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Economic outcome of off-pump coronary artery bypass surgery: A prospective randomized study

ANNALS OF THORACIC SURGERY 1999年第6期68卷 2237-2242页

作者： Ascione, R Lloyd, CT Underwood, MJ Lotto, AA Pitsis, AA Angelini, GD Bristol Royal Infirm & Gen Hosp Inst Heart Bristol BS2 8HW Avon England

Background. Emphasis on cost containment in coronary artery bypass surgery is becoming increasingly important in modern hospital management. The revival of interest in off-pump (beating heart) coronary artery bypass surgery may influence the economic outcome. This study examines these effects. Methods. Two hundred patients undergoing first-time coronary artery bypass surgery were prospectively randomized to either conventional cardiopulmonary bypass and cardioplegic arrest or off-pump surgery. Variable and fixed direct costs were obtained for each group during operative and postoperative care. The data were analyzed using parametric methods. Results. There was no difference between the groups with respect to pre- and intraoperative patient variables. Off-pump surgery was significantly less costly than conventional on-pump surgery with respect to operating materials, bed occupancy, and transfusion requirements (total mean cost per patient: on pump, $3,731.6 +/- 1,169.7 vs off-pump, $2,615.13 +/- 953.6;p < 0.001). Morbidity was significantly higher in the on-pump group, which was reflected in an increased cost. Conclusions. Off-pump revascularization offers a safe, cost-effective alternative to conventional coronary revascularization with cardiopulmonary bypass and cardioplegic arrest. (C) 1999 by The Society of Thoracic Surgeons.

关键词：输血/经济学心肺转流术/经济学冠状动脉分流术/经济学冠状动脉分流术/方法费用节省成本及成本分析手术后并发症前瞻性研究老年人女(雌)性人类男(雄)性中年人

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Costs of revascularization over eight years in the randomized and eligible patients in the Emory Angioplasty versus Surgery Trial (EAST)

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AMERICAN JOURNAL OF CARDIOLOGY 2000年第7期86卷 747-752页

作者： Weintraub, WS Becker, ER Mauldin, PD Culler, S Kosinski, AS King, SB Med Univ S Carolina Sch Med Hlth Policy & Management Div Cardiol Charleston SC 29425 USA Emory Univ Sch Publ Hlth Atlanta GA 30322 USA

The Emery Angioplasty versus Surgery Trial (EAST) was a randomized trial that compared, by intention to treat, the clinical outcome and costs of percutaneous transluminal coronary angioplasty (PTCA) and coronary bypass grafting (CABG) for multivessel coronary artery disease. We present the findings of the economic analysis of EAST through 8 years of follow-up and compare the cost and outcomes of patients randomized in EAST versus patients eligible but not randomized (registry patients). Charges were assessed from hospital UB82 and UB92 bills and professional charges from the Emery Clinic. Hospital charges were reduced to cost through step-down accounting methods. All costs and charges were inflated to 1997 dollars. Costs were assessed for initial hospitalization and for cumulative costs of the initial hospitalization and additional revascularization procedures up to 8 years. Total 8-year costs were $46,548 for CABG and $44,491 for PTCA (p = 0.37), Cost of CABG in the eligible registry group showed a pattern similar to that for randomized patients, but total cost of PTCA was lower for registry patients than for randomized patients, Thus, the primary procedural costs of CABG are more than those for PTCA;this cost advantage, given the limits of measurement, is largely or even completely lost for randomized patients over the course of 8 years because of additional procedures after a first revascularization by PTCA, (C) 2000 by Excerpta Medica, Inc.

关键词：血管成形术经腔经皮冠状动脉/经济学冠状动脉分流术/经济学冠心病/治疗费用医疗随访研究医院费用统计学非参数治疗结果女(雌)性人类男(雄)性中年人

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Comparing physician-specific two-year patient outcomes after coronary angiography - Methodologic issues and results

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JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY 1999年第5期33卷 1278-1285页

作者： Ellis, SG Miller, D Keys, TF Brown, K Ellert, R Howell, G Lincoff, AM Topol, EJ Cleveland Clin Fdn Dept Cardiol Cleveland OH 44195 USA Cleveland Clin Fdn Dept Epidemiol & Biostat Cleveland OH 44195 USA Cleveland Clin Fdn Off Qual Management Cleveland OH 44195 USA Ischemia Res & Educ Fdn San Francisco CA USA

