(Circulation. 1995;92:2831-2840.)
© 1995 American Heart Association, Inc.
Articles |
A Comparison of the Costs of and Quality of Life After Coronary Angioplasty or Coronary Surgery for Multivessel Coronary Artery Disease
Results From the Emory Angioplasty Versus Surgery Trial (EAST)
Presented in part at the 66th Scientific Sessions of the American Heart Association, Atlanta, Ga, November 8-11, 1993.
From the Division of Cardiology, Department of Medicine, Emory University School of Medicine, and the Division of Health Policy and Management, Emory University School of Public Health, Atlanta, Ga.
Correspondence to William S. Weintraub, MD, Division of Cardiology, Emory University Hospital, 1364 Clifton Rd NE, Atlanta, GA 30322. Email bill@hp3.eushc.org.
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Abstract |
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 Top Abstract IntroductionMethods Results Discussion References |
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Background The Emory Angioplasty Versus Surgery Trial (EAST) is a randomized trial that compares, by intention to treat, the clinical outcome and costs of percutaneous transluminal coronary angioplasty (PTCA) and coronary surgery for multivessel coronary artery disease.
Methods and Results The primary end point was a composite of death, Q-wave myocardial infarction, and a large reversible thallium defect at 3 years. Multiple measures of quality of life also were made. Charges were assessed from the hospital UB-82 bills; professional charges were assessed from the Emory Clinic. Hospital charges were reduced to cost through step-down accounting methods. All costs and charges were deflated to 1987 dollars. Costs were assessed for the initial hospitalization and the cumulative costs of the initial hospitalization and additional revascularization procedures for up to 3 years. There was no difference in mortality or the primary end point. Mean initial hospital charges were $12 654 for the PTCA group and $20 214 for the surgery group (P<.0001). Professional charges were $4538 for PTCA and $9426 for surgery (P<.0001). Three-year hospital charges were $19 047 for PTCA and $21 174 for coronary surgery (P<.0001). Three-year professional charges were $6412 for PTCA and $9861 for surgery (P<.0001). Three-year total charges were $25 458 for PTCA and $31 033 for surgery (P<.0001). Total 3-year costs were $23 734 for PTCA and $25 310 for coronary surgery (P<.0001). There were more hospitalizations for angina and more antianginal medications used in the PTCA group, which would further narrow the differences in cost.
Conclusions There was no difference in the primary end point or its components at 3 years. Although the primary procedural costs of coronary surgery are more than for coronary angioplasty, this cost advantage is largely, although probably not completely, lost by 3 years because of more frequent additional procedures and other resource consumption after a first revascularization by PTCA.
Key Words: coronary disease • angioplasty • cost-benefit analysis
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Introduction |
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TopAbstractIntroductionMethods Results Discussion References |
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As coronary angioplasty became as common as coronary surgery,1 2 many patients were found to be anatomically suitable for either procedure. Several trials currently are addressing the relative efficacies of these procedures. Efficacy may be measured by mortality, acute myocardial infarction, additional revascularization procedures, angina, and use of antianginal medications. There are additional aspects of efficacy generally included under the term "quality of life" that are more difficult to measure. These include returning to work, social functioning, and psychological state.
Another aspect of a comparison of the two procedures is cost. In principle, if both relative efficacy and relative cost could be measured, then determining which form of therapy was superior in terms of improved efficacy per dollar spent would be simple.3 The multiple measures of efficacy make this a difficult proposition. Similarly, it is not possible to arrive at one final figure for costs. Costs may be reflected in initial in-hospital costs and various measures of cost over different periods of time. Determining the boundaries of what to include in the cost of a procedure after discharge is difficult and arbitrary. Furthermore, there are multiple potential measures of cost.4
The purpose of this article is to present the initial in-hospital charges and costs of procedures in patients with multivessel disease randomized to percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass graft surgery (CABG) in the Emory Angioplasty Versus Surgery Trial (EAST).5 6 In addition, the costs of additional revascularization procedures over 3 years and several indexes of quality of life are presented.
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Methods |
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TopAbstractIntroductionMethods Results Discussion References |
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Overall Trial Description
EAST is a single-center, randomized clinical trial designed to evaluate whether initial revascularization with PTCA is as efficacious and safe as CABG for patients with multivessel coronary artery disease.5 6 Patients were randomized in EAST from 1987 through 1990 within strata of severity of disease (see definitions below). The primary end point was a composite of death, Q-wave myocardial infarction within 3 years, or a large reversible thallium defect at 3 years. A registry included all patients eligible but not randomized and a complete list of all patients screened for the trial.
