Eur J Cardiothorac Surg 1999;16:S76-S79
© 1999 Elsevier Science NL
Economic evaluation of different minimally invasive procedures for the treatment of coronary artery disease
Hermann Reichenspurner*,
Dieter Boehm,
Christian Detter,
Wolfgang Schiller,
Bruno Reichart
Department of Cardiac Surgery, University Hospital Grosshadern, Marchioninistreet 15, D-81366 Munich, Germany
* Corresponding author. Tel. +49-89-7095-3450; fax: +49-89-7095-3465 (Email: hcr{at}hch.med.uni-muenchen.de).
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Abstract
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Objective: Several different techniques exist within the field of minimally invasive coronary artery surgery. In this study the impact of all these techniques on the total costs and economics has been evaluated. Methods: Since May 1997, 121 minimally invasive direct coronary artery bypass (MIDCAB) procedures, 125 off-pump coronary artery bypass (OPCAB), ten Port-AccessTM coronary artery bypass (PA-CABG) and 10 endoscopic coronary artery bypass grafting (ENDO-CABG) procedures were performed at our institution. A relative cost analysis of the different procedures was carried out in addition to a thorough evaluation done in five patients of each group dividing the costs into staff-related costs, material-related costs and general hospital costs. The costs were set in relation to regular CABG procedures. Results: Specific less invasive coronary artery surgical techniques, such as the MIDCAB or OPCAB technique already are able to reduce the total costs when compared to regular CABG procedures. Within the Port-AccessTM group as well as the ENDO-CABG group, increased material- and general costs are present when compared to regular CABG leading to increased total hospital costs for PA-CABG and Endo-CABG in Germany. Conclusion: At present, MIDCAB and OPCAB procedures are able to reduce total hospital charges, when compared to regular CABG procedures. Increased costs for Port-AccessTM, as well as Endo-CABG surgeries may be compensated in the future by decreased costs due to a shorter phase of rehabilitation and faster return to regular professional activities.
Key Words: Minimally invasive cardiac surgery • Coronary artery surgery • Economical evaluation
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1. Introduction
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Different surgical techniques have been developed for the less invasive treatment of coronary artery disease. Most of these techniques are done on the beating heart eliminating the need for cardiopulmonary bypass. Other techniques allow the surgery to be done through small incisions, e.g. thoracic ports, using a regular or a specific endovascular, so called Port-AccessTM cardiopulmonary bypass system [1].
Although the patients may benefit from these new less invasive techniques, the impact on the total costs and economics needs to be evaluated.
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2. Patients and techniques
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The following different cardiac surgical techniques were evaluated.- 1. MIDCAB: minimally invasive direct coronary artery bypass grafting done through a left anterolateral mini-thoracotomy. The left internal mammary artery (LIMA) is anastomosed to the left anterior descending artery (LAD) using a pressure stabilizer (Cardiothoracic Systems Inc., Cupertino, CA).
- 2. OPCAB: off-pump coronary artery bypass grafting is done through a sternotomy using a suction stabilizer for the treatment of multi-vessel disease (OctopusTM, Medtronic GmbH, Düsseldorf, Germany).
- 3. PA-CABG: Port-AccessTM coronary artery bypass grafting is done through a left anterior mini-thoracotomy using a specific endovascular cardiopulmonary bypass system (Heartport Inc, Redwood City, CA). Using these technique, bypass grafts to multiple coronary arteries can be anastomosed.
- 4. DD-CABG: Dresden technique. This surgery is performed also through a left anterior minithoracotomy using direct aortic and right atrial canulation [2]. Also using this approach, multiple coronary artery bypass grafts can be anastomosed to the coronary arteries.
- 5. Endo-CABG: endoscopic coronary bypass grafting done through small thoracic ports using endoscopic visualization and computer enhanced and robotically assisted surgical systems [3]. Usually the LIMA is anastomsed to the LAD.
Between May 1997 and December 1998 the following numbers of different coronary artery revascularization procedures were carried out at the University of Munich: MIDCAB (n=121); OPCAB (n=125); PA-CABG (n=10); Endo-CABG (n=10).
