PTCAs, not CABGs, rise at St. Thomas Hospital
But cost-effectiveness? The jury’s out
St. Thomas Hospital in Nashville, TN, ranks third in the nation in terms of volume of cardiac patients. Cardiologists and surgeons there performed 2,197 cath lab procedures and 2,602 bypasses last year.
Cathy Osten, RN, St. Thomas’ cardiac case manager, says, "Our heart center increased its number of interventional cath lab procedures by 54% between 1995 and 1996. The operations include angioplasty with or without stent, directional coronary atherectomy where surgeons shave and suction plaque, and percutaneous coronary transluminal rotational atherectomy (PTCA) in which surgeons use a rotoblade on heavily calcified lesions. The number of coronary artery bypass grafts (CABG) increased by only 7.3% between 1995 and 1996."
CABG patients typically are worked up as outpatients, then are in the hospital for four to five days. The surgery alone on average costs $55,000 to $60,000 and takes four to five hours. Patients receive general anesthesia and are placed on the heart-lung machine. For PTCA, which typically costs $15,000 to $17,000, the patient goes to the cath lab the day of the procedure. The angioplasty takes an hour, following which the patient must stay in bed for two to six hours with a sheath in the femoral artery. After its removal, bed rest is required for an additional six to eight hours. The patient is then discharged on the same day or the next day.
Cost Management in Cardiac Care asked Osten if she could compare the cost-effectiveness of PTCA and CABG.
"Even if one supposes that all things can be equal," she says, "comparing cost-effectiveness of the two procedures is very complex. It must take into account restenosis rates, the lifetime expectancy of grafts, and many other factors. For example, consider the patient with major pulmonary and other problems who would be put at high risk by general anesthesia and a median sternotomy where the sternum is split to allow a six-inch opening. That individual’s symptoms are relieved and he or she is better served with the less invasive angioplasty."
"Then the picture is muddied further by the scenario of the patient who comes in and already has had a bypass procedure, or even two. A lesion has developed on the graft, and we do an angioplasty and/or place a stent in the graft itself, giving the patient several more quality years of life. Analyzing cost would have to take into account complex factors like that," continues Osten.
"Frankly," says Osten, "cost-effectiveness issues are not looked at by our cardiologists and surgeons. They look at the clinical problem and how to best treat it."
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