OBJECTIVES We sought to evaluate methodologies to compare physician-related long-term patient outcomes appropriately. BACKGROUND Evaluation of physicians on the basis of short-term patient outcome is becoming widely practiced. These analyses fail to consider the importance of long-term outcome, and methods appropriate to such an analysis are poorly defined. METHODS All patients undergoing coronary angiography between 1992 and 1994 who received all of their cardiac care at our institution were followed for 27 +/- 13 months (mean +/- SD). Patients (n = 754) were cared for by one or more of 17 staff physicians. Risk-adjusted models were developed for four candidate clinical end points and cost. Physicians were then evaluated for each outcome measure. RESULTS Of the clinical end points, death could be modeled most accurately (c-statistic = 0.83), The c-statistics for other end points ranged from 0.63 to 0.70. Physicians with outcomes statistically different (p < 0.05) from other physicians were identified more commonly than would be expected from the play of chance (p = 0.005). However, improvement in the c-statistics by the addition of physician identifiers was very modest. Physician's evaluations by the four measures of clinical outcome were variably correlated (r = .00 to .85). Graphic display of clinical and cost results for each physician did identify certain physicians who might be judged to provide more cost-effective care than others. CONCLUSIONS Although comparisons of groups of physicians on the basis of long-term patient outcomes may have merit, individual physician-to-physician comparisons will be more difficult, owing to 1) multiple physicians contributing care to individual patients;2) the poor predictive capacity of models other than that for survival;and 3) the modest apparent impact of differences in physician providers on long-term patient outcome. With these caveats in mind, modeling to compare patient outcomes of individual physicians with homogeneou

关键词：血管成形术气囊冠状动脉/经济学血管成形术气囊冠状动脉/死亡率血管成形术气囊冠状动脉/统计学和数值数据冠状血管造影术/经济学冠状血管造影术/死亡率冠状血管造影术/统计学和数值数据冠状动脉分流术/经济学冠状动脉分流术/死亡率冠状动脉分流术/统计学和数值数据冠心病重症监护病房/统计学和数值数据冠心病/诊断显像冠心病/经济学冠心病/治疗成本及成本分析无病生存随访研究结果评价(卫生保健)/经济学结果可重复性回顾性研究存活率老年人人类中年人

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Cost estimates for treatment of cardiac ischemia (from the Asymptomatic Cardiac Ischemia Pilot [ACIP] study)

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AMERICAN JOURNAL OF CARDIOLOGY 1999年第11期84卷 1311-1316页

作者： Pepine, CJ Mark, DB Bourassa, MG Chaitman, BR Davies, RF Knatterud, GL Forman, S Pratt, CM Sopko, G Conti, CR Univ Florida Coll Med Div Cardiovasc Med Gainesville FL USA Duke Univ Sch Med Durham NC USA Montreal Heart Inst Res Ctr Montreal PQ H1T 1C8 Canada St Louis Univ Med Ctr St Louis MO USA Univ Ottawa Inst Heart Res Ctr Ottawa ON Canada Maryland Med Res Inst Baltimore MD USA Baylor Coll Med Houston TX 77030 USA NHLBI Bethesda MD 20892 USA

Costs for management of myocardial ischemia are enormous, yet comparison cost and outcome data for various ischemia treatment strategies from randomized trials are lacking and will require cost and resource utilization data fram a large prospective trial. The Asymptomatic Cardiac Ischemia Pilot provided feasibility data for planning such a trial and on opportunity to estimate the long-term costs of different treatment strategies. Economic implications for ischemia management were compared in 558 patients with stable coronary artery disease and myocardial ischemia during both stress testing and daily life. Participants were randomized to 3 different initial treatment strategies and followed for 2 years. Based on cost trends over follow-up, costs for subsequent care were estimated. As expected, due to initial procedural costs, at 3 months, estimated costs for revascularization were approximately 10 times greater than costs for a medical care strategy. Extrapolated costs for anticipated resource consumption for care beyond 2 years, however, were approximately 2 times greater for an initial medical care strategy than for initial revascularization. This was due to increased need for drugs and hospitalizations for bath late revascularizations and other ischemia-related events. Estimated costs for anticipated care in the medical strategies reached the anticipated cost of the revascularization strategy within 10 years. Because this cost-equal time period is well within the median life expectancy for such a patient population, these findings could have important public health implications and require testing in a full-scale prognosis trial. We anticipate that over the patients' life expectancy, early revascularization is likely to become either cost-neutral or cost-effective. (C) 1999 by Excerpta Medica, Inc.

