Primary Stenting More Costly Over the Long Term than CABG or PTCA
NEW YORK (Reuters Health) – The estimated long-term costs of primary stenting in patients with multivessel coronary disease appear to be higher than long-term costs associated with coronary artery bypass grafting (CABG) or percutaneous transluminal coronary angioplasty (PTCA), according to a report by California researchers.
Dr. Mark A. Hlatky, from Stanford University School of Medicine, and a multicenter team extended data from the 1987 Bypass Angioplasty Revascularization Investigation (BARI) to create a decision model that projected the long-term costs associated with CABG, PTCA, and “provisional stenting of suboptimal PTCA results and primary stenting of all angiographically eligible lesions.”
The costs of CABG were updated to reflect current costs, according to the researchers’ report in the October issue of the American Heart Journal.
“One of the main things we wanted to do was to demonstrate that you could tack modeling onto trials. We need to figure out ways to keep trials current and update the conclusions that we have drawn from them,” Dr. Hlatky told Reuters Health.
According to the model constructed by Dr. Hlatky’s group, “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,” the investigators report.
Conversely, Dr. Hlatky and colleagues found that primary stenting was associated with higher costs than PTCA (+ $333, or +0.7%) over 4 years, as was CABG (+ $1243, or +2.5%). These increased costs were due to the higher costs associated with initial stenting, the team reports.
In a related editorial, Drs. Patricia A. Cowper and Eric D. Peterson, from the Duke Clinical Research Institute, Durham, North Carolina, take issue with the method used by Dr. Hlatky and colleagues to reach their conclusions. Clinical trials, they note, may not contain the best data on which to base clinical practice or calculate long-term costs.
Because of technological advances since 1987, Drs. Cowper and Peterson believe that the use of data from BARI is inherently flawed. “Such technological advances call into question the relevance of the BARI results to current clinical practice,” they write.
The editorialists go on to point out that “in a recent survey of cardiologists and cardiac surgeons from 13 major centers, more than 70% of responders reported that the BARI findings had not significantly affected their treatment patterns, primarily because of the subsequent technologic innovations.”
Commenting on the editorial, Dr. Hlatky said to Reuters Health, “People do a trial, and life changes, and does this mean that we just throw it the trash? Or does it mean that we can extract something and maybe make reasonable inferences? I find it distressing that it is so easy for people to dismiss, completely out of hand, studies they don’t happen to like, because they say everything is different now–so that means they can ignore it.”
Am Heart J 2000;140:556-564.
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