Definitions
Clinical variables were defined in a data
dictionary in the
EAST trial.5 6 Double-vessel disease meant the
presence of 
50% diameter luminal narrowing in two of the three major
epicardial vessel systems. Triple-vessel disease was defined as the
presence of 50% diameter luminal narrowing in all three major
epicardial vessel systems or in the left anterior descending and
proximal circumflex arteries in patients with nondominant right
coronary arteries. Strata 1 included double-vessel disease
with 50% diameter luminal narrowing at one site in each affected
vessel. Strata 2 was double-vessel disease with 50% diameter
luminal narrowing in more than one site in at least one affected
vessel. Strata 3 included triple-vessel disease with 50%
diameter luminal narrowing at one site in each affected vessel. Strata
4 was triple-vessel disease with 50% diameter luminal narrowing
in more than one site in at least one affected vessel. A staged
procedure was angioplasty during the initial hospitalization at a site
different from any previously dilated site and within the same
hospitalization or 14 days of the original procedure. Myocardial
infarction was defined as Q-wave myocardial infarction determined by
the ECG committee. Q waves were analyzed according to the
Minnesota Code. ECGs were gathered during the index hospitalization and
for all cardiac-related hospitalizations during follow-up.
Thallium defect was defined as a large reversible thallium defect at
the 3-year follow-up as judged by the thallium committee. The
hospitalization for chest pain category included patients hospitalized
for chest pain without myocardial infarction or additional procedures.
Variables defined by patient history were hypertension, diabetes,
severity of angina, and prior myocardial infarction. Angina was defined
by the Canadian Cardiovascular Society
Classification.7 Congestive heart failure was defined by
the New York Heart Association criteria.
Procedure and Data Collection
All angioplasty and surgery
procedures were performed with
previously described standard techniques.8 9 Baseline
and
restudy demographic, clinical, angiographic, and procedural data,
including complications, were recorded prospectively on
standardized forms and entered into a computerized database. All fields
were defined in a data dictionary.
Patient Follow-up
Follow-up information was obtained from the
patients or
physicians. Follow-up was obtained by telephone every 6 months for
3 years. Follow-up status for each end point also was assessed at
each subsequent hospital admission. Patients not readmitted were
contacted by telephone or letter. Information obtained included
occurrence of myocardial infarction since the initial angioplasty,
subsequent need for an additional revascularization
procedure (angioplasty or coronary surgery), death (cardiac and
noncardiac), recurrent angina, and information on economies and quality
of life. All follow-up information was recorded on standardized
forms and entered into the computerized database. All repeated
procedures performed at Emory University Hospital were confirmed by the
database.
Economic Data and Analyses
All hospital charges were obtained
from the UB-82 hospital
billing form from the hospital finance offices. The UB-82 is a uniform
billing statement used by all third-party insurance carriers.
Although all available codes were used in this study, charges for
catheterizations before and for days in the hospital
before the original angioplasty or coronary surgery were not
included. All professional charges for all hospitalizations at Emory
were obtained electronically from the Emory Clinic Business Office,
which performs all professional billing at Emory.
Costs were estimated from the charge data. From the actual resource use in each category, cost-to-charge ratios were determined by the Emory University Hospital Finance Department by use of variations of microcosting and vertical costing.10 These estimates were made by assessment of the use of space, manpower, equipment, and time of services for procedures. Total charges for specific services and centers were determined as follows: once direct costs were calculated for each center, the department-specific indirect cost was added on the basis of the step-down allocation methodology10 used in Medicare cost reports, and an additional amount based on the history of noncollectibles of the particular department was added to the cost figure. Finally, an amount was added for nonpayments. With knowledge of costs and charges for each department, the cost-to-charge ratios were calculated and applied to our sample of patients to determine actual hospital resource use (costs). An example of the calculation of cost-to-charge ratios and application of this procedure to a patient bill is presented in the "Appendix." Physician charges were used as a proxy for professional costs. The mean charges and costs from Emory were used to estimate those for follow-up procedures performed at other institutions. Because treatment therapies should be compared at one point in time, the value of resources that are not used entirely in the present should be adjusted for annual inflation, the percentage rate at which the general level of prices is changing. Therefore, costs were deflated to 1987 dollars by use of the Medical Consumer Price Index. This is particularly important because the patterns of resource use are different for each therapy, with patients undergoing CABG consuming more resources during the original hospitalization and patients undergoing PTCA requiring additional resources over several years. In principle, costs may be inflated to 1993 by multiplying all dollar figures in this article by 1.56. Although 1993 costs might seem more relevant, costs inflated to 1993 may not fully reflect current costs because the efficiency of intervention procedures and cardiac surgery services probably has increased during the last couple of years. Thus, the costs may best be used for comparison between procedures.
