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(Circulation. 1995;92:2480-2487.)
© 1995 American Heart Association, Inc.
Articles |
In-Hospital and One-Year Economic Outcomes After Coronary Stenting or Balloon Angioplasty
Results From a Randomized Clinical Trial
From the Cardiovascular Division, Beth Israel Hospital, Boston, Mass (D.J.C., C.A.S., K.K.L.H., D.S.B.); the Department of Health Policy and Management, Harvard School of Public Health, Boston, Mass (D.J.C., R.B.S.); Yale School of Medicine, New Haven, Conn (H.M.K., M.C.); Arizona Heart Institute, Phoenix (R.R.H.); Johns Hopkins Hospital, Baltimore, Md (J.A.B.); Lenox Hill Hospital, New York, NY (J.W.M.); Jefferson Medical College, Philadelphia, Pa (M.P.S.); the University of Pittsburgh (Pa) (K.D.); and the Washington (DC) Cardiology Center (M.B.L.).
Correspondence to David J. Cohen, MD, MSc, Cardiovascular Division, Beth Israel Hospital, 330 Brookline Ave, Boston, MA 02215. E-mail djc@hsph.harvard.edu.
Background Coronary stenting has been shown to improve initial success, reduce angiographic restenosis, and reduce the need for repeat revascularization compared with conventional balloon angioplasty (PTCA). Although previous studies have demonstrated that initial hospital costs for stenting are considerably higher than those for conventional PTCA, the impact of coronary stenting on long-term medical care costs remains unknown.
Methods and Results Between January 1991 and June 1993, 207
consecutive patients with symptomatic coronary
disease requiring revascularization of a single
coronary lesion were randomized to receive initial treatment by
either PTCA (n=105) or Palmaz-Schatz coronary stent
implantation (n=102) in the multicenter STRESS trial. Detailed resource
utilization and cost data were collected for each patient's initial
hospitalization and for any subsequent hospital visits for 1 year after
randomization. Compared with conventional angioplasty, coronary
stenting resulted in additional catheterization
laboratory costs, increased vascular complications, and longer length
of stay. Initial hospital costs were thus 
$2200 higher for stenting
than for PTCA ($9738±3248 versus $7505±5015;
P<.001).
Over the first year of follow-up, however, patients assigned to
initial stenting were less likely to require rehospitalization for a
cardiac condition and underwent fewer subsequent
revascularization procedures. Follow-up medical
care costs thus tended to be lower for stenting than for conventional
angioplasty ($1918±4841 versus $3359±7100,
P=.21).
Nonetheless, cumulative 1-year medical care costs remained higher for
patients undergoing initial stenting ($11 656±5674 versus
$10 865±9073, P<.001). Even after adjustment for the
higher incidence of vascular complications in the stent group, total
1-year costs were $300 higher for stenting than for balloon
angioplasty.
Conclusions Elective coronary stenting, as performed in
the randomized STRESS trial, increased total 1-year medical care costs
by $800 per patient compared with conventional angioplasty. Future
studies will be necessary to determine whether ongoing refinements in
stent design, implantation techniques, and anticoagulation regimens can
narrow this cost difference further by reducing stent-related
vascular complications or length of stay.
Key Words: stents • angioplasty • trials • cost-benefit analysis • coronary disease
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|
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|
|
|
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|
|
|
|
|
|
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|
|
|
|
|
|
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|
|
|
|
|
|
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|
|
|
|
 |
|
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|
|
|
|
|
|
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|
|
|
|
|
|
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|
|
|
|
|
|
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|
|
|
|
|
|
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|
|
|
|
|
|
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|
|
|
|
|
|
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|
|
|
|
|
|
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|
|