PTCA vs CABG: Five-year outcomes reported
BARI trial turns focus to cost, quality of life
Various factors complicate attempts to compare the cost-effectiveness of percutaneous transluminal coronary angioplasty (PTCA) with that of coronary artery bypass graft (CABG). The Bypass Angioplasty Revascularization Investigation (BARI) trial looked at outcomes measures, but conclusions were relatively ambivalent on economic factors. (See related article on the BARI study, p. 50.)
Surgically treated patients stay in the hospital longer than those assigned to PTCA, but those who undergo CABG require less follow-up antianginal medication and are less likely to need another revascularization procedure. The initial cost of straightforward bypass grafting is two to three times higher than that of angioplasty, but the costs related to two or more sequential procedures following PTCA, as well as medication and hospitalization, can be substantial.
Five-year outcomes just published
Five-year-mark findings from the BARI trial were published last month.1 Survival rates, clinical and functional outcomes, and quality of life measures of patients who undergo PTCA or CABG are similar at the five-year mark, investigators say, but differences appear prior to reaching the present. (See related article on PTCA and CABG trends, p. 49.)
The BARI investigators state in their report that an excess of repeated procedures in the angioplasty arm of their study significantly diminishes the cost advantage of PTCA. "Within the time frame of the study," they say, "the medical cost of PTCA did not quite reach that of CABG, despite much greater use of staged procedures in the trial than is the current practice. Our cost analysis of [a related German investigation] . . . revealed that the initial hospitalization was 49% less expensive for patients undergoing PTCA than for those undergoing CABG. Because of the higher rate of subsequent interventions in the angioplasty group, the difference was reduced to approximately 25% after one and two years of follow-up. . . . Future economic comparisons will need to take into account changing economic realities and practice patterns."
Quality of life issues gain status
Because BARI reveals comparable data on survival and myocardial infarction (MI) rates at the five-year mark, symptoms, functional status, and quality of life attain more stature.
Rick Mace, MA, president of Rick Mace Associates in Orlando, FL, says, "After five years, it’s no longer an issue of which approach is better from a mortality point of view, but rather from cost and quality of life points of view. Angioplasty is less costly initially and causes less trauma for the patient. Cardiologists are well-skilled at PTCA as well. The potential cost to the payer for PTCA is about $15,000 to $17,000. That’s without a stent being placed. If stents are placed, add $2,000 to that. For open-heart surgery with cardiac catheterization, the average cost with physicians’ fees and hospitals' average charges are $55,000 to $60,000. You can do a lot of angioplasties before you catch up to the cost of CABG."
A meta-analysis of other randomized clinical trials comparing the two revascularization procedures draw similar conclusions: After one to three years, patients assigned to CABG are significantly more likely to be angina-free and less likely to undergo subsequent revascularization.
Stent usage impacts procedure costs
Resources are more intense with stents than with PTCA alone. Robin Steaban, RN, is the administrator of the cardiovascular patient care center at Vanderbilt University Medical Center in Nashville, TN. Steaban says, "PTCA has a significant reocclusion rate. For this reason, we rarely do straight angioplasty. We typically place stents, and that affects cost-effectiveness outcomes." Placing stents can add significantly to the cost of the procedure. On average, two to three stents are placed for a vessel lesion. One stent can cost $3,500, and that must be added to a $1,500 surgical cost.
Medicare is looking at the resources consumed with stent placement. The agency will analyze costs over a couple of years, look at resource utilization, and determine if stents should be placed in a different DRG with a higher reimbursement rate.
"When you’re trying to figure out the dollars associated with either revascularization procedure, it requires a close look," says Karen Elder, RN, MSN, coordinator of case management practices at Vanderbilt. "The patient may be coming in for an elective procedure and be in and out in under a day. If the patient has had a massive MI, he or she may be there for seven days. Patients undergoing PTCA have electrophysiology studies and thrombolytic therapy, and those drive costs up even higher."
Will CABG continue to be the preferred revascularization procedure?2 Many patients are less than optimal candidates for PTCA because of the following reasons:
• a recent MI;
• previous revascularization;
• occluded coronary arteries;
• a degree of narrowing of the left main coronary artery;
• stenosis of the left main coronary artery.
CABG carries advantages in addition to its influence on the frequency and severity of angina. Bypass grafting improves survival in patients who have involvement of the proximal left anterior descending artery as well as three-vessel coronary artery disease and left ventricular systolic dysfunction. Although PTCA may have a similar affect, its influence on survival in such patients is so far untested.
In any case, therapy must be individualized. There will be continued clinical and electrocardiographic follow-up of these BARI participants, especially in light of what seems to be long-term narrowing treatment differences. There’s gradual loss in saphenous vein graft patency after seven to 10 years, so late results of CABG may be compromised.
References
1. The Writing Group for the Bypass Angioplasty Revascularization Investigation (BARI) Investigators. Five-year clinical and functional outcome comparing bypass surgery and angioplasty in patients with multivessel coronary disease. JAMA 1997; 277:715-721.
2. Hillis LD, Rutherford JD. Coronary Angioplasty compared with bypass grafting (editorial). N Engl J Med, 1994; 331:1,086-1,087.
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