Statistical Analyses
Data are expressed as proportions or
mean±SD and as median for
the cost data. The two groups were compared according to intention to
treat. Follow-up for mortality and repeated procedures was complete
at 3 years or the time of death for all patients. Because the data for
procedures were not censored, except for death, and all procedures, not
just the first one in the follow-up period, were considered, these
usually timed end points were considered proportions; actuarial
statistics were not used. This was necessary because actuarial
statistics will count only the first follow-up procedure; the error
that resulted because actuarial statistics were not used was minimal
and similar in the two groups because at 3 years the actuarial
mortality was just 7% for PTCA patients and 6% for CABG
patients.5 Information on myocardial infarctions was
dependent on the availability of ECGs at 3 years; thus, some data were
missing for myocardial infarctions and the primary variable. More
data were missing for quality of life at 3 years. The denominator is
presented for all data when any data are missing. Cost data are
available on 384 patients. The 8 patients with missing data had
procedures performed at the Atlanta Veterans Administration Hospital.
Three-year cost data include data on those patients who died up to
the time of their deaths. Differences in categorical variables were
analyzed by 
2 (or Fisher's exact test);
differences in continuous variables were analyzed by
Student's t tests. When the assumption of normality was
violated, largely for the cost data, the two arms were compared by the
Mann-Whitney test and across strata by the Kruskal-Wallis test.
Correlates of costs in-hospital and over 3 years were determined
with multiple regression. Models were created by use of preprocedural
variables only and preprocedural and postprocedural variables.
All variables presented in the tables were evaluated for
each set of regression analyses. Log-linear models also
were tested. Statistical testing was performed with SAS,
S-PLUS, and BMDP statistical software
packages.
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Results |
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TopAbstractIntroductionMethods Results Discussion References |
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Baseline and clinical end point data in the EAST trial have been published5 and are reviewed in Table 1
.
There was no difference in the baseline values for age, sex, presence
of diabetes, systolic arterial hypertension,
severity of angina, or congestive heart failure. Most of the patients
suffered from severe angina. Despite a significant incidence of prior
myocardial infarction, few patients had congestive failure. In each
arm, 60% of the patients had two-vessel disease and 40% had
three-vessel disease. There was no difference in ejection fraction
between the treatment arms. In-hospital deaths were infrequent at
1%. This was also the mortality at 30 days. There was a trend toward
more in-hospital Q-wave myocardial infarctions in the surgical
group. At 3 years, there was no difference noted in death, Q-wave
myocardial infarction, or the primary end point.
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Table 2 gives the initial, additional in-hospital,
and follow-up procedures. A complex pattern of original
in-hospital resource use can be noted. To summarize, 196 of 198
patients in the PTCA arm initially had angioplasty. Of these 196
patients, 88 (45%) had additional angioplasties during the initial
hospitalization: 74 (38%) were treated with staged procedures and 14
(7%) had repeated angioplasty because of an adverse outcome of the
initial procedure. Of the PTCA patients, 10% required in-hospital
coronary surgery, while only 1 CABG patient required an
additional revascularization procedure. Over the
next 3 years, many more PTCA than CABG patients required additional
angioplasties and coronary surgical procedures. Of 162
additional procedures, only 8 (4.9%) were performed at institutions
other than Emory.
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Table 3 shows additional hospitalizations for myocardial
infarction, chest pain, congestive heart failure, and congestive heart
failure plus chest pain. There were more hospitalizations for chest
pain in the PTCA than the CABG group. Whereas no statistically
significant difference was noted for any other category, there was a
trend for more hospitalizations for myocardial infarction in the PTCA
group.
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Table 4 shows quality of life parameters at
3 years. Angina was more prevalent in the PTCA patients.
