The efficacy of TEVAR versus OTAR to reduce early morbidity and mortality, with similar long-term survival has been established.6
In light of this and other perceived benefits, we have employed endovascular techniques to address thoracic aortic disease with enthusiasm. In this study, since FDA approval of the GORE TAG device and more recently other devices, our practice has shifted to perform TEVAR over OTAR on a 2:1 basis. Indeed, a recent analysis of the Nationwide Inpatient Sample(NIS) by Orandi and co-authors revealed in late 2005, TEVAR was being performed three times more often than OTAR.9
It may be anticipated as the collective national experience grows, the fraction of OTAR patients will continue to decrease as devices proliferate and longevity can be demonstrated. Notable exceptions to the application of TEVAR are first, those patients currently affected by connective tissue disorders(who constitute a significant percentage of our practice), and second, those afflicted with acute and chronic dissections for which consensus documents rightly describe the inherent limitation of FDA approved devices to achieve suitable outcomes.10
Traditional supply-and-demand models of economies of significant scale suggest device cost should decrease with increasing market competition of available devices. In the arena of endovascular repair of abdominal aortic aneurysms(EVAR), now over 10 years into widespread practice, device costs have continued to escalate despite market presence of more companies. Indeed, prior EVAR reports suggested insufficient coverage of Medicare reimbursement due to high device costs.11
In a later report, Noll continued to reveal high device costs as a contributor to total cost of delivery of care in the long-term.12
In our assessment of TEVAR, 56% of total costs was derived from OR supply charges which include all stent-graft devices and adjunctive endovascular supplies. Clearly, early cost effectiveness would be likely demonstrated with a reduced device charge for TEVAR, but to date, all available devices are entering the market with similar costs. Our study builds on the experience of two prior reports comparing TEVAR with OTAR. Orandi et al. found no difference in OTAR versus TEVAR costs in a large cohort of patients.9
In contrast, Beaver et al. found higher operating room costs for the TEVAR group, but overall hospitalization costs were greater in the OTAR group due to increased utilization of anesthesia, pharmacy, and radiology services.13
This study is more specific in relating the charge buckets underlying the total expenditures; and due to the inability to account for cost-shifting in other studies, this report may be more accurate given the unique payment system in the state of Maryland.
In contradistinction, Glade and colleagues, in 2005, demonstrated cost efficacy in their assessment of the index TEVAR procedure over OTAR(€ 20,663 vs €33,770).14
Interestingly, their comparison shadows our charge categories, with the notable exception of a much reduced prosthesis charge of only €10,000 for two devices – yielding a conversion to US dollars of $11,720 by a contemporaneous 2005 Interbank Rate Conversion to USD. Hence, considering the multiplicity of devices available in the European Union in 2005 which lowered their costs, it is unclear how to reconcile the current state of device pricing in the United States market. In the current era of cost-effectiveness, it may become incumbent on the cardiovascular surgery community in the US to assume a more proactive role in lowering device costs.
Costs of TEVAR therapy include both the initial cost of placement and also the long-term cost of follow-up and surveillance. Endoleak formation and aneurysm expansion are well-known occurrences after endovascular interventions on the aorta, and contribute to the long-term cost of follow-up.14
Patients undergoing TEVAR require routine, lifelong surveillance, typically with computerized tomography(CT), and many require secondary interventions. Addressing the issue of long-term costs requires ongoing monitoring and longer follow-up than is currently available in the published literature- only recent studies document the postplacement costs of endovascular therapy in the abdominal aorta.12
In their report of EVAR, postplacement cost of EVAR was increased eight fold with requirement for secondary procedure($31, 696) versus those without procedures($3,668). Our charge assessment of the secondary procedures in Table 3 parallels the experience of EVAR. Our secondary reintervention rate is 7.8%, higher than the 3.6% reintervention rate of the 5yr followup of the Gore TAG Pivotal trial.6
The higher rate of reintervention in our study likely reflects our experience in managing patients with difficult proximal fixation zones, and accordingly, a higher event rate. Our costs on the secondary interventions are largely dependent on the nature of the intervention, but again, device costs are the majority of the expenditure(data not shown).
The limitations of the current study are the use of hospital charges as an index of cost. It is important to cite the unique insurance structure present in the State of Maryland which serves to neutralize this issue. The Maryland HSCRC was established by the state legislature in 1971 and supported by the hospital industry. The HSCRC was authorized to establish hospital payment rates to promote cost containment, thus improving access to care. The HSCRC sets all payment rates for insurers, both private and public, including Medicare and Medicaid within all Maryland hospitals. Thus, the common practice of “cost shifting” by overcharging privately insured patients is absent, making our charge data consistent and predictable. The authors’ institution HSCRC rate for charge payment has been cost + 1–3%
over the study interval. This formula applies evenly to each charge category included in this analysis. Accordingly, we believe this study represents the most accurate assessment of TEVAR and OTAR costs to date. Similar reports have cited costs as equivalent, but alluded to increased charges consistent with “cost shifting.” In a non-rate controlled state, charges were $119,932 for open TAAA repair, but cost was cited as equal.9
Exact charges for post-discharge inpatient rehabilitation care were not available for rigorous analysis from the billing office. However, estimates for one month of inpatient physical therapy, which was more common in the OTAR group, are $30,000(Personal communication rehabilitation facility executive). The purpose of this paper was to compare the costs of delivering care for each form of therapy during the index hospitalization. As well, slightly different time frames were studied between the two groups, but significant resource utilization for OTAR is still the rule.