The technical details of the different coronary artery surgical methods are listed in Table 1
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In addition to a relative cost analysis of the different procedures, a thorough cost analysis was done in five patients of each group dividing the total costs into staff related costs, material related costs and general costs (e.g. ICU stay, hospitalization, etc.). The latter evaluation was done in cooperation with a professional economic analyzer (Roland Berger GmbH, Germany).
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3. Results
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The intra- and postoperative results of the patients undergoing the different techniques in coronary artery surgery are listed in Table 2
. In comparison to the clinical results achieved in patients undergoing conventional coronary artery bypass grafting (CABG, n=475) which are also listed in Table 2, time of surgery was reduced in MIDCAB and OPCAB procedures and stay on ICU and total hospitalization were reduced in all the different minimal invasive treatment groups.
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Table 2. Perioperative and postoperative results in patients undergoing the different coronary artery surgical techniques
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A relative cost assessment of the different surgical procedures is outlined in Fig. 1. All data have been set in relation of the costs of a conventional CABG procedure.- 1. In MIDCAB procedures the costs for operating room (OR) time, OR staff, cardiopulmonary bypass, ICU stay, total hospitalization and postoperative rehabilitation are decreased in addition to a reduced time interval of return to normal activities. The costs for OR material may be increased.
- 2. In the OPCAB group costs for OR time, cardiopulmonary bypass, ICU stay and hospitalization are reduced. The costs for OR staff may be equivalent, for OR material may be higher as for conventional CABG procedures.
- 3. In the Port-AccessTM group costs are lower for ICU stay, total hospitalization and postoperative rehabilitation. Costs are increased for OR time, OR staff, OR material and cardiopulmonary bypass.
- 4. In the DD-CABG group costs for ICU stay hospitalization and rehabilitation are decreased; OR time is increased.
- 5. In the Endo-CABG group the costs for ICU stay, hospitalization and postoperative rehabilitation are reduced. Costs are higher with regard to OR time, OR staff, OR material and, if needed, cardiopulmonary bypass.
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Fig. 1. Relative cost assessment. The various minimally invasive coronary artery surgical procedures in relation to regular coronary artery bypass grafting (MIDCAB, minimally invasive direct coronary artery bypass; OPCAB, off-pump coronary artery bypass; PA-CABG, Port-AccessTM coronary artery bypass; DD-CABG, Dresden technique; Endo-CABG, endoscopic coronary artery bypass grafting). OR-Mat, OR-material; CPB, cardiopulmonary bypass; ICU, ICU-stay; Hosp, hospitalization; REHA, rehabilitation; RTNA, return to normal activities. For an explanation and interpretation of this figure see text.
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A thorough cost analysis studying 60 CABG patients, five MIDCAB patients, five OPCAB patients and five Port-Access-CABG patients is listed in Table 3
. This analysis demonstrated similar costs for staff comparing all four techniques. Costs for material were decreased in the MIDCAB and OPCAB group, but increased in the Port-AccessTM group. General costs were less in the MIDCAB group but increased in the OPCAB and Port-AccessTM group. The overall cost analysis demonstrated decreased costs for MIDCAB (US$14 050) and OPCAB (US$14 060) procedures, but increased costs for the Port-AccessTM group (US$17 230) compared to regular CABG (US$16 230).
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Table 3. Specific cost evaluation in US dollars (US$) of patients undergoing conventional coronary artery surgical procedures, minimally invasive direct coronary artery bypass, off-pump coronary artery bypass and Port-AccessTM coronary artery bypass
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4. Discussion
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The impact of specific surgical techniques for minimally invasive coronary artery surgery on total costs and economics has not been the emphasis in most papers describing those surgeries. This study analyzed the relative cost assessment of the different techniques in relation to the costs of regular CABG procedures. In addition, a thorough cost analysis was done in a limited number of patients undergoing each coronary artery surgical procedure.
