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Repeat Angioplasty, Stenting in
Elderly Adding $700 Million to Medicare Costs
June 30, 2004 - Repeating balloon angioplasty
and/or stenting procedures to open narrowed arteries in elderly patients
may add more than $700 million a year to Medicare expenses, according to
a report published yesterday in the rapid access issue of
Circulation: Journal of the American Heart Association.
The study is the first to examine the rates of
restenosis of percutaneous coronary interventions (PCIs) and their
economic consequences in a contemporary, unselected elderly population.
Researchers used Medicare records of 9,868
patients aged 65 or older who underwent balloon angioplasty or stenting
in 1998 and identified those who had repeat revascularization procedures
31 to 365 days after the initial procedure.
About 17 percent of these patients required one or
more repeat procedures during the year following the first procedure
13.2 percent had repeat PCI and 4.9 percent required bypass surgery,
said David J. Cohen, M.D., M.Sc., the studys senior author and an
associate professor of medicine at Harvard Medical School.
Average one-year medical care costs increased
five-fold among patients with repeat procedures. Follow-up costs in the
first year were $26,186 for those who needed additional
revascularization versus $5,344 for PCI patients who did not require
revascularization. After adjusting for baseline differences, the added
cost for each patient who required repeat revascularization was about
$19,000.
In PCI procedures, a tiny catheter is threaded up
into the heart from an artery in the groin or arm to the blocked or
narrowed vessel. Once the catheter is in place, a tiny balloon is
inflated to open the vessel. Often, a tiny, flexible tube called a
stent is also deployed to help prop open the vessel in order to allow
blood to flow freely. Sometimes the vessel re-narrows, which is called
restenosis. If the restenosis is severe, repeat procedures are
required.
Considering both the cost of repeat interventions
and their frequency in the Medicare population, we estimate that
treatment of restenosis adds about $2,700 to the cost of each
percutaneous coronary intervention over the following year, Cohen
said. Given the current PCI volumes, these findings imply that the
aggregate cost to the Medicare Program for treatment of restenosis is
more than $700 million per year.
He said many patients require two or three repeat
procedures or, eventually, they may need bypass surgery.
Based on previous research indicating that 85
percent of repeat procedures in the general population are due to
restenosis, researchers in this study estimated that the clinical
restenosis rate at one year was 14.4 percent, which is actually a
better restenosis rate than previously reported for bare metal stents,
he said. So the bare metal stents were actually working reasonably
well, except for the high costs associated with patients who needed
repeat procedures.
Bare metal stents cost about $1,000. Newer
drug-eluting stents, which reduce the rates of restenosis, are about
$3,000.
Cohen and his colleagues conclude that drug-eluting
stents are an unlikely cost-saving option for the general Medicare
population. But, they said newer stents may be more cost-effective
in patients with diabetes or kidney disease. In those patients, they
project true long-term cost savings might still be achieved
Co-authors are Mary Ann Clark, M.H.A.; Ameet
Bakhai, M.D.; Michael J. Lacey, M.S.; and Elise M. Pelletier, M.S.
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