and CMS data facilitates studying long-term outcomes and costs of cardiothoracic surgery.

Is the Preoperative Administration of Amiodarone or Metoprolol More Effective in Reducing Atrial Fibrillation: After Coronary Bypass Surgery?

This study examined the influence of preoperative administration of amiodarone and metoprolol in preventing postoperative atrial fibrillation (AF) after coronary artery bypass grafting (CABG) surgery.The study comprised 251 patients who underwent CABG surgery at our hospital between January 2012 and May 2014. The patients were randomly divided into 2 groups: amiodarone therapy group (n = 122 patients) and metoprolol therapy group (n = 129 patients).In the amiodarone group, the patients received amiodarone tablet orally 1 week before coronary bypass surgery and during the postoperative period. In the metoprolol group, the patients received metoprolol tablet orally 1 week before surgery and during the postoperative period. The AF development rate was retrospectively evaluated between the first 3 days and 4 weeks after surgery.AF developed in 14 patients in the amiodarone group and 16 patients in the metoprolol group 4 weeks after the operation (P = 0.612).No significant difference was observed between the groups in terms of intensive care unit and hospital stay. Furthermore, hospital charges were similar in both groups (P = 0.741).The results of the logistic regression analysis showed age, left ventricular ejection fraction, left atrial diameter, and aortic cross-clamping time to be predictors for postoperative AF.This study demonstrates that amiodarone and metoprolol have similar effects in prevention of AF after cardiac surgery. However, larger-scale studies need to be conducted to substantiate these findings.

Time-driven activity-based costing of multivessel coronary artery bypass grafting across national boundaries to identify improvement opportunities: study protocol

INTRODUCTION

Coronary artery bypass graft (CABG) surgery is a well-established, commonly performed treatment for coronary artery disease--a disease that affects over 10% of US adults and is a major cause of morbidity and mortality. In 2005, the mean cost for a CABG procedure among Medicare beneficiaries in the USA was $32, 201 ± $23,059. The same operation reportedly costs less than $2000 to produce in India. The goals of the proposed study are to (1) identify the difference in the costs incurred to perform CABG surgery by three Joint Commission accredited hospitals with reputations for high quality and efficiency and (2) characterise the opportunity to reduce the cost of performing CABG surgery.

METHODS AND ANALYSIS

We use time-driven activity-based costing (TDABC) to quantify the hospitals' costs of producing elective, multivessel CABG. TDABC estimates the costs of a given clinical service by combining information about the process of patient care delivery (specifically, the time and quantity of labour and non-labour resources utilised to perform each activity) with the unit cost of each resource used to provide the care. Resource utilisation was estimated by constructing CABG process maps for each site based on observation of care and staff interviews. Unit costs were calculated as a capacity cost rate, measured as a $/min, for each resource consumed in CABG production. Multiplying together the unit costs and resource quantities and summing across all resources used will produce the average cost of CABG production at each site. We will conclude by conducting a variance analysis of labour costs to reveal opportunities to bend the cost curve for CABG production in the USA.

ETHICS AND DISSEMINATION

All our methods were exempted from review by the Stanford Institutional Review Board. Results will be published in peer-reviewed journals and presented at scientific meetings.

Clinical impact and cost-effectiveness of coronary computed tomography angiography or exercise electrocardiogram in individuals without known cardiovascular disease

It is not clear whether screening by coronary computed tomographic angiography (CCTA) and/or exercise electrocardiogram (ECG) can improve clinical outcomes and reduce costs in individuals without known cardiovascular disease (CVD). In total, 71,811 consecutive individuals without known CVD who underwent general health examinations were enrolled. Using propensity-score matching according to screening tests, 1-year clinical outcomes and 6-month total and coronary artery disease-related medical costs were analyzed in separate groups: group 1 (CCTA [n = 2578] vs no screening [n = 5146]), group 2 (exercise ECG [n = 2898] vs no screening [n = 5796]), and group 3 (CCTA and exercise ECG [n = 2003] vs no screening [n = 4006]). There were no significant differences in the composite outcome of death, myocardial infarction, and stroke in each matched group: group 1 (0.35% vs 0.45%, P = 0.501), group 2 (0.14% vs 0.28%, P = 0.157), and group 3 (0.25% vs 0.27%, P = 0.858). However, revascularization was more frequent in the CCTA screening groups: group 1 (2.02% vs 0.45%, P < 0.001) and group 3 (1.40% vs 0.45%, P < 0.001). Matched screening groups had higher 6-month total and coronary artery disease-related medical costs: group 1 ($777 vs $603, P < 0.001 and $177 vs $39, P < 0.001), group 2 ($544 vs $492, P = 0.045 and $12 vs $15, P = 0.611), and group 3 ($705 vs $627, P = 0.090 and $135 vs $35, P < 0.001). In individuals without known CVD, CCTA screening with or without exercise ECG led to more frequent revascularization at the expense of higher medical costs, but did not decrease the 1-year risk of death, myocardial infarction, and stroke.