Consistent with this finding, there was a need for more
antianginal medication in the PTCA group. Congestive heart failure
remained infrequent. Almost two thirds of the patients reported good or
very good health. There was a strong trend for CABG patients to report
that they believed they had recovered completely compared with the PTCA
group. Conversely, there was a slight trend for more angioplasty
patients to feel optimistic about their health compared with CABG
patients. Most patients in each group reported the same or improved
economic status 3 years after their procedures as before the procedure.
Only about half the patients were working at the time of entry into the
study. Almost all the patients who were working before their procedures
returned to work, at least part-time. Nonetheless, of the patients
who were working before their original procedures, 
40% in each
group were retired by 3 years. This was consistent with a mean
age of 62 at the time of randomization. No difference was noted between
the treatment arms in job status before or after the original procedure
or at follow-up.
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Table 5 gives initial in-hospital and 3-year
procedural charges and costs. Cost data are displayed as mean±SD; the
median value also is displayed. The median values were always less than
the mean values, which is consistent with a tail of higher
costs for some patients. For all cost estimates, the difference between
median and mean was greater for angioplasty, and there were larger SDs
for each measure of cost for angioplasty, consistent with more
variability in the number of procedures performed. The initial hospital
charges, professional charges, and hospital costs in the group
randomized to surgery were all higher than for the angioplasty group.
The sum of hospital costs and professional charges was
$16 223±11 552 for the PTCA group and $24 005±6222 for the CABG
group (P<.0001). If these numbers were inflated to 1993
dollars, the figures would be $24 821±17 675 for PTCA and
$36 728±9520 for CABG. The in-hospital charges for angioplasty
were profoundly affected by the number of procedures. Thus, for the 94
angioplasty patients with one angioplasty procedure and no
coronary surgery, the original hospital charge was $8086±3904,
the hospital cost was $7946±3975, and the professional charge was
$3104±715.
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Although total procedural charges and costs for the two groups became closer at 3 years, the professional charges remained higher for the CABG group. There was no difference in total hospital costs, with a trend toward a higher mean value for angioplasty, but a higher median for coronary surgery. Thus, in these patients with multivessel disease, the total hospital and professional charges remained higher for coronary surgery than for coronary angioplasty. More than half of the cost advantage of angioplasty was lost when the charges were reduced to cost. At 3 years, the sum of professional charges and hospital costs was $23 734±15 798 (median, $19 059) for coronary angioplasty and $25 310±7480 (median, $23 572) for coronary surgery, numbers that were close but statistically different (P<.0001). Inflated to 1993 dollars, the sum for angioplasty becomes $36 313±24 171 (median, $29 160); for surgery, $38 724±11 444 (median, $36 065).
Figs 1 and 2 show initial hospital and
the total of initial hospital and 3-year costs, respectively, for the
cumulative percent of patients. The costs presented are
hospital costs and professional charges. In these types of figures, a
normal distribution would have a symmetrical sigmoid shape. The initial
hospital costs are clearly higher for CABG. In both groups but
especially for PTCA patients, the lack of a normal distribution may be
noted, with a tail of the last 10% to 15% of cases having costs that
are several times the median. At 3 years, the separation between groups
is less certain, with more PTCA than CABG patients having lower costs,
but the overlap between groups is greater than initially. Thus, the
curves actually cross. Although both groups now have a tail of patients
with higher costs, this tail is more prominent in the PTCA group.
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Fig 3 shows the initial hospital costs plus physician
charges by assigned treatment group and strata. For each stratum, the
costs were higher for CABG than PTCA. Costs rose slightly with CABG
from strata 1 to 4 (P=.013), and there was a slight increase
for PTCA (P=.09). Fig 4 shows similar data
for the full 3 years. Once again, costs rose slightly for CABG from
strata 1 to 4 (P=.028), and there was a slight trend in
favor of PTCA (P=.14). At 3 years, the variance in costs for
PTCA is much wider than initially and wider than for CABG. This was due
to considerable variation in the number of procedures for PTCA
patients; most CABG patients had only the original procedure. The costs
remain higher with surgery, although they drew closer together by 3
years compared with after the initial hospitalization for each stratum.
There remains a difference between angioplasty (mean,
$20 875±13 533; median, $16 392) and surgery (mean,
$23 639±6848;
median, $22 063) for stratum 1, while for stratum 4 the difference
between the mean costs of angioplasty (mean, $23 970±10 790; median,
$22 944) and surgery (mean, $27 022±7495; median, $25 591) is
smaller and of borderline statistical significance.