关键词：血管成形术经腔经皮冠状动脉/经济学冠状动脉分流术/经济学成本及成本分析可行性研究卫生保健费用心肌缺血/经济学心肌缺血/死亡率心肌缺血/治疗心肌血管重建术/经济学心肌血管重建术/方法试点项目前瞻性研究存活率治疗结果女(雌)性人类男(雄)性中年人

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A multidisciplinary process to improve the efficiency of cardiac operating rooms

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JOURNAL OF CARDIOTHORACIC AND VASCULAR ANESTHESIA 1999年第6期13卷 661-665页

作者： Krasner, H Connelly, NR Flack, J Weintraub, A Baystate Med Ctr Dept Anesthesiol Springfield MA 01199 USA Baystate Med Ctr Dept Cardiac Surg Springfield MA 01199 USA

Objective: To alter the approach to cardiac operating room services in an attempt to remain competitive in a cost-driven market. Design: Study of processes and strategies for tracking and decreasing the times required for the multiple components of the operating room period. Setting:Cardiac operating rooms in a tertiary care, university-affiliate hospital. Participants:All patients undergoing primary coronary artery bypass grafting during December 1996 (baseline) and the following year (1997). Interventions:After participation in cost-containment meetings, site visits, and development of a working group, data collection was begun detailing the times of the various components of the operating room period. Changes of process were made to reduce operating room times. Most of these changes involved multitasking care: multiple people performing various tasks at the same time. All measured operating room intervals were decreased. There was no difference in morbidity and mortality over this time period. Conclusion: Development of a working group, with support from the hospital administration, can significantly decrease the time of tasks in a cardiac surgery operating room without adversely affecting morbidity and mortality. Copyright (C) 1999 by W.B. Saunders Company.

关键词：心脏外科手术/经济学冠状动脉分流术/经济学冠状动脉分流术/死亡率费用控制效率手术室/经济学手术室/组织和管理病人医疗小组时间因素人类

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Diagnosis of suspected coronary artery disease in women: A cost-effectiveness analysis

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AMERICAN HEART JOURNAL 1999年第6期137卷 1019-1027页

作者： Kim, C Kwok, YS Saha, S Redberg, RF Univ Calif San Francisco Div Cardiol San Francisco CA 94131 USA Univ Calif San Francisco Dept Med San Francisco CA 94131 USA

Background The optimal strategy for the diagnosis of coronary artery disease (CAD) in women is not well defined. We compared the cost-effectiveness of several strategies for diagnosing CAD in women with chest pain. Methods we performed decision and cost-effectiveness analyses with simulations of 55-year-old ambulatory women with chest pain. With a Markov model, simulations of patients underwent exercise electrocardiography, exercise testing with thallium scintigraphy, exercise echocardiography, angiography, or no workup. Results Diagnosis with angiography cost less than $17,000 per quality-adjusted life-year compared with exercise echocardiography if the patient had definite angina and less than $76,000 per life-year if she had probable angina. If she had nonspecific chest pain, diagnosis with exercise echocardiography increased life-years compared with no testing. Conclusions Cost-effectiveness of first-line diagnostic strategy for diagnosis of CAD in women varies mostly according to pretest probability of CAD. Diagnosis of coronary artery disease with angiography is cost-effective in 55-year-old women with definite angina. In 55-year-old women with probable angina, diagnosis with angiography would increase quality-adjusted life-years but significantly increase costs. Use of exercise echocardiography as a first-line diagnosis for CAD is cost effective in 55-year-old women with probable angina and nonspecific chest pain.

关键词：加利福尼亚胸痛/诊断胸痛/经济学胸痛/治疗冠状动脉分流术/经济学冠状动脉分流术/统计学和数值数据冠心病/诊断冠心病/经济学冠心病/治疗费用效益分析决策支持技术卫生保健费用 Markov链心肌梗死/诊断心肌梗死/经济学心肌梗死/治疗质量校正寿命敏感性与特异性女(雌)性人类中年人

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Variability in cost of coronary bypass surgery in New York State: Potential for cost savings

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AMERICAN HEART JOURNAL 2002年第1期143卷 130-139页

作者： Cowper, PA DeLong, ER Peterson, ED Hannan, EL Ray, KT Racz, M Mark, DB Duke Clin Res Inst Outcomes Res & Assessment Grp Durham NC 27715 USA SUNY Albany Dept Hlth Policy Management & Behav Albany NY 12222 USA New York State Dept Hlth Albany NY USA Marist Coll Poughkeepsie NY USA

