Clinical and Economic Outcomes of Multivessel Coronary Stenting
Clinical and Economic Outcomes of Multivessel Coronary Stenting
Background: Randomized trials comparing multivessel stenting with coronary artery bypass surgery (CABG) have demonstrated similar rates of death and myocardial infarction but higher rates of repeat revascularization after stenting. The impact of these alternative strategies on overall medical care costs is uncertain, particularly within the US health care system.
Methods: We performed a retrospective, matched cohort study to compare the clinical and economic outcomes of multivessel stenting and bypass surgery. The stent group consisted of 100 consecutive patients who underwent stenting of ≥2 major native coronary arteries at our institution. The CABG group consisted of 200 patients who underwent nonemergent isolated bypass surgery during the same time frame, matched (2:1) for age, sex, ejection fraction, diabetes mellitus, and extent of coronary disease. Detailed clinical follow-up and resource utilization data were collected for a minimum of 2 years. Total costs were calculated by use of year 2000 unit prices.
Results: Over a median follow up period of 2.8 years, there were no significant differences in all-cause mortality rates (3.0% vs 3.0%), Q-wave myocardial infarction (5.1% vs 4.0%), or the composite of death or myocardial infarction (7.1% vs 7.0%) between the stent and CABG groups (P = not significant for all comparisons). However, at 2-year follow up, patients with stents were more likely to require ≥1 repeat revascularization procedure (32.0% vs 4.5%, P < .001). The initial cost of multivessel stenting was 43% less than the cost of CABG ($11,810 vs $20,574, P < .001) and remained 27% less ($17,634 vs $24,288, P = .005) at 2 years.
Conclusions: Multivessel stenting and CABG result in comparable risks of death and myocardial infarction. Despite a higher rate of repeat revascularization, multivessel stenting was significantly less costly than CABG through the first 2 years of follow-up.
Over the past decade, multiple randomized clinical trials have compared balloon angioplasty (percutaneous transluminal coronary angioplasty [PTCA]) with coronary artery bypass surgery (CABG) for the treatment of multivessel coronary disease. In general, these trials have demonstrated that both treatments result in similar rates of long-term death and myocardial infarction (MI) (with the possible exception of treated patients with diabetes) but that balloon angioplasty is associated with a much greater need for additional revascularization procedures. Although PTCA is significantly less costly as an initial procedure, long-term costs are nearly identical for the 2 treatment strategies.
Since the completion of these first randomized trials, there have been numerous advances in both percutaneous and surgical coronary revascularization. Percutaneous coronary intervention (PCI) has been revolutionized by the development of coronary stents and glycoprotein IIb/IIIa inhibitors, which have substantially improved the safety and long-term durability of these procedures. Although bypass surgery has undergone less radical change, in the US health care system, economic pressures have led to the development of critical pathways and quality improvement initiatives, with dramatic reductions in length of stay and hospital costs.
The net effect of such advances on the long-term outcomes and costs of these alternative revascularization strategies is unknown. Although 3 randomized trials comparing multivessel stenting with bypass surgery have been reported recently, only 1-year economic and clinical outcomes are currently available. Moreover, these studies were conducted entirely outside of the United States, limiting the interpretation of economic data. To address these limitations, we performed a matched cohort study to compare the long-term clinical and economic outcomes of coronary stenting with bypass surgery for the treatment of multivessel coronary disease within the US health care system.
Background: Randomized trials comparing multivessel stenting with coronary artery bypass surgery (CABG) have demonstrated similar rates of death and myocardial infarction but higher rates of repeat revascularization after stenting. The impact of these alternative strategies on overall medical care costs is uncertain, particularly within the US health care system.
Methods: We performed a retrospective, matched cohort study to compare the clinical and economic outcomes of multivessel stenting and bypass surgery. The stent group consisted of 100 consecutive patients who underwent stenting of ≥2 major native coronary arteries at our institution. The CABG group consisted of 200 patients who underwent nonemergent isolated bypass surgery during the same time frame, matched (2:1) for age, sex, ejection fraction, diabetes mellitus, and extent of coronary disease. Detailed clinical follow-up and resource utilization data were collected for a minimum of 2 years. Total costs were calculated by use of year 2000 unit prices.
Results: Over a median follow up period of 2.8 years, there were no significant differences in all-cause mortality rates (3.0% vs 3.0%), Q-wave myocardial infarction (5.1% vs 4.0%), or the composite of death or myocardial infarction (7.1% vs 7.0%) between the stent and CABG groups (P = not significant for all comparisons). However, at 2-year follow up, patients with stents were more likely to require ≥1 repeat revascularization procedure (32.0% vs 4.5%, P < .001). The initial cost of multivessel stenting was 43% less than the cost of CABG ($11,810 vs $20,574, P < .001) and remained 27% less ($17,634 vs $24,288, P = .005) at 2 years.
Conclusions: Multivessel stenting and CABG result in comparable risks of death and myocardial infarction. Despite a higher rate of repeat revascularization, multivessel stenting was significantly less costly than CABG through the first 2 years of follow-up.
Over the past decade, multiple randomized clinical trials have compared balloon angioplasty (percutaneous transluminal coronary angioplasty [PTCA]) with coronary artery bypass surgery (CABG) for the treatment of multivessel coronary disease. In general, these trials have demonstrated that both treatments result in similar rates of long-term death and myocardial infarction (MI) (with the possible exception of treated patients with diabetes) but that balloon angioplasty is associated with a much greater need for additional revascularization procedures. Although PTCA is significantly less costly as an initial procedure, long-term costs are nearly identical for the 2 treatment strategies.
Since the completion of these first randomized trials, there have been numerous advances in both percutaneous and surgical coronary revascularization. Percutaneous coronary intervention (PCI) has been revolutionized by the development of coronary stents and glycoprotein IIb/IIIa inhibitors, which have substantially improved the safety and long-term durability of these procedures. Although bypass surgery has undergone less radical change, in the US health care system, economic pressures have led to the development of critical pathways and quality improvement initiatives, with dramatic reductions in length of stay and hospital costs.
The net effect of such advances on the long-term outcomes and costs of these alternative revascularization strategies is unknown. Although 3 randomized trials comparing multivessel stenting with bypass surgery have been reported recently, only 1-year economic and clinical outcomes are currently available. Moreover, these studies were conducted entirely outside of the United States, limiting the interpretation of economic data. To address these limitations, we performed a matched cohort study to compare the long-term clinical and economic outcomes of coronary stenting with bypass surgery for the treatment of multivessel coronary disease within the US health care system.