Within the relative analysis, costs for OR time were lower in MIDCAB and OPCAB procedures, but higher in the Port-AccessTM cases and patients undergoing Endo-CABG or the Dresden technique [2]. OR staff was reduced in the MIDCAB group, unchanged in the OPCAB group, Port-Access and Dresden technique, but increased in the Endo-CABG group. Costs for OR material were increased in MIDCAB, OPCAB, Port-AccessTM and Endo-CABG procedures, which was not the case in the Dresden technique group. Costs for cardiopulmonary bypass were reduced in all Off-Pump procedures, but increased in the Port-AccessTM group. Costs for ICU stay and total hospitalizations were decreased in all groups. In addition, costs for postoperative rehabilitation were reduced and the time interval until return to normal activities was also significantly shorter in all groups of patients undergoing less invasive coronary artery surgical procedures.
Looking at the thorough cost analysis, costs for OR staff are similar among all groups. Most of the material costs were decreased in the MIDCAB and OPCAB group, but increased in the Port-AccessTM group, while general costs were decreased in the MIDCAB group, but increased in the OPCAB and Port-AccessTM group.
In the literature reduced costs for MIDCAB procedures have been published even suggesting that the costs for MIDCAB procedures may be less than the costs for PTCA and insertion of coronary stents [4]. Port-AccessTM mitral valve surgical cases and Port-AccessTM-CABG were analyzed at the New York University. The authors drew the conclusion that total hospital charges were less for patients undergoing the Port-AccessTM surgical technique. This is mainly based on the fact that ICU stay and hospitalization were reduced markedly in this patient group leading to a reduction in total hospital costs [5]. This may be due to the specific reimbursement system in the United States; in Germany, however, a different reimbursement system exists which does not allow the discharge of a cardiac surgical patient before postoperative day 5 in order to charge for a total cardiac case fee; in case the patient would be discharged earlier, the hospital would not be able to charge the full cardiac surgical fee and thus would actually lose money.
Often neglected issues are costs for rehabilitation and time of return to normal activities. Due to the improved results in ICU stay and total hospitalization, it can be assumed that costs for postoperative rehabilitation could be decreased significantly in patients undergoing less invasive coronary artery surgery procedures. This shortened rehabilitation may also lead to a decreased time interval until return to normal activities. The patients could also be integrated back earlier into their regular professional activities which would further decrease the general costs caused by the illness process.
In conclusion, specific new coronary artery surgical techniques such as the MIDCAB or OPCAB technique already are able to reduce the total treatment costs of patients undergoing these less invasive techniques of coronary artery surgery. Increased material- and general charges as in patients undergoing the Port-AccessTM surgery or the newer Endo-CABG technique may be compensated in the near future by decreased costs due to shorter rehabilitation and a faster return to regular professional activities. Currently patients undergoing Port-AccessTM surgery as well as Endo-CABG techniques still show increased total hospital costs at least in Germany.
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Footnotes
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Presented at the International Symposium ‘Present State of Minimally Invasive Cardiac Surgery – Meet the Experts', Dresden, Germany, December 3– 5, 1998.
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References
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- Stevens JH, Burdon TA, Peters WS, Pompili MF, St Goar FG, Berry GJ, Ribakove GH, Vierra MA, Mitchell RS, Toomasian JM, Reitz BA. Port-access coronary artery bypass grafting: a proposed surgical method. J Thorac Cardiovasc Surg 1996;111:567-573.[Abstract/Free Full Text]
- Gulielmos V, Knaut M, Wagner FM, Schüler S. Minimally invasive surgical technique for the treatment of coronary artery multi-vessel disease. Ann Thorac Surg 1998;65:1331-1334.[Abstract/Free Full Text]
- Reichenspurner H, Damiano RJ, Boehm DH, Gulbins H, Meiser B, Ellgass R, Reichart B. Use of the voice-controlled and computer-assisted surgical system ZeusTM for endoscopic coronary artery bypass grafting. J Thorac Cardiovasc Surg 1999;118:11-16.[Abstract/Free Full Text]
- Doty JR, Fonger JD, Nicholson CF, Sussmann MS, Salomon NW. Cost analysis of current therapies for limited coronary artery revascularization. Circulation 1997;96(SII):11-20.
- Grossi EA, Galloway AC, Ribakove GH, Zakow PK, Buttenheim PM, Baumann FG, Green J, Schwesinger DW, Colvin SG. Impact of minimally invasive approach on valvular heart surgery: a case controlled study. New Orleans, LA: American College of Cardiology (ACC); 1999. pp. 842-846(Abstract).
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Abstract
1. Introduction