Use of pulmonary artery catheter in coronary artery bypass graft. Costs and long-term outcomes

Background

Pulmonary artery catheters (PAC) are used widely to monitor hemodynamics in patients undergoing coronary bypass graft (CABG) surgery. However, recent studies have raised concerns regarding both the effectiveness and safety of PAC. Therefore, our aim was to determine the effects of the use of PAC on the short- and long-term health and economic outcomes of patients undergoing CABG.

Methods

1361 Chinese patients who consecutively underwent isolated, primary CABG at the Cardiovascular Institute of Fuwai Hospital from June 1, 2012 to December 31, 2012 were included in this study. Of all the patients, 453 received PAC during operation (PAC group) and 908 received no PAC therapy (control group). Short-term and long-term mortality and major complications were analyzed with multivariate regression analysis and propensity score matched-pair analysis was used to yield two well-matched groups for further comparison.

Results

The patients who were managed with PAC more often received intraoperative vasoactive drugs dopamine (70.9% vs. 45.5%; P<0.001) and epinephrine (7.7% vs. 2.6%; P<0.001). In addition, costs for initial hospitalization were higher for PAC patients ($14,535 vs. $13,873, respectively, p = 0.004). PAC use was neither associated with the perioperative mortality or major complications, nor was it associated with long-term mortality and major adverse cardiac and cerebrovascular events. In addition, comparison between two well-matched groups showed no significant differences either in baseline characteristics or in short-term and long-term outcomes.

Conclusions

There is no clear indication of any benefit or harm in managing CABG patients with PAC. However, use of PAC in CABG is more expensive. That is, PAC use increased costs without benefit and thus appears unjustified for routine use in CABG surgery.

Cost implication of an early invasive strategy on weekdays and weekends in patients with acute coronary syndromes

BACKGROUND

Early invasive intervention is associated with shorter length of stay (LOS) and similar outcomes in a delayed strategy in lower-risk patients with non-ST segment elevation acute coronary syndromes (NSTEACS), but is superior in higher-risk patients. However, early invasive intervention might be constrained by the need to mobilize the on-call team on weekends. We evaluated costs associated with an early vs delayed invasive intervention strategy, including patients who present on weekends.

METHODS

Health care utilization was extracted from the Timing of Intervention in Acute Coronary Syndromes (TIMACS) trial for Canadian patients from case report forms. Only direct costs were considered and only hospitalization events were included. Canadian unit costs were applied to health care resources consumed for all patients. Sensitivity and subgroup analyses were performed.

RESULTS

Early invasive intervention reduced LOS costs by $2808 (95% confidence interval [CI], $4,629-$987). Total costs per Canadian patient for early invasive intervention were $16,579 (95% CI, $14,949-$18,209) compared with $19,517 (95% CI, $17,897-$21,136) for the delayed invasive approach. This resulted in a savings of $2938 (95% CI, $5236-$640). Findings were confirmed using bootstrap simulation. Sensitivity analyses confirmed savings regardless of proportion of cases done on weekends. All subgroup costs favoured early intervention.

CONCLUSIONS

Early invasive strategy was cost-saving, even on weekends, for Canadian NSTEACS patients because of significant LOS savings. Because many high-risk NSTEACS patients receive delayed intervention because of weekend catheterization laboratory status, these findings support opening catheterization laboratories on weekends to facilitate the use of early invasive intervention.