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Multiple regression was used to determine correlates of cost. Table
6 gives correlates of the total hospital costs and
physician charges. The clinical variables and complications in
Table 1
were considered potential correlates. The most powerful
correlate was assignment to the surgical group. The other correlates
were a history of congestive heart failure, older age, male sex, a
history of hypertension, and trends for angina class and strata. Note
that the variables are weak correlates, except for surgical
assignment. The multiple r value was .46 and
r2 was .21, revealing that only 21% of
the variability in cost could be accounted for by these variables.
Adding length of stay to the model would increase the r
value to .86 and the r2 value to .74.
However, length of stay is a composite variable incorporating many
other variables; thus, it destroys the ability to examine the
individual clinical correlates of cost. Table 7 gives
correlates of the 3-year cumulative hospital costs and physician
charges. The statistically significant correlates were ejection
fraction, a history of hypertension, and male sex, and there were
trends for angina class, older age, strata, surgical group, and
congestive heart failure. The big difference from initial costs is that
assignment to the CABG group changes from being the only powerful
correlate to having just a bare trend. In addition, the r
value fell to .27 and the r2 value to
.07, meaning that only 7% of the variability in cost was accounted
for. If the number of angioplasty and coronary surgical
procedures was included, r would rise to .75 and
r2 to .57. However, this would
essentially be a tautology in which procedures predict procedures.
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Discussion |
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TopAbstractIntroductionMethods Results Discussion References |
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CABG and PTCA are both expensive; >600 000 of these procedures are performed annually11 at a cost of more than $17 billion. There has been uncertainty as to their relative efficacies and costs in the treatment of multivessel coronary artery disease. Results from the 3-year evaluation of EAST reveal no difference in the primary end point or the components of the primary end point—death, Q-wave myocardial infarction, or a large reversible thallium defect—between treatment arms.5 In this investigation, we report on the hospital and professional charges and costs of the two procedures at 3 years, all deflated to the starting year of the trial, 1987. Some costs inflated to 1993 are included for comparison. Direct conversion to expected contemporary costs is not possible because of recent efforts to increase efficiency, technological change, and reimbursement reductions from Medicare and private insurance carriers.
At 3 years, the EAST results present a clear and striking use pattern. During the initial hospitalization, 102 of 198 patients (52%) in the PTCA group were treated with more than one procedure. Thereafter, the high percentage of patients with repeated revascularizations in the PTCA group resulted in a substantial increase in resource use, with 106 additional angioplasties and 23 additional coronary surgeries in the PTCA group. In contrast, after 3 years barely a quarter as many follow-up angioplasty procedures (28) and only one additional coronary surgery were required in the CABG group. As a consequence, at 3 years there remained only a small, albeit statistically significant, difference between the CABG and PTCA groups in the overall composite measure of hospital costs and physician charges. However, procedural costs do not reflect total direct costs. Total direct costs are probably even closer than the cost data presented here because of the additional hospitalizations for angina and additional use of antianginal medications in the PTCA group. As an estimate, if the cost of hospitalization for an angina patient without myocardial infarction and without or before additional revascularization is between $3000 and $6000 and there were 44 more such hospitalizations in the PTCA group, this would raise the mean cost in the PTCA group overall by $666 to $1333. If the total mean direct cost in the angioplasty group increased by $1000 to $2000 more than in the CABG group over 3 years as a result of additional medication and hospitalization for chest pain, then angioplasty would cost from $568 less to $432 more than coronary surgery. On the other hand, the costs of loss of income or other opportunities resulting from more prolonged hospitalization, time lost from work, or medical or nursing care after coronary surgery may be greater. Thus, the uncertainties of measurement are great, and the differences in cost over several years are small.
In terms of initial hospitalization, PTCA patients' hospital costs were significantly lower than CABG patients' costs, $11 684 versus $14 579. At 3 years, however, cumulative hospital costs for the two groups were similar. This pattern was seen with hospital costs specifically because the catheterization laboratory at Emory uses a higher cost-to-charge ratio than the operating room or surgical intensive care units and because of the larger number of repeated angioplasties in the PTCA group.
