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July 2000
Economic Outcome of Off-Pump Coronary Artery Bypass Surgery: A Prospective Randomized Study.
Ascione R, Lloyd CT, Underwood MJ, Lotto AA, Pitsis AA, Angelini GD. Ann Thorac Surg 1999;68:2237-42.
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Commentary by Katherine Grichnik, M.D.
[see abstract below]
This is a study from 1999 done in the United Kingdom, which I reviewed in preparation for a talk. It is an important study, which should be investigated in the United States in a similar manner.
This is one of the few studies with a large number of patients in which the authors prospectively studied the economic benefits of off-pump cardiac surgery (OPCAB - coronary artery bypass grafting surgery performed on the beating heart without cardiopulmonary bypass). 200 patients undergoing first-time coronary artery bypass grafting were randomized to having conventional coronary artery bypass with cardiopulmonary bypass - the CCABG group versus having OPCAB surgery. The preoperative and operative characteristics were not different between groups (age, sex, ejection fraction, parsonnet score, operative time, number of grafts, etc), however, there were multiple exclusion criteria. These included impaired ejection fraction, recent MI, raised serum creatinine, respiratory impairment, prior stroke or TIA, and coagulopathy. Patients with distal left circumflex disease were also excluded due to the difficulty in approaching these lesions with OPCAB.
The outcome variable was the total cost for both operative and postoperative services. Professional fees, preoperative costs, operating room, perfusionist staff and drug costs were excluded. Variable and fixed direct costs were obtained for each care area. Indirect costs were excluded.
Ascione et al. found significant cost savings for the OPCAB group as compared to the CCAB group. Further, there were two deaths in the CCAB group ( due to multiorgan failure and low cardiac output state) and one patient required reoperation for graft revision. There were 2 perioperative MIs, one in each group. These costs were converted to US dollars for comparison.
The cost comparisons are outlined below:
| |
Per Patient Cost |
OPCAB |
CCAB |
| |
| I. |
Material costs ($): |
946 |
1252 |
| II. |
Bed occupancy cost ($) |
1830 |
2163 |
| III. |
Transfusion requirements ($) |
22 |
185 |
| IV. |
Cost for postoperative complication
| 28 |
117 |
| |
management ($) (consumable items, not LOS) |
|
|
| V. |
Total Costs from above ($) |
2615 |
3731 |
As OPCAB becomes more popular, it is being studied intensively. The benefits of avoiding CPB may be multiple including decreased intubation time, decreased ICU time and decreased LOS (although not shown in this study, these results have been shown in other studies). Further benefits may be decreased inflammatory response, better temperature regulation, decreased coagulopathy, and perhaps overall decreased postoperative complications (yet to be determined). With all of these benefits, significant cost saving should be realized. This study needs to be reproduced in the United States with the benefits and constraints of our healthcare system in a prospective randomized fashion. OPCAB has become a viable alternative to CCAB for a many patients needing coronary artery bypass grafting.
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ABSTRACTS
Economic Outcome of Off-Pump Coronary Artery Bypass Surgery: A Prospective Randomized Study.
AUTHORS:
Ascione R, Lloyd CT, Underwood MJ, Lotto AA, Pitsis AA, Angelini GD.
SOURCE:
Ann Thorac Surg 1999;68:2237-42.
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.
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