Evaluation of long-term clinical and health service outcomes following coronary artery revascularisation in Western Australia (WACARP): a population-based cohort study protocol

INTRODUCTION

Coronary artery bypass grafting (CABG) and percutaneous coronary interventions (PCI) are procedures commonly performed on patients with significant obstructive coronary artery disease to relieve symptoms of ischaemia, improve survival or both. Although the efficacy of both procedures at the individual level has been established, the impact of advances in coronary artery revascularisation procedures (CARP) on long-term outcomes and cost-effectiveness at the population level are yet to be assessed. Our aim is to evaluate a minimum of 6-year outcomes and costs for the total population of patients who had CARP in Western Australia (WA) in 2000-2005.

METHODS AND ANALYSIS

This retrospective population cohort study will link clinical and administrative health data for a previously defined cohort including all patients in WA who had a CARP in the period 2000-2005. The cohort consists of 19,014 patients who had 21,175 procedures (15,429 PCI and 5746 CABG). We are now collecting a minimum of 6 years follow-up of morbidity and mortality data for the cohort using the WA Data Linkage System, clinical registries and hospital records, with 12 years follow-up for cases in the year 2000. Comparison of long-term outcomes for different CARP will be reported (PCI vs CABG; bare metal stents vs drug-eluting stents vs CABG). Cost-effectiveness analysis of CARP from the perspective of the healthcare sector will be performed using individual level cost data and average costs from Australian Refined Diagnosis Related Groups.

ETHICS AND DISSEMINATION

This study has received ethics approval from the University of Western Australia, the Western Australian Department of Health and all participating hospitals. Being a large population cohort study, approval included a waiver of informed consent. All findings will be presented at local, national and international healthcare/academic conferences and published in peer-reviewed journals.

The nature of surgeon human capital depreciation

To test how practice interruptions affect worker productivity, we estimate how temporal breaks affect surgeons' performance of coronary artery bypass grafting (CABG). Examining 188 surgeons who performed 56,315 CABG surgeries in Pennsylvania between 2006 and 2010, we find that a surgeon's additional day away from the operating room raised patients' inpatient mortality by up to 0.067 percentage points (2.4% relative effect) but reduced total hospitalization costs by up to 0.59 percentage points. Among emergent patients treated by high-volume providers, where temporal distance is most plausibly exogenous, an additional day away raised mortality risk by 0.398 percentage points (11.4% relative effect) but reduced cost by up to 1.4 percentage points. This is consistent with the hypothesis that as temporal distance increases, surgeons are less likely to recognize and address life-threatening complications. Our estimates imply additional intraprocedural treatment intensity has a cost per life-year preserved of $7871-18,500, well within conventional cost-effectiveness cutoffs.

Treatment for stable coronary artery disease: a network meta-analysis of cost-effectiveness studies

Introduction and Objectives

Numerous studies have assessed cost-effectiveness of different treatment modalities for stable angina. Direct comparisons, however, are uncommon. We therefore set out to compare the efficacy and mean cost per patient after 1 and 3 years of follow-up, of the following treatments as assessed in randomized controlled trials (RCT): medical therapy (MT), percutaneous coronary intervention (PCI) without stent (PTCA), with bare-metal stent (BMS), with drug-eluting stent (DES), and elective coronary artery bypass graft (CABG).

Methods

RCT comparing at least two of the five treatments and reporting clinical and cost data were identified by a systematic search. Clinical end-points were mortality and myocardial infarction (MI). The costs described in the different trials were standardized and expressed in US $ 2008, based on purchasing power parity. A network meta-analysis was used to compare costs.

Results

Fifteen RCT were selected. Mortality and MI rates were similar in the five treatment groups both for 1-year and 3-year follow-up. Weighted cost per patient however differed markedly for the five treatment modalities, at both one year and three years (P<0.0001). MT was the least expensive treatment modality: US $3069 and 13 864 after one and three years of follow-up, while CABG was the most costly: US $27 003 and 28 670 after one and three years. PCI, whether with plain balloon, BMS or DES came in between, but was closer to the costs of CABG.

Conclusions

Appreciable savings in health expenditures can be achieved by using MT in the management of patients with stable angina.

Clinical and economic impact of substituting dexmedetomidine for propofol due to a US drug shortage: examination of coronary artery bypass graft patients at an urban medical centre

BACKGROUND

Propofol has reduced healthcare costs in coronary artery bypass graft (CABG) surgery patients by decreasing post-operative duration of mechanical ventilation. However, the US shortage of propofol necessitated the use of alternative agents.

