Comparison Of Beating Heart Coronary Artery Surgery And Conventional CABG With Regard To Cost Effectiveness
S Bayrak, ? Özsöyler, U Yetkin, B Pamuk, N Yakut, N Karahan, A Gürbüz
beating heart, cardiopulmonary bypass, cost
S Bayrak, ? Özsöyler, U Yetkin, B Pamuk, N Yakut, N Karahan, A Gürbüz. Comparison Of Beating Heart Coronary Artery Surgery And Conventional CABG With Regard To Cost Effectiveness. The Internet Journal of Thoracic and Cardiovascular Surgery. 2006 Volume 10 Number 2.
Aim: In this study we aimed to compare conventionel coronary artery bypass surgery (CCABG) with offpump coronary artery bypass (OPCAB) for coronary artery disease by means of cost.
Methods: The study is a prospective nonrandomized study. Data of 294 patients who have been operated in our clinic for coronary artery disease were prospectively collected between March 2001 and through July 2005. There were 147 patients in conventionel CABG group (Group 1), and 147 patients OPCAB group (Group 2).
Results: Group 1 had statistically significant high costs in terms of service costs, operative procedure costs, intensive care costs, blood transfusion costs and total hospitality costs.
Conclusion: OPCAB procedure when performed under appropriate indications can be applied with less cost than CCABG and can be achieved safely and with succesful results by experienced surgical teams.
Coronary artery disease(CAD) is one of the most important health problem in developed and developing countries and the cost of the treatment modalities are so important because of the economic burden.In this study we compared the costs and comorbidities of coronary artery bppass surgery that influencing the cost, which is the most important treatment choice for CAD.
Materials And Methods
This study is a prospective nonrandomized study. Data of 294 patients who have been operated in our clinic for coronary artery disease were prospectively collected between March 2001 and through July 2005. There were 147 patients in conventionel coronary artery bypass surgery group (CCABG) (Group 1), and 147 patients in offpump coronary artery bypass (OPCAB) group (Group 2).
Exclusion criterias were; left ventricular dysfunction with the left ventricular ejection fraction(LVEF) 20% and lower, early myocardial infarction within one month, blood creatinin higher than 200 µmol/ L, CABG with valvular disease, severe respiratory dysfunction, history of stroke or transient ischemic attack and coagulopaty. None of the angiographic findings were taken as exclusion criteria for the study.
Preoperative patient data were shown in table 1. There was no statistically significant difference between the groups for unstable angina, diabetes mellitus (DM),hypertension(HT), peripheral arterial disease and left ventricular dysfunction.
Standart median sternotomy incision was done in both groups. In Group 1 cardiopulmonary bypass (CPB) was initiated with ascendan aortic cannulation and two stage venous cannulation after the administraion of 3mg/kg heparin and maintaining the activated clotting time (ACT) above 480 seconds. The patients were cooled to 28-30 C. After crossclamping the aorta, antegrade isotermic blood cardiopledgia was given. During CPB, the systemic pressure was maintained between 70-90 mmHg. The cardioplegia was given in every 20 minutes. Distal anostomoses were performed with 7/0 polypropylene suture and proximal anostomoses were performed upon side clamped aorta with 5/0 polypropylene suture.
In group 2, 1mg/kg heparin was administered and the ACT was kept between 250-350 seconds. The anostomose priority was determined by the surgical team for distal anostomoses. Firstly the anterior, then the posterior and than the lateral wall coronary vessels were revascularised. For the right coronary artery (RCA), right posterior descending artery (RPD) and right posterolateral artery (RPl), the traction sutures were put to right atrioventricular groove taking the inside and the adjacent thick tissue together with RCA. For the left anterior descending artery (LAD), diagonal artery (D) and high lateral artery (HL) the heart was elevated with the spounges inserted beneath the heart. The Octopus III (Medtronic Inc., Minneapolis, MN, USA) was used for cardiac stabilization. After stabilization of the heart the anostomoses were performed with 7/0 polypropylene continuous suture. Air blowing was used to get a dry area for anostomosis. In the patients with unstable conditions and RCA dominancy, to avoid excessive bleeding and electrocardiographic instability the anostomosis was performed by using an intracoronary shunt. For the safety of operation, CPB system was kept ready without putting the prime solution.
The Analysis Of Cost
For total cost; preoperative, operative and postoperative unit costs were calculated for each patient and these parameters were accepted as variable parameters.Variable and fixed direct costs were including bed distraction (nursery service), operation room, transfusion, postoperative intensive care unit and postoperative complication costs and each of these were calculated seperately.
Procedure Cost (Combine Operation Materials)
Cost of anesthesia include the anesthesia induction and continuation, intubation and mechanic ventilation, monitoring, pulse oximetry, invasive monitoring of arteriel and venous pressures and pulmonary artery catheterization. Combined operation costs were calculated with the data taken from the perfusionists and opeation room staff. Procedure cost included procedure set, operation bag and the price that was determined by the institution. Perfusion cost included CPB and cardioplegia materials for the on-pump group. Stabilizer, air blowing system and intracoronary shunt when used for off-pump group. Operation team and perfusionist team were the same for both of the groups. In this section the CPB cost, suture cost and routine procedure cost were analyzed as subsections. CPB was invariable for conventional CABG. CPB was kept ready but wasn't used for off-pump group. For this reason it was made out an invoice for on-pump group. The lines, roller pump and oxigenator costs were totally investigated in CPB.
Bed Distraction And Nursery Costs
Bed distraction calculation was performed seperately for service and intensive care units prices those were determined by the institution. This subsection include the 8 hours periodic care of the nurses, the treatments and the drug costs used in these treatments. The total values of these parameters are in the service and intensive care unit cost section. Intensive care unit stay costs were investigated as total values of the treatments those were given in the intensive care unit, drug costs, the materials those were used, bed distraction cost, the nursery care, and visites. In the service unit cost the total values of preoperative bed distraction, nursery care, the teratments those were given and the cost of drugs those were given in the service unit were investigated.
