Implications of cost in treatment selection for patients with coronary heart disease

The growth of managed care and other types of capitated payment systems for medical care has forced cost into the therapeutic equation. The benefits of treatment must now be balanced against their costs. Clinicians are being challenged to prove that what they do has sufficient "value." Particular targets for these challenges are surgeons and interventional cardiologists who, in aggregate, perform expensive high-volume procedures.

A cost analysis of percutaneous transluminal coronary angioplasty, coronary artery bypass grafting, and medical management of coronary artery disease has been undertaken using the Duke University database of 4,000 patients. The costs of the three procedures were compared at several fixed time points.

The costs for the three treatments are critically dependent on the time points selected for comparison. At 60 days, the cost of the medical group was about one quarter the cost of the bypass group, whereas the cost of the angioplasty group was on average 60% of that of the surgical group. By 1 year, the costs in the angioplasty group reached 66% of those in the bypass group, but both remained far above the costs of medical therapy alone. There is a significant cost gradient for percutaneous transluminal coronary angioplasty as the extent of the disease increases, which is not apparent for coronary artery bypass grafting.

Medical costs arise in a complex manner, and their prediction is difficult. Unexpected events during or after the initial treatment are a major cause of increased costs, and complications often cannot be predicted. Patient-related factors have only a small effect on costs in comparison with the choice of treatment. High-risk, high-cost patients tend to get the most benefit.