OBJECTIVE

This study sought to evaluate clinical and economic implications of substituting dexmedetomidine for propofol in patients undergoing CABG surgery.

METHODS

This was a retrospective cohort study. Patients undergoing isolated, elective CABG surgery and sedated with either propofol or dexmedetomidine during the study period were included. The cohorts were matched 1:1 based on important characteristics. The primary outcome was the number of patients achieving a post-operative duration of mechanical ventilation ≤6 h. Secondary outcomes were post-operative intensive care unit (ICU) length of stay (LOS) ≤48 h, total post-operative LOS ≤5 days, the need for adjunctive opioid therapy and associated cost savings. Variables recorded included patient demographics, co-morbid medical conditions, health risks, sedation drug doses, post-operative medical complications and sedation-related adverse events. Univariate and multivariate analyses were completed to examine the relationship between these covariates and post-operative LOS. The cost analysis consisted of examination of the net financial benefit (or cost) of choosing dexmedetomidine versus propofol in the study population, with utilisation observed in the study converted to costs using institutional data from the Premier database.

RESULTS

Eighty-four patients were included, with 42 patients per cohort. Mechanical ventilation duration ≤6 h was achieved in 24 (57.1 %) versus 7 (16.7 %) in the dexmedetomidine and propofol cohorts, respectively (p < 0.001). More patients treated with dexmedetomidine achieved ICU LOS ≤48 h (p < 0.05) and total hospital LOS ≤5 days (p < 0.05), as compared with the propofol group. Multivariate analysis revealed that having one or more post-operative medical complication was the most significant predictor of increased post-operative LOS, whereas choosing dexmedetomidine was also significant in terms of reduced post-operative LOS. The estimated net financial benefit of choosing dexmedetomidine versus propofol was US$2,613 per patient (year 2012 value).

CONCLUSIONS

Findings suggest that use of dexmedetomidine as an alternative to propofol for sedation of CABG patients post-operatively contributes to reduced mechanical ventilation time, ICU LOS and post-operative LOS. Higher drug costs resulting from the propofol shortage were offset by savings in post-operative room and board costs. Additional savings may be possible by preventing medical complications to the extent possible.

Fractional flow reserve versus angiography in guiding management to optimize outcomes in non-ST-elevation myocardial infarction (FAMOUS-NSTEMI): rationale and design of a randomized controlled clinical trial

BACKGROUND

In patients with acute non-ST-elevation myocardial infarction (NSTEMI), coronary arteriography is usually recommended; but visual interpretation of the angiogram is subjective. We hypothesized that functional assessment of coronary stenosis severity with a pressure-sensitive guide wire (fractional flow reserve [FFR]) would have additive diagnostic, clinical, and health economic utility as compared with angiography-guided standard care.

METHODS AND DESIGN

A prospective multicenter parallel-group 1:1 randomized controlled superiority trial in 350 NSTEMI patients with ≥1 coronary stenosis ≥30% severity (threshold for FFR measurement) will be conducted. Patients will be randomized immediately after coronary angiography to the FFR-guided group or angiography-guided group. All patients will then undergo FFR measurement in all vessels with a coronary stenosis ≥30% severity including culprit and nonculprit lesions. Fractional flow reserve will be disclosed to guide treatment in the FFR-guided group but not disclosed in the "angiography-guided" group. In the FFR-guided group, an FFR ≤0.80 will be an indication for revascularization by percutaneous coronary intervention or coronary artery bypass surgery, as appropriate. The primary outcome is the between-group difference in the proportion of patients allocated to medical management only compared with revascularization. Secondary outcomes include the occurrence of cardiac death or hospitalization for myocardial infarction or heart failure, quality of life, and health care costs. The minimum and average follow-up periods for the primary analysis are 6 and 18 months, respectively.

CONCLUSIONS

Our developmental clinical trial will address the feasibility of FFR measurement in NSTEMI and the influence of FFR disclosure on treatment decisions and health and economic outcomes.

Adoption and effectiveness of internal mammary artery grafting in coronary artery bypass surgery among Medicare beneficiaries

OBJECTIVES

The aim of this study was to assess the pattern of the adoption of internal mammary artery (IMA) grafting in the United States, test its association with clinical outcomes, and assess whether its effectiveness differs in key clinical subgroups.

