Related Experiment Video
Updated: Mar 7, 2026
Vascular Gene Transfer from Metallic Stent Surfaces Using Adenoviral Vectors Tethered through Hydrolysable Cross-linkers
Published on: August 12, 2014
Fixed and variable cost of carotid endarterectomy and stenting in the United States: A comparative study
Tammam Obeid1, Husain Alshaikh1, Besma Nejim1
1Division of Vascular Surgery, Department of Surgery, Johns Hopkins Medical Institution, Baltimore, Md.
Insights
Carotid artery stenting (CAS) is significantly more expensive than carotid endarterectomy (CEA) for the US healthcare system. This study found CAS costs 37-40% more than CEA, regardless of patient or hospital factors, highlighting cost implications for clinical decisions.
Area of Science:
- Health Economics
- Vascular Surgery
- Health Services Research
Background:
- Limited real-world data exists on the comparative costs of carotid artery stenting (CAS) and carotid endarterectomy (CEA) in the United States.
- Understanding these costs is crucial for healthcare system resource allocation and clinical decision-making regarding stroke prevention.
Purpose of the Study:
- To investigate and compare the actual hospitalization costs between CAS and CEA procedures.
- To analyze cost differences across various patient subgroups and healthcare settings using a nationally representative database.
Main Methods:
- Utilized the Premier Perspective Database, analyzing hospital discharge and billing records from Q3 2009 to Q1 2015.
- Employed 1:1 propensity score matching on 32 variables to control for patient, hospital, and comorbidity differences between CAS and CEA cohorts.
- Calculated total in-hospital costs, including fixed and variable expenses, inflation-adjusted to 2015 USD.
Main Results:
- After matching, CAS was associated with significantly higher total hospitalization costs: 40% higher in asymptomatic patients ($11,814 vs $8,378) and 37% higher in symptomatic patients ($19,426 vs $14,190).
- These cost disparities persisted across different cost types (fixed/variable), U.S. regions, and symptomatic statuses.
- CAS performed by various surgical specialties incurred higher costs compared to CEA, with specific cost differences noted for vascular, cardiac, and neurological surgeons.
Conclusions:
- Carotid artery stenting (CAS) incurs substantially higher hospitalization costs than carotid endarterectomy (CEA), even after rigorous statistical matching and stratification.
- These findings provide critical economic data relevant to the ongoing debate on the optimal indications and utilization of CAS versus CEA.
Objective:
Despite multiple landmark clinical trials, little data exists on real-world cost of carotid artery stenting (CAS) and carotid endarterectomy (CEA) to the United States healthcare system. We aim to study differences in actual hospitalization cost between patients who underwent CAS vs CEA in a nationally representative database.
Methods:
We studied hospital discharge and billing records of all patients, in the Premier Perspective Database, who underwent CEA or CAS between the third quarter of 2009 and the first quarter of 2015. Nearest-neighbor 1:1 propensity score matching was performed, to account for differences in patient and hospital characteristics as well as clinical comorbidities of patients who underwent both procedures, for both symptomatic and asymptomatic cohorts using 32 variables. Pearson χ2, Student t-test, and nonparametric K-sample equality-of-medians tests were used to analyze the data, as appropriate. The primary outcome was total in-hospital cost, including fixed (administrative, capital and utilities) and variable costs (labor and supply). Cost data were presented as medians, inflation-adjusted for 2015 U.S. dollar and rounded to the nearest dollar.
Results:
A total of 115,548 procedures were identified. The mean age was 71 and 69 years; 58% and 57% were male patients; and 81% and 77% were white among asymptomatic and symptomatic patients, respectively. After propensity score matching, 25,812 asymptomatic (12,906 CEA and 12,906 CAS) and 3864 symptomatic (1932 CEA and 1932 CAS) patients were included. Total hospitalization cost per CAS was 40% ($11,814 vs $8378; P < .001) and 37% ($19,426 vs $14,190; P < .001) higher than CEA among asymptomatic and symptomatic patients, respectively. Patients who underwent CAS incurred significantly higher total hospitalization cost despite stratifying by type of cost (fixed and variable), U.S. census regions and symptomatic status. Moreover, asymptomatic patients who underwent CAS performed by any surgical specialty incurred an average of $2717 to $4918 higher total hospitalization cost compared with patients who underwent CEA (all P < 001). Among symptomatic patients, those who underwent CAS performed by vascular, cardiac, and neurologic surgeons, incurred $2108 ($16,114 vs $14,006; P = .006), $7055 ($17,351 vs $10,296; P = .023) and $6479 ($27,290 vs $20,811; P = .002) higher total hospitalization cost compared with patients who underwent CEA, respectively.
Conclusions:
The total hospitalization cost incurred by patients who underwent CAS was significantly higher than for those who underwent CEA, despite matching cohort based on patient and hospital characteristics, and stratifying by symptomatic status, type of cost, hospital region, and surgeon specialty. Our findings could provide additional important information giving the ongoing controversy regarding the appropriate indication for CAS.