Quality of life measures also suggest some interesting patterns. The less complete revascularization with angioplasty appears to result in more frequent continuing angina in the PTCA group. In addition, fewer patients in this group felt that their recoveries were complete. However, more PTCA than CABG patients were optimistic about their health. This difference between PTCA patients' perceptions of their current and future health may relate to the more invasive nature of CABG and the resulting psychological impact. Future results from the ongoing EAST should shed more light on the relation between patients' perceptions of their health and their ultimate functional capabilities.
The EAST results are consistent with those from other trials reported to date,12 13 14 which have shown few clinical differences between the two forms of revascularization in acute myocardial infarction or death, except for more revascularization procedures in the angioplasty group. Although preliminary results of one Argentinean trial15 have found PTCA to be less expensive than CABG and economic outcome data are still expected from some European trials, the comparability of results from the European and South American trials and US trials, with varying clinical practices and reimbursement systems, is unclear and awaits further study. Neither clinical nor economic results from the American multicenter trial16 are available.
Limitations
Considering the cost of medical procedures, the
perspective that
would be most meaningful would be overall resources consumed by society
as a consequence of the procedure. This will always require some
assumptions, and it probably is impossible to assess this in an
accurate, thorough manner for complex procedures with consequences
extending over several years. The limitations of such a complete cost
analysis are detailed below. In lieu of a complete picture from
a societal standpoint, we have developed a perspective from the point
of view of the providers (hospitals and professionals), with some
information about additional resource use from a patient
perspective.
In this study, we have presented hospital charges and costs as derived from the UB-82 hospital billing form. Hospital charges are widely recognized as weak proxies for hospital costs, which depend more on institutional accounting peculiarities than uniform standards.17 However, to the degree that hospital charges reflect the relative relation between variables, they are informative and revealing. Multiple accounting methods have been proposed to try to extract costs from charges, although some might argue with limited success.18 The top-down method used in this study assumes a constant cost-to-charge ratio across a department.10 If the cost-to-charge ratio was lower for the catheterization laboratory, then the in-hospital and follow-up hospitalization costs for the angioplasty arm would be lower, while the costs for coronary surgery would be largely unchanged.
In principle, a better method to calculate cost than the top down would be to do accurate cost accounting for each service. Although cost accounting systems are beginning to be used in hospitals, these methods are only as good as the accuracy of the measurements, which may be both complicated and of questionable accuracy and validity. The costs presented in this study are average costs. Another approach would be to calculate marginal cost, the cost of doing one more procedure of a specific type.4 This might or might not be of more interest but would involve yet another set of assumptions about what constitutes marginal cost. Marginal costs are of more interest only if at least some fixed costs could be eliminated. There are also difficulties in determining physician costs. In the present study, we have presented physician charges as a proxy for costs. These charges do not equate to reimbursement. Collections may be expected to be a smaller fraction of charges in the future as Medicare and managed care programs reduce professional reimbursements. Future analyses may examine the Resource Based Relative Value Scale as a measure of professional costs.19 20
Follow-up direct and indirect costs are more difficult to measure than in-hospital costs. Direct costs are all direct medical expenses, including additional procedures, related hospitalizations, office visits, and medications. Indirect costs include additional expenses such as time lost from work. It is difficult to know which costs over several years of follow-up to attribute to a procedure. For instance, is a hospitalization for pneumonia 2 weeks after a myocardial infarction experienced 1 year after angioplasty attributable to the angioplasty? Indirect costs suffer similar difficulties. Is time lost from work merely hours lost times wage? The answer is "yes" if the patient is not paid, but if the patient continues to be paid, the patient suffers no loss of income. Can we attribute the cost to a loss to the employer? The answer is "yes" if the wage is the real loss to the employer. However, the loss to the employer may be either much less or much greater and is unmeasurable in a study such as this one. Thus, in a clinical cost study there must inevitably be a recognition that all follow-up costs cannot be accounted for. What is reported, however, should be complete or at least accounted for. A simple, straightforward approach was taken in the present study: the cost data presented are only for additional revascularization procedures. Collection of these data was straightforward because all but 8 procedures (5.0%) were performed at Emory and could easily be attributed to the original procedure. However, as noted above, the differences in the procedures make it likely that there are differences in follow-up direct and indirect costs. Additional analyses may explore other costs, including costs for lost wages or other opportunities, albeit with more assumptions and uncertainty about the data.