BACKGROUND

The effect of IMA grafting on major clinical outcomes has never been tested in a large randomized trial, yet it is now a quality standard for coronary artery bypass graft (CABG) surgery.

METHODS

We identified Medicare beneficiaries ≥66 years of age who underwent isolated multivessel CABG between 1988 and 2008, and we documented patterns of IMA use over time. We used a multivariable propensity score to match patients with and without an IMA and compared rates of death, myocardial infarction (MI), and repeat revascularization. We tested for variations in IMA effectiveness with treatment × covariate interaction tests.

RESULTS

The IMA use in CABG rose slowly from 31% in 1988 to 91% in 2008, with persistent wide geographic variations. Among 60,896 propensity score-matched patients over a median 6.8-year follow-up, IMA use was associated with lower all-cause mortality (adjusted hazard ratio: 0.77, p < 0.001), lower death or MI (adjusted hazard ratio: 0.77, p < 0.001), and fewer repeat revascularizations over 5 years (8% vs. 9%, p < 0.001). The association between IMA use and lower mortality was significantly weaker (p ≤ 0.008) for older patients, women, and patients with diabetes or peripheral arterial disease.

CONCLUSIONS

Internal mammary artery grafting was adopted slowly and still shows substantial geographic variation. IMA use is associated with lower rates of death, MI, and repeat coronary revascularization.

Cost-effectiveness of percutaneous coronary intervention with drug eluting stents versus bypass surgery for patients with diabetes mellitus and multivessel coronary artery disease: results from the FREEDOM trial

BACKGROUND

Studies from the balloon angioplasty and bare metal stent eras have demonstrated that coronary artery bypass grafting (CABG) is cost-effective compared with percutaneous coronary intervention (PCI) for patients undergoing multivessel coronary revascularization-particularly among patients with complex coronary artery disease or diabetes mellitus. Whether these results apply in the drug-eluting stent (DES) era is unknown.

METHODS AND RESULTS

Between 2005 and 2010, 1900 patients with diabetes mellitus and multivessel coronary artery disease were randomized to PCI with DES (DES-PCI; n=953) or CABG (n=947). Costs were assessed from the perspective of the U.S. health care system. Health state utilities were assessed using the EuroQOL 5 dimension 3 level questionnaire. A patient-level microsimulation model based on U.S. life-tables and in-trial results was used to estimate lifetime cost-effectiveness. Although initial procedural costs were lower for CABG, total costs for the index hospitalization were $8622 higher per patient. Over the next 5 years, follow-up costs were higher with PCI, owing to more frequent repeat revascularization and higher outpatient medication costs. Nonetheless, cumulative 5-year costs remained $3641 higher per patient with CABG. Although there were only modest gains in survival with CABG during the trial period, when the in-trial results were extended to a lifetime horizon, CABG was projected to be economically attractive relative to DES-PCI, with substantial gains in both life expectancy and quality-adjusted life expectancy and incremental cost-effectiveness ratios <$10 000 per life-year or quality-adjusted life-year gained across a broad range of assumptions regarding the effect of CABG on post-trial survival and costs.

CONCLUSIONS

Despite higher initial costs, CABG is a highly cost-effective revascularization strategy compared with DES-PCI for patients with diabetes mellitus and multivessel coronary artery disease.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinical-trials.gov. Unique identifier: NCT00086450.

Comparing cost aspects of coronary artery bypass graft surgery with coronary artery stenting

Randomized trials have compared revascularization of coronary artery disease by coronary artery bypass graft surgery (CABG) or percutaneous coronary intervention (PCI). CABG is an expensive treatment. However, it manages to improve quality of life, restore general well being, and alleviate symptoms of patients. Coronary stents have improved the safety and durability of PCI. Nonetheless, stenting remains limited by a relatively high in-stent restenosis and thrombosis rate. The costs and cost-effectiveness for these different treatment modalities are relevant issues because cardiovascular disease and its management are prime targets for cost reduction initiatives. There is a debate as to which is the optimal treatment strategy as well as to the cost-effectiveness comparing CABG and PCI. This review provides an overview of cost-effectiveness of CABG compared with PCI. PCI has high costs due to the need for subsequent revascularization procedures, with absence of mortality and survival benefit compared with CABG. Despite the relative lower initial costs of PCI in the first year, PCI is not a cost-effective intervention in comparison with CABG. However, the studies undertaken to date have predominantly been short term and provide a very limited evidence base by which to assess the cost-effectiveness of modern clinical practice. It seems that in longer term, the benefits of CABG may exceed those of stenting and the difference in net cost may be in favour of CABG as the risk of repeat revascularization still increases with PCI regardless of the use of DES. However, to date no long-term data are available in cost-effectiveness between CABG and PCI. The 5-year outcome of the ongoing SYNTAX trial is essential and might therefore provide new insights into the comparison of cost-effectiveness between CABG and DES PCI.

