Comparison of Cost and Clinical Outcome of Isolated Patent Ductus Arteriosus
ABSTRACT & COMMENTARY
Synopsis: Transcatheter coil occlusion of patent ductus arteriosus is equally effective and safe as well as less costly than surgical closure.
Source: Prieto LR, et al. Comparison of cost and clinical outcome between transcatheter coil occlusion and surgical closure of isolated patent ductus arteriosis. Pediatrics 1998; 101:1020-1024.
This study compared the cost and clinical effectiveness of transcatheter coil occlusion vs. surgical closure of patent ductus arteriosus (PDA). Patients were included in the study if they were eligible for either closure technique. Patients were excluded if they had other significant cardiac or non-cardiac problems. The study population consisted of 36 patients; 24 underwent PDA coil occlusion and 12 underwent surgical closure over a three-year period at a single institution. Median procedural duration was the same for both groups. The total hospital costs of transcatheter coil occlusion were significantly lower than that of surgical closure ($5273 vs $8509). The differences were due to the costs of hospital stay and professional costs, both of which were significantly higher in the surgical group. Additional technical costs of the surgical procedure related to general anesthesia and postoperative care made up the rest of the difference. No patient in either group had complications or a residual PDA murmur at discharge or on follow-up.
COMMENT BY ALAN FRIEDMAN, MD, FAAP
Transcatheter closure of PDA using Gianturco coils has become an alternative to surgical closure (see PAMR 1998;3:22-23 for a review of transcatheter intervention). Clinical results for the transcatheter techniques have been shown to be comparable with surgical closure for PDAs that measure less than 5 mm in diameter, and there are no significant long-term complications. This study compared the costs of resource use by the institution, the use of transcatheter coil technique and surgical closure in patients with isolated PDA. The results indicate that the cost of the transcatheter approach is significantly less than surgery ($5237 ± $1940 for transcatheter closure vs $8509 ± $1615 for surgery).
In the current environment of managed care, cost analysis of alternative treatment modalities is becoming increasingly important in patient management decisions. This study is the latest comparison between the surgical and transcatheter closure techniques for PDA. In 1993, Gray and associates reported on the cost of PDA closure by transcatheter and surgical techniques, and they found that the transcatheter technique was in fact more costly.1 However, in the study evaluated, the considerably more expensive Rashkind occluder device was used. The mean hospital stay for transcatheter patients in Gray's study was 2.4 days, and it is now less than one day with the coil technique. Finally, insertion of Rashkind devices were commonly performed under general anesthesia. The majority of coil techniques are performed with sedation only, yielding shorter cath lab stays, recovery room time, and lower complication rates.
Based on the results of the current study, transcatheter PDA closure using the coil technique is significantly less costly in terms of dollars to perform than the surgical closure, with comparable results. But dollars are not the only way to measure the cost of a procedure. In fact, one must also realize that resource use is only one aspect of the true cost of a procedure. One must also take into account the cost to payers, the patients and their families, and society. According to Fedderly and colleagues, the cost to payers is significantly lower for coil occlusion than for surgical closure.2 Some of the more difficult costs to measure include number of work days missed by parents, days of school missed by patients, care of siblings during the patient's convalescence, and the potential psychological cost of a thoracotomy scar to the child. While no data exist to assess these less tangible but important aspects to PDA closure, transcatheter coil occlusion would intuitively seem to be less expensive than surgery with regard to family and patient stress as well as missed time from work and school. Thus, it seems as if the transcatheter coil occlusion of the PDA is indicated from both the "dollars and sense" standpoint.
References
1. Gray DT, et al. Clinical outcomes and costs of transcatheter as compared with surgical closure of patent ductus arteriosus. N Engl J Med 1993;29:1517-1523.
2. Fedderly RT, et al. Comparison of hospital charges for closure of patent ductus arteriosus by surgery and transcatheter coil occlusion. Am J Cardiol 1996;77: 776-779.
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