Objective Previous analyses of variability in bypass resource use have not focused on hospital-level variation or adequately explored the influence of patient risk. We combined a clinical database with claims data to fully characterize patient level and hospital level variability in bypass surgery cost and length of stay in New York State and explored the extent to which lower cost is associated with worse quality of care. Methods By use of 1992 clinical and claims data, we identified by multivariable regression which patient characteristics influence bypass cost and length of stay. Hospital was then incorporated as a random variable in mixed linear models to determine its impact on resource use. The relationship between risk-adjusted in-hospital mortality and cost was then explored. Results In the 21 hospitals for which cost data were available, mean leveled cost (exclusive of professional fees and noncomparable costs) was $15,713, with a mean length of stay of 14 days (n = 12,087). One fifth of the variation in resource use was explained by baseline patient risk. After adjustment for patient risk, hospital explained an additional 42% of variation in cost and an additional 8% of variation in length of stay. Among hospitals, risk-adjusted cost varied almost 3-fold and risk-adjusted length of stay varied 50%. There was no association between cost and in-hospital mortality. Conclusions As of 1992, there was considerable interhospital variability in bypass surgery cost after patient baseline risk was accounted for. This suggests that reductions in bypass cost could be achieved by normalizing clinical practice.

关键词：心排血量冠状动脉分流术/经济学冠状动脉分流术/死亡率成本及成本分析卫生资源/经济学卫生资源/利用医院费用/统计学和数值数据医院死亡率住院时间/经济学住院时间/统计学和数值数据线性模型纽约/流行病学回归分析危险性评估疾病严重程度指数老年人女(雌)性人类男(雄)性

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Projected long-term costs of coronary stenting in multivessel coronary disease based on the experience of the Bypass Angioplasty Revascularisation Investigation (BARI)

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AMERICAN HEART JOURNAL 2000年第4期140卷 556-564页

作者： Yock, CA Boothroyd, DB Owens, DK Winston, C Hlatky, MA Stanford Univ Sch Med Dept Hlth Res & Policy Stanford CA 94305 USA Stanford Univ Sch Med Dept Med Stanford CA 94305 USA Palo Alto Vet Affairs Med Ctr Palo Alto CA USA

Background Stents are now used in the majority of percutaneous coronary revascularization procedures. It is not clear whether the higher initial cost of stenting is later repaid by reducing costly complications and repeat revascularization procedures, especially for patients with multivessel disease. Methods To project the long-term costs of using coronary stents, angioplasty, or bypass surgery to treat patients with multivessel coronary artery disease, we developed a decision model based on the outcomes documented in the Bypass Angioplasty Revascularization Investigation (BARI) randomized trial of coronary artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA). We studied 2 clinical strategies: provisional stenting of suboptimal PTCA results and primary stenting of all angiographically eligible lesions. The cost of CABG was also updated to reflect contemporary practice. Results Provisional stenting had lower projected costs over a 4-year period than either traditional PTCA (-$1742, or -3.4%) or contemporary CABG (-$832, or -1.7%), mostly because of reductions in emergency CABG after PTCA, In contrast, primary stenting had higher projected costs over a 4-year period than either PTCA (+$333, or +0.7%) or contemporary CABG (+$1243, or +2.5%), mainly because of the higher initial procedure costs. These results were not substantially altered when we systematically varied the key parameters of the models in 1-way and 2-way sensitivity analyses. Conclusions A primary stenting strategy in patients with multivessel disease has higher projected long-term costs than CABG. In contrast, a provisional stenting strategy in multivessel disease has lower projected costs than either PTCA or CABG.

关键词：冠状血管造影术冠状动脉分流术/经济学冠心病/经济学冠心病/放射摄影术冠心病/外科学费用效益分析决策支持技术随访研究支架/经济学人类

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Comparison of analytic approaches for the economic evaluation of new technologies alongside multicenter clinical trials

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AMERICAN HEART JOURNAL 2003年第3期145卷 452-458页

作者： Taira, DA Seto, TB Siegrist, R Cosgrove, R Berezin, R Cohen, DJ Beth Israel Deaconess Med Ctr Div Cardiovasc Harvard Clin Res Inst Dept Med Boston MA 02215 USA Harvard Univ Sch Med Boston MA USA Harvard Univ Sch Publ Hlth Dept Hlth Policy & Management Boston MA 02115 USA Hawaii Med Serv Assoc Honolulu HI USA Queens Med Ctr Honolulu HI USA