Why do patients having coronary artery bypass grafts have different costs or length of stay? An analysis across 10 European countries

We analyse variations in cost or length of stay (LoS) for 66,587 patients from 10 European countries receiving a coronary artery bypass graft (CABG) procedure. In five of these countries, variations in cost are analysed using log-linear models. In the other five countries, negative binomial regression models are used to explore variations in LoS. We compare how well each country's diagnosis-related group (DRG) system and a set of patient-level characteristics explain these variations. The most important explanatory factors are the total number of diagnoses and procedures, although no clear effects are evident for our CABG-specific diagnostic and procedural variables. Wound infections significantly increase LoS and costs in most countries. There is no evidence that countries using larger numbers of DRGs to group CABG patients are better at explaining variations in cost or LoS. However, refinements to the construction of DRGs to group CABG patients might recognise first and subsequent CABGs or other specific surgical procedures, such as multiple valve repair.

Coronary artery bypass graft surgery in acute coronary syndrome: incidence, cost impact, and acute clopidogrel interruption

BACKGROUND

Guidelines stipulate that clopidogrel should be interrupted ≥ 5 days prior to elective coronary artery bypass graft (CABG) surgery to reduce the risk of bleeding unless the need for revascularization and/or the net benefit of the clopidogrel outweighs the potential risks of bleeding. This study describes real-world patterns of acute clopidogrel use, CABG surgery, and inpatient costs among patients with acute coronary syndrome (ACS).

METHODS

The study used the MarketScan® Commercial, Medicare Supplemental, and Hospital Drug databases, comprising health care data for > 63 million individuals in the United States. Acute coronary syndrome episodes, defined as hospitalizations for ACS (primary International Classification of Diseases, Ninth Revision, Clinical Modification codes 410.xx, 411.1x) occurring between January 1, 2005 and June 30, 2009, were identified from patients aged ≥ 18 years. Outcomes included cost of and length of stay (LOS) for ACS episodes and, among patients experiencing ACS episodes treated with acute clopidogrel administration followed by CABG surgery, the duration of clopidogrel interruption prior to CABG surgery. Analyses were descriptive.

RESULTS

A total of 160 168 ACS episodes were identified, and the mean patient age was 63.5 years. Coronary artery bypass graft surgery episodes comprised 9.3% (14 896 of 160 168) of all ACS episodes. The mean LOS was 9.8 (standard deviation [SD], 6.8) days per CABG surgery episode, and mean inpatient costs were $71 140 (SD, $68 012) per CABG surgery episode. Among patients experiencing ACS episodes with inpatient drug data and to whom acute clopidogrel was administered followed by CABG surgery (n = 8101), the mean duration of clopidogrel interruption was 3.3 (SD, 2.6) days, and the majority (62.1%) of these patients underwent surgery within 1 to 3 days after their last acute clopidogrel dose. The mean incremental increase in inpatient costs associated with 1 extra LOS day was $1991.

CONCLUSION

Coronary artery bypass graft surgery is used relatively infrequently among patients who experience ACS episodes. When CABG surgery is performed in a real-world setting, the majority or procedures are performed < 5 days after the last acute clopidogrel dose. However, among patients for whom urgent CABG surgery is not indicated, withholding CABG surgery to allow for clopidogrel interruption may only minimally affect inpatient costs and must be considered in the broader context of patient management.

Rationale and design of the coronary artery bypass grafting surgery off or on pump revascularization study: a large international randomized trial in cardiac surgery

BACKGROUND

Uncertainty remains regarding the benefits and risks of the technique of operating on a beating heart (off pump) for coronary artery bypass grafting (CABG) surgery versus on-pump CABG. Prior trials had few events and relatively short follow-up. There is a need for a large randomized, controlled trial with long-term follow-up to inform both the short- and long-term impact of the 2 approaches to CABG.

