Dec. 15, 1999 GAINESVILLE, Fla. --- Bypass surgery and angioplasty initially cost much more than a prescription for pills, but in certain patients they have the potential to treat heart disease so effectively that long-term medical expenses could end up about equal, University of Florida researchers have found.
The study of relative health-care costs, published in the Nov. 15th issue of the American Journal of Cardiology, built on findings from a recent multicenter pilot trial that showed patients who initially are treated aggressively may actually fare better than those who simply take medication. The cost analysis was the first to use data generated by the random assignment of treatment strategies for patients with chronic heart disease.
"It's a 'pay now or pay later' kind of thing, but paying later is at the expense of a poorer clinical outcome for the patient," said Dr. Carl J. Pepine, professor and chief of cardiovascular medicine at UF's College of Medicine, and the study's lead author.
The findings also underscore problems with how health insurance plans view treatment for chronic diseases.
"This study emphasizes the importance of looking at the long-term outcomes and costs of a chronic disease such as coronary artery disease," said study co-author Dr. Daniel B. Mark, professor of medicine at Duke University Medical Center and director of the Outcomes Research and Assessment Group at the Duke Clinical Research Institute. "In today's managed-care environment, the emphasis is very much on saving cost over the short term. Since employers change managed care contracts every few years, managed-care companies know they will not have to bear the long-term costs of care for a patient and therefore focus on controlling short-term costs. This study suggests that such a short-term focus may not be good either for the patient or the health-care budget."
The American Heart Association estimates about 12 million Americans have coronary heart disease, generating total costs-including health expenditures and lost productivity-of $99.8 billion annually.
Standard treatment ranges from a conservative approach using medication to a more aggressive one known as revascularization, involving angioplasty or bypass surgery to restore blood flow. But which option to pursue has frequently been left to patients' and physicians' personal preference because of a lack of strong scientific data favoring one alternative over another.
So UF researchers decided to weigh the costs and benefits associated with various treatment strategies. They tallied the health-care costs the patients generated over a two-year follow-up period using Medicare Diagnosis Related Group rates and Physician Fee Schedules to estimate costs of hospitalization, medical procedures and physician fees. Medication costs were calculated from the Drug Topics Red Book using 1993 average wholesale prices. They then extrapolated the data to 12 years. Indirect costs, such as time lost from work, were not included in the analysis.
While undergoing angioplasty or bypass surgery was initially more expensive-at three months, estimated costs were 10 times greater than those incurred by patients who simply took medicine-total expenses over a 12-year period were roughly the same, researchers found. In fact, follow-up costs for hospitalization and medication were more for study participants in the conservative strategy and increased at a rate two to three times that of those who initially underwent revascularization.
Furthermore, angioplasty or bypass surgery improved patients' ability to exercise and reduced their need for medication. At one year, these patients appeared to be less likely to have a poorer outcome. At two years, the aggressive approach's benefit was even more apparent, Pepine said.
"You consume a lot of medical resources early to pay for the revascularization procedure, as you would expect," Pepine said. "However, because the medically treated patients continue to consume resources at a higher rate than the revascularized patients, within about 10 years the situation becomes cost neutral. And this was well within the expected life of the patients who were in the trial."
The study tracked 558 patients who had stable coronary artery disease and reduced blood flow to the heart during both stress testing and daily activities. Participants were randomly assigned to three different initial treatment strategies and were tracked for two years. They either took medication only when experiencing the chest pain known as angina (conservative care) or daily to treat reduced blood flow to the heart, a condition known as ischemia (intermediate care), or underwent angioplasty or bypass surgery after doctors detected reduced blood flow to the heart on an angiogram (aggressive care).
UF researchers found that after one year, cumulative average costs per patient for angioplasty or bypass surgery were roughly three times the costs required for the conservative or intermediate strategies that initially relied on medication alone. But by the end of the second year, costs for medical strategies increased twice that observed for revascularization. After 12 years, cumulative costs of hospitalizations, revascularization procedures, physician fees and medications were equivalent in the medical and revascularization treatment strategies.
UF's study was funded by the National Heart, Lung, and Blood Institute. The project was conducted in collaboration with the institute and Duke University School of Medicine, Montreal Heart Institute Research Center, St. Louis University Medical Center, University of Ottawa Heart Institute Research Center, Maryland Medical Research Institute and the Baylor College of Medicine.
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