Long-Term Cost of Coronary Stenting
Abstract & Commentary
Synopsis: Stenting improves long-term patient outcomes without increasing cumulative hospital costs.
Source: Peterson ED, et al. J Am Coll Cardiol 1999;33:1610-1618.
Coronary artery stenting has become increasingly popular because of excellent short- and long-term results using newer adjuvant antiplatelet strategies. However, the initial costs of stenting are formidable, especially in the United States, and this issue is a frequent flashpoint between cardiologists and hospital administrators. Thus, Peterson and colleagues evaluated the Duke University Medical Center’s interventional observational database to compare the economic and clinical outcomes of patients undergoing stenting vs. plain old balloon angioplasty (POBA). Patients were excluded if they were not candidates for both procedures and if target vessel diameter was less than 2.7 mm. Also, only elective cases were considered, not acute infarction patients, and only those receiving Palmaz-Schatz stents. In addition to clinical outcomes, hospital costs were evaluated at six and 12 months. Clinical characteristics of the 384 stented and 159 POBA patients were similar but not identical; significantly more POBA patients had prior bypass surgery, fewer had severe angina, and more had right and circumflex target lesions compared to the stented patients. Initial hospital costs were higher in the stented patients ($14,802 vs $11,534; P = 0.002), but they were less likely to have repeat revascularization (9 vs 26%; P = 0.001) at six months. Consequently, mean cumulative costs were almost identical ($19,598 vs $18,820) at six months and at one year ($22,140 vs $22,571). Adjustments for baseline characteristics that may influence cost, such as age, heart failure, etc., did not alter the conclusions. Peterson et al concluded that stenting improves long-term patient outcomes without increasing cumulative hospital costs.
Comment by Michael H. Crawford, MD
The basic conclusion of this study is that the increase in initial hospital costs due to stenting is offset over six months by a 53% decrease in repeat procedures. The cost estimates in this study are limited to hospital and physician charges. The cost of medications, repeat clinic visits, etc., are not estimated. Since the stented patients tended to have less angina (27% vs 36%; P = 0.07) at six months, they may have had lower medication and return visit costs. Also, indirect costs such as lost work were not considered. Since the stented patients were more likely to be employed at six months (86 vs 66%; P = 0.001), indirect costs could have been lower for them. Thus, total costs could be even more favorable for the stented patients, producing an actual cost savings over the longer term.
There are several limitations to this study that need to be considered. Since it is an observational study, wellmatched groups cannot be assured and there were some potentially important differences between them, such as the fact that more left anterior descending lesions were in the stent group where interventional success is likely to be better. Also, those in whom stents could not be placed, such as due to ostial or bifurcating lesions, were included in the POBA group. It could be argued that restenosis would be more common in such patients. Consequently, the clinical outcomes and hence lower costs may have been stacked toward the stent group. However, the better clinical outcomes in this analysis are similar to those observed in randomized trials, which argues against a major selection bias.
Coronary intervention, like all therapy, is a moving target. This was a single-center study using one stent at a time (1995-96) when platelet glycoprotein IIb/IIIa inhibitors were not extensively used. Perhaps the results would be different if done today, but hopefully the stent group’s outcomes would be even better. However, the cost of stents and IIb/IIIa drugs today are not likely to reduce the initial costs of stenting. In a traditional fee-for-service environment, this could set up a lose-lose situation for the hospital —higher initial costs with less repeat business. Thus, until hospitals begin taking a more societal view of cost-effectiveness, the conflicts are likely to continue between cardiologists and administrators. These data may help cardiologists strengthen their position.
Which is most correct concerning elective coronary stenting vs. angioplasty alone?
a. High initial costs
b. Lower long-term costs
c. Higher total costs
d. a and b.
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