METHODS

We plan to randomize 4,700 patients in whom CABG is planned to undergo the procedure on pump or off pump. The coprimary outcomes are a composite of total mortality, myocardial infarction (MI), stroke, and renal failure at 30 days and a composite of total mortality, MI, stroke, renal failure, and repeat revascularization at 5 years. We will also undertake a cost-effectiveness analysis at 30 days and 5 years after CABG surgery. Other outcomes include neurocognitive dysfunction, recurrence of angina, cardiovascular mortality, blood transfusions, and quality of life.

RESULTS

As of May 3, 2011, CORONARY has recruited >3,884 patients from 79 centers in 19 countries. Currently, patient's mean age is 67.6 years, 80.7% are men, 47.0% have a history of diabetes, 51.4% have a history of smoking, and 34.4% had a previous MI. In addition, 20.9% of patients have a left main disease, and 96.6% have double or triple vessel disease.

CONCLUSIONS

CORONARY is the largest trial yet conducted comparing off-pump CABG to on-pump CABG. Its results will lead to a better understanding of the safety and efficacy of off-pump CABG.

Globalization of health care delivery in the United States through medical tourism

This study highlights some of the inefficiencies in the U.S. health care system and determines what effect medical tourism has had on the U.S. and global health care supply chains. This study also calls attention to insufficient health communication efforts to inform uninsured or underinsured medical tourists about the benefits and risks and determines the managerial and cost implications of various surgical procedures on the global health care system into the future. This study evaluated 3 years (2005, 2007, and 2011) of actual and projected surgical cost data. The authors selected 3 countries for analysis: the United States, India, and Thailand. The surgeries chosen for evaluation were total knee replacement (knee arthroplasty), hip replacement (hip arthroplasty), and heart bypass (coronary artery bypass graft). Comparisons of costs were made using Monte Carlo simulation with variability encapsulated by triangular distributions. The results are staggering. In 2005, the amount of money lost to India and Thailand on just these 3 surgeries because of cost inefficiencies in the U.S. health care system was between 1.3 to 2 billion dollars. In 2011, because many more Americans are expected to travel overseas for health care, this amount is anticipated to rise to between 20 and 30.2 billion dollars. Therefore, more attention should be paid to health communication efforts that truly illustrate the benefits/risks of medical travel. The challenge of finding reliable data for surgeries performed and associated surgical cost estimates was mitigated by the use of a Monte Carlo simulation of triangular distributions. The implications from this study are clear: If the U.S. health care industry is unable to eliminate waste and inefficiency and thus curb rising costs, it will continue to lose surgical revenue to foreign health providers.

Effectiveness and cost-effectiveness of coronary artery bypass surgery versus drug eluting stents in Armenia: a feasibility study

We evaluated the cost-effectiveness of PCI with DES versus CABG in terms of preventing MACE (composite outcome of myocardial infarction (MI), repeat revascularization (RR), and death) after four years of procedure among patients with ischemic heart disease (IHD) treated at NMMC from January 1 2004 to December 31 2005. Patients who were more than 70 years old, who had prior revascularization (CABG or PCI), cardiogenic shock, end-stage renal disease defined as a serum creatinine>2 mg/dl, severe left ventricular dysfunction defined as a left ventricular ejection fraction<30%, or cancer at the time of admission were excluded from the sample. We also excluded patients whose procedures were covered by the Ministry of Health of Armenia (3 patients at the time of study). PCI and CABG patients were matched 1:1 for three important predictors that may potentially affect the selection of procedures and the outcomes--age (±3 years), gender, and diabetes mellitus status. Patients in the CABG group had significantly longer event-free survival times than patients in the PCI group (p<0.037, unadjusted difference) in 4.2 years of follow-up. CABG was less costly by $6,540 with preventing one more MACE compared to PCI with DES. According to our findings, CABG is a more cost-effective strategy than PCI with DES in terms of preventing RR, MI and death and saving costs. Prospective evaluation with longer time horizon would add more information to the results of our study, since the number of patients referred to the PCI replacement is increasing, the pricing is frequently changing, and there are new technologies in development.