The Cost Of Transfusion
Fresh blood, fresh frozen plasma, erythrocte and trombocyte suspansions costs were included in this section.
The Statistical Analysis
The results were given as +/- standard deviation. The Chi-Square test was used for the nonparametric values for both groups. Independent variable t test was used for the parametric values. P values below 0.05 was accepted as statistically significant.
Preoperative and operative features are shown in table 1. The age, gender, coronary artery disease with NYHA classification, DM, stable, unstable angina existence were evaluated in groups and no statistically significant difference was determined (Table 1).
Presence of preoperative chronic obstructive pulmonary disease was statistically significant between the groups (p=0.001) as was the preoperative cerebrovascular event history (p=0.014).
Distal anostomoses count was statistically significant in favor of on-pump group in the operative analysis section (p=0.001)(Table 2).
Cardiovascular disease is the most frequent cause of mortality especially in the developed countries. Coronary artery disease is responsible for 50% of cardiovascular mortality. It is estimated that there are 2.8 million people who has coronary artery disease. Annually mortality rate due to coronary artery disease is 0.51% in males and 0.33% for females (1) so treatment cost of coronary artery disease has a great importance.
Studies showing the availability of performing anostomosis on beating heart safely make the OPCAB procedure popular again. Besides decreasing the cost increasing factors like bypass material, staying period in intensive care unit and at hospital made OPCAB popular (7). The recently emphasized topics for heart health and health care are patient pleasure, the quality of therapy, the cost of surgical procedures and the comorbid factors effecting these parameters. However, CCABG is still the widespread used procedure.
The alternatives for this procedure are coronary angioplasty and stenting, minimal invasive coronary artery bypass (MIDCAB), off-pump coronary artery bypass (OPCAB) with midline sternotomy, hybrid procedures, transmyocardial laser revascularization, angiogenic and stem cell transfer (8). It is thought that OPCAB establishes good revascularization, low perioperative morbidity, low blood transfusion need and it prevents the neurologic impairment due to low perfusion with CPB.
The parameters were seperated into 8 main topics as intensive care, service unit, CPB, blood transfusion, suture, anesthesia, routine operation room procedures and total cost analysis for cost evalution.
The total values of preoperative bed distraction, nursery care, the treatments and drugs those were given in the service unit were included into the service unit cost. It has been shown that the mean service cost for patient was higher in on-pump group (9). We also had similar results. This difference is thought to be due to less hospital stay in the postoperative service unit, possible low rate of respiratory complications, less need for medication and early mobilization of the patients for OPCAB group.
CPB was hold ready but wasn't routinely used for off-pump group. For this reason it was made out an invoice in on-pump group.
In the study that Ascione made, the suture costs were 41.024$ for on-pump group and 34.174$ for off-pump group (10). Similarly, in our prospective analysis mean suture cost was significantly higher in the on-pump group (p<0.001). This difference was probably due to the sutures used for cannulation in on-pump group.
Routinely used operation equipments, disinfection materials, sterile and nonsterile gloves and routine operation cost that is made out an invoice for operation are included to procedure cost analysis. These parameters were 1.252 $ for on-pump group, 854.98±27.36$ for off-pump group in Ascione's study (11). In our study similar significant lower costs were found in the off-pump group.
Intensive care unit costs included costs of the medications, materials used, bed distractions, nursery care and visites. In a study that was made in Utah Heart Center and published in 2001. The mean intensive care unit cost was 3.323±1.754 $ on-pump group and 3.183±1.612 $ for off-pump group. One of the most important causes for this significant difference is low stay in intensive care unit for OPCAB group. Besides mechanic ventilatory support, less respiratory complications (ards, lcos, pneumonia, other respiratory infections etc), less IABP, antibiotic, respiratoy and bronchodilatory drugs usage may be the other reasons.
In the study Ascione and Coll made the mean blood transfusion costs were 184.8 ±35.2 $ for on-pump and 21.47 ±6.9 $ for off pump group. We also had lower transfusion costs in OPCAB group. Certainly these findings were related to less bleeding and less transfusion need. Another important point is that the cost for possible transfusion complications might be lesser.
Total operation cost includes the total expense that is done from hospitalization till discharge of the patient and it is the most important data for cost analyses. In the study that Van Dick and Coll made these costs were 9118$ for on-pump group, 8796 $ for off-pump group (12) and in the study that Ascione and coll made these values were 3.731±1.169 $ for on-pump group and 2.615±953.6 $ for off-pump group (13). Conclusion of another study performed by Bull and Coll showed the mean cost as 17.963±7.233 $ for on-pump group and 17.110±7.057 $ for off-pump group (14). Our study demonstrated significantly higher operation expenses for conventional bypass group.
One of the most important facts is effecting the health politics of a country is the influence of the applied treatment on the cost. Besides the safety of a procedure, cost of the technology is also important and must be taken into consideration. All of the centers around the world are trying to reevaluate their techniques and applications for better patient care while decreasing the costs. Moreover a new method that decreases the cost must also aim to decrease the morbidity and hospitalization. In the recent years by using the cardiac stabilizers complete revascularization can be performed safely with OPCAB procedure and when compared with conventional CABG, OPCAB decreases complication rates and morbidity and mortality (15). With OPCAB procedure; the operation time, ventilatory support duration,and intensive care unit stay decrease. These allow the early discharge and also minimize the productive power lost. The main parameters determined in our study showed that OPCAB procedure can be performed much more economically than the conventional procedure. This is a very important subject for the countries health politics.
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