Invited Commentary

Abstract

The 1-year outcomes of the CORONARY trial were published this past year and demonstrated no significant difference between on-pump and off-pump coronary artery bypass grafting (CABG) with regard to the primary composite endpoint or rate of repeat coronary revascularization. Combined with the recent outcomes of the GOPCABGE study [German Off-Pump Coronary Artery Bypass Grafting in Elderly Patients] demonstrating no difference in on-pump or off-pump CABG in elderly patients, much of the large, contemporary literature on off-pump CABG indicates that, unlike the results of the ROOBY [Randomized On/Off Bypass] trial, off-pump is at least noninferior to on-pump CABG [1Diegeler A. Börgermann J. Kappert U. et al.Off-pump versus on-pump coronary-artery bypass grafting in elderly patients.N Engl J Med. 2013; 368: 1189-1198Crossref PubMed Scopus (343) Google Scholar, 2Shroyer A.L. Grover F.L. Hattler B. et al.On-pump versus off-pump coronary-artery bypass surgery.N Engl J Med. 2009; 361: 1827-1837Crossref PubMed Scopus (874) Google Scholar]. In this growing era of comparative effectiveness research, however, we see a trend toward assessing new technologies not only with regard to their clinical effectiveness but also cost effectiveness [3Iribarne A. Russo M.J. Moskowitz A.J. Ascheim D.D. Brown L.D. Gelijns A.C. Assessing technological change in cardiothoracic surgery.Semin Thorac Cardiovasc Surg. 2009; 21: 28-34Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar]. Thus, while on-pump and off-pump techniques appear to have similar clinical outcomes, could one technique prove more effective through lower overall costs? Lamy and colleagues [4Lamy A. Tong W. Devereaux P.J. et al.The cost implications of off-pump versus on-pump coronary artery bypass graft surgery at one year.Ann Thorac Surg. 2014; 98: 1620-1626Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar] begin to address this question in their current analysis and demonstrate that after 1 year there was no significant difference in total cost per patient between on-pump and off-pump groups. However, this analysis does have some notable limitations. The CORONARY trial recruited 4,752 patients from 79 centers and 19 countries. Variability exists among countries in event costs used to calculate health care utilization costs, and furthermore the conversion of such event costs to standardized US dollars using purchasing power parties relies on several significant economic assumptions. More importantly, the authors do not include the cost for surgical supplies in their analysis. The high costs associated with disposables such as retractors and stabilizers have the potential to significantly alter the conclusions of the study, as demonstrated by the authors' sensitivity analysis. While Lamy and colleagues [4Lamy A. Tong W. Devereaux P.J. et al.The cost implications of off-pump versus on-pump coronary artery bypass graft surgery at one year.Ann Thorac Surg. 2014; 98: 1620-1626Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar] offer an important starting point for assessing the cost effectiveness of on-pump versus off-pump CABG, further research is necessary before drawing final conclusions. An ideal cost effectiveness analysis would be performed in 1 or more hospitals in the same country to limit economic assumptions, be high volume in both on-pump and off-pump techniques to eliminate operator bias, and account for differences in direct costs of surgical supplies such as disposables. The Cost Implications of Off-Pump Versus On-Pump Coronary Artery Bypass Graft Surgery at One YearThe Annals of Thoracic SurgeryVol. 98Issue 5PreviewThe purpose of this study was to determine the cost implications of the Coronary Artery Bypass Graft Off or On Pump Revascularization Study (CORONARY) at 1 year. Full-Text PDF