In an era of great changes in medicine, all areas examined in EAST are "moving targets." Coronary surgery is changing the least, while angioplasty continues to undergo methodological change. Although intervention today includes new devices,21 the impact on overall results has been variable.22 23 Perhaps the greatest changes are in cost. In EAST, 38% of the angioplasties were performed as staged procedures; today, this figure would be much lower. In addition, professional fees are falling. Hospitals are currently making great efforts to become more efficient, and length of stay is decreasing. Thus, interpretation of the EAST economic data over the next several years will have to be done from the perspective of changes in hospital and professional economic trends and secular inflationary trends.
It should be noted that while these analyses are for only 3 years, the EAST patients will be followed for 8 to 11 years. A recent study from Emory24 has shown that over a longer period, up to 12 years, coronary surgery patients also experience increasing rates of repeated revascularizations, which may accelerate the late cost of coronary surgery. Thus, it remains to be seen from an economic perspective which procedure will ultimately show the larger long-term cost increase.
Finally, the results are from a randomized cohort of patients with multivessel disease in a single institution and must be generalized to broader populations with caution. Other institutions may have different cost bases for both hospitalizations and professional fees. Other institutions also may have different practice patterns and use resources, especially for procedures, in somewhat different ways. Nonetheless, in such an important area where virtually no comprehensive data from randomized trials exist, investigations like the present one represent important starting points.
Conclusions
What do these data suggest for medical decision
making? At 3
years, it appears that in patients with multivessel disease who are
anatomically suitable for either procedure, no significant differences
were found in death rates, myocardial infarction, or ischemic
potential, while there was little difference in cost. Quality of life
measures, especially angina, favored coronary surgery, although
patients have to undergo the more difficult procedure to achieve this
improved quality of life. Thus, when
revascularization is needed in patients for whom
either procedure is appropriate, it is essential for physicians and
medical personnel to work with patients and families to make the best
choice. Some patients may seek to avoid surgery and would prefer the
less invasive approach of angioplasty, knowing that they have a greater
probability of recurrent symptoms. Conversely, other patients may
prefer coronary surgery over angioplasty because of the lower
probability of additional revascularization and
recurrent symptoms over the first several years after the original
procedure.
This investigation underscores the importance of patient satisfaction and quality of life in evaluating the outcomes of these procedures. In light of the growing pressure to contain costs and provide patient satisfaction, data on patients' subjective evaluations of outcome, symptomatic status, rates of death, myocardial infarction, and additional revascularization and on cost must be considered with each patient's specific clinical status and point of view to select the appropriate therapy. Because the randomization process eliminates the inevitable selection bias when patients and physicians choose the form of therapy, the clinical trials comparing coronary angioplasty and coronary surgery are providing important data for making sound clinical decisions.
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Acknowledgments |
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This work was supported in part by grant R01-HL-33965 from the NHLBI, Bethesda, Md. We thank Chuck Ackers for his tireless efforts with the EAST data set.
Calculation of Hospital Costs From Charges
The
primary sources of information to analyze the UB-82
statements were the cost reports prepared annually by the hospital's
Finance Department. Total charges for specific services and centers are
developed by the Department of Financial Planning of each hospital. The
method for charge determination is as follows. Once direct costs have
been calculated for each procedure, the department-specific
indirect cost is added on the basis of the step-down allocation
methodology10 (as used in Medicare cost reports), and
additional amounts for uncollectibles and profit are added to ensure
that the hospital remains solvent.
Table 8 contains a
hypothetical translation of a
patient's UB-92 statement to economic cost. The operating room charge
of $7987.24 multiplied by the cost-to-charge ratio of 0.627852
yields a cost of $5014.80. The other services and centers on the UB-92
form, except for the patient room charges, are calculated by the same
method. General room cost and the intensive care unit are
presented as cost per diem rather than left as
cost-to-charge ratios. This methodology conforms to
microcosting principles and is very similar to the calculations for the
other cost centers. As shown in Table 8, the calculations of
the costs
of the private room and intensive care unit encompass the same cost
items (ie, laundry, nursing, and administration) as all other cost
centers and services (ie, operating room and anesthesia).
However, the total cost for the room units is divided by the total
inpatient days attributed to those units, calculating a cost per diem.
Thus, when applied to the UB-82 form (Table 8), this cost is
multiplied
by the total units (days) used by the patient, resulting in the total
cost for the use of the unit by the patient.
Received December 20, 1994; revision received May 24, 1995; accepted June 23, 1995.
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