Economic Evaluation of Open Bypass and Novel Endovascular Therapies for Peripheral Arterial Disease

Abstract

During the past decade, endovascular peripheral arterial disease (PAD) therapies have steadily increased in prevalence, with newer approaches incorporating novel stent, drug-coated balloon, and atherectomy technologies. This study evaluated procedural and economic burdens associated with each treatment modality. A retrospective database for PAD surgeries at a single academic institution, containing 796 procedures from 2011 to 2015, was stratified by initial therapeutic modality: open bypass (OBP), percutaneous transluminal angioplasty with stenting (PTA/S), percutaneous transluminal angioplasty with atherectomy (PTA/A), or percutaneous transluminal angioplasty alone (PTA). Records were analyzed for all subsequent institutional inpatient and ambulatory ipsilateral revascularizations during the study period. Health system costs included procedural costs using 2016 Medicare relative value units, device costs including novel drug-coated balloon and drug-eluting stent costs, and institution-specific costs of hospital length of stay derived from a statewide payments-reporting database. Demographic characteristics and health system costs of index and follow-on revascularizations were compared between study arms. Among the population of 796 procedures, 183 (23.0%) were OBP, 265 (33.3%) were PTA/S, 81 (10.2%) were PTA/A, and 267 (33.5%) were PTA alone. The institutional proportion of endovascular cases increased from 70.2% to 80.6% (2011-2015). The PTA/S arm included 44 (21.3%) procedures using both stents and atherectomy devices; 93 (23.5%) endovascular procedures employed novel drug-coated balloon or drug-eluting stent technologies. Femoral-popliteal procedures were most common (55.5%). Patients were predominantly male, in both the OBP (68.9%) and endovascular (57.6%) arms. Patients were older in the endovascular arms vs OBP (71.0 vs 67.4 years; P < .01). Total study period costs were highest for OBP ($49,661) on average, followed by PTA/S ($34,748), PTA ($33,223), and PTA/A ($31,045; P < .01). The cost of hospital stay composed most of the variance ($43,781 for OBP vs $26,457 for endovascular), whereas PTA/A had the highest device costs; 3.1% of patients underwent major amputations, averaging $1080. The OBP arm demonstrated lower need for revascularization (26.2%) than endovascular (54.6%; P < .01). In our study population, OBP was associated with higher costs but decreased need for revascularization compared with endovascular intervention. The economic costs of treatment may be an important consideration in treating PAD.