Background In reporting economic evaluations of clinical trials, results are often stated without a description of the methodology used to derive the cost estimates. We compared methods for measuring costs from multicenter clinical trials to determine the extent to which the methodology affects results., Methods Patient-level data (n = 1849) from,3 multicenter clinical trials of percutaneous coronary revascularization were used to compare 4,methods of estimating costs: 1) hospital charges;2) hospital charges converted to costs by use of hospital-level cost-to-charge ratios;3) hospital charges converted to costs by use of department-level cost-to-charge ratios;4) itemized catheterization laboratory costs with nonprocedural hospital costs generated from department-level cost-to-charge ratios. Results The method used to approximate costs did not affect the main results of the economic comparisons for any of the trials. The magnitude of the cost estimates and the cost differences between treatment groups varied considerably by method, however. Charges were approximately twice as high as hospital cost estimates. At the patient level, costs generated by use of method 1 were within 10% of those generated by use of method 4 for only 5% of patients, compared with 34% and 22% of patients with methods 2 and 3, respectively. Only method 3 produced estimates of between-group cost differences that were consistently within $500 of the reference standard. Conclusion Cost estimates derived from clinical trials in the cardiovascular arena vary substantially according to accounting methodology. Thus, in reporting the results of economic analyses, a detailed description of cost derivation is necessary, particularly when the absolute magnitude of the cost estimates is important to clinical decision-making or policy-level recommendations. For the purposes of group-level comparisons, conversion of hospital charges to costs on the basis of department-level cost-to-charge ratios appears to

关键词：血管成形术经腔经皮冠状动脉/经济学心脏外科手术/经济学冠状动脉分流术/经济学冠心病/外科学冠心病/治疗费用效益分析成本及成本分析/方法卫生保健费用医院收费医院费用回顾性研究支架/经济学治疗临床研究性/经济学女(雌)性人类男(雄)性中年人

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Clinical correlates of the initial and long-term cost of coronary bypass surgery and coronary angioplasty

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AMERICAN HEART JOURNAL 1999年第2期138卷 376-383页

作者： Hlatky, MA Boothroyd, DB Brooks, MM Winston, C Rosen, A Rogers, WJ Reeder, GS Smith, HC Ryan, TJ Pitt, B Whitlow, PL Wiens, RD Mark, DB Stanford Univ Sch Med Dept Hlth Res & Policy Stanford CA 94305 USA Stanford Univ Sch Med Dept Med Stanford CA 94305 USA Univ Alabama Birmingham Birmingham AL USA Mayo Clin & Mayo Fdn Rochester MN 55905 USA Boston Univ Sch Med Boston MA 02118 USA Univ Michigan Sch Med Ann Arbor MI USA Cleveland Clin Fdn Cleveland OH 44195 USA St Louis Univ Sch Med St Louis MO USA Duke Univ Med Ctr Durham NC USA

Background Medical costs vary substantially among patients. Understanding the baseline factors that predict subsequent cost may allow better selection of therapy for individual patients. Understanding the postprocedure events that increase cost should help to improve efficiency and effectiveness of coronary revascularization. Methods Data on 4-year costs were collected from patients randomly assigned to coronary angioplasty or bypass surgery as part of the BARI (Bypass Angioplasty Revascularization Investigation) trial. Regression models First examined factors known at the time of randomization that prospectively predicted initial procedure cost and long-term cost. Subsequent models tested the value of postrandomization events as explanatory variables for cost. Results The independent baseline predictors of higher initial percutaneous transluminal coronary angioplasty cost included 3-vessel disease (+12%) and acute presentations (+22%), whereas the independent predictors of higher initial coronary artery bypass grafting cost included the number of comorbid conditions (+5% per condition) and female sex (+7%). The independent baseline predictors of 4-year cost included heart failure (+26%), diabetes (+22%), comorbidity (+10%), and angioplasty assignment in patients with 2-vessel disease (-15%). Postrandomization models showed higher initial and long-term costs were strongly correlated with the number of repeat revascularization procedures (+30% to +128%) and the occurrence of clinical complications (+8% to +131%). Conclusions Two-vessel disease identifies patients likely to have lower costs after angioplasty, whereas heart failure, comorbid conditions, and diabetes identify patients likely to accrue higher costs after either angioplasty or bypass surgery. Long-term costs can be potentially reduced by interventions that decrease procedural complications or reduce the need for repeat revascularization.

关键词：血管成形术经腔经皮冠状动脉/经济学冠状动脉分流术/经济学冠心病/经济学冠心病/外科学冠心病/治疗治疗过程片断卫生保健费用/统计学和数值数据卫生服务研究/经济学 Medicare 美国老年人女(雌)性人类男(雄)性中年人

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