Elective EVAR Yielding Better Short-Term Results at Lower Cost Than Before


Despite being used in patients with an increasing comorbidity burden, perioperative outcomes with elective endovascular aneurysm repair (EVAR) have substantially improved in recent years compared with in the early years after its approval, according to a study published online August 4, 2015, ahead of print in the Journal of Vascular Surgery. Importantly, the trend has been accompanied by decreases in procedure-related costs.

Take HOme:  Elective EVAR Yielding Better Short-Term Results at Lower Cost Than Before

“Advanced technology is often implicated in escalating healthcare spending, and the value of novel techniques is often questioned,” Andrew J. Meltzer, MD, of NewYork-Presbyterian Hospital (New York, NY), and colleagues write. “EVAR offers an interesting example for stakeholders to consider in the era of cost-containment pressures and criticism of nascent, expensive technology in healthcare.”

The researchers looked at data from the Nationwide Inpatient Sample on 185,249 patients who underwent elective EVAR for intact AAA between 2000 and 2011. EVAR was approved by the FDA in 1999. 

The total number of procedures performed each year grew from 1,712 in 2000 to 22,457 in 2011 (P < .001). At the same time, rates of major comorbidities—including obesity, diabetes, hypertension, cerebrovascular disease, and dyslipidemia—increased.

Adverse Outcomes, Costs Decline

In-hospital outcomes improved, however, with lower rates of mortality, acute MI, respiratory complications, perioperative bleeding, and postoperative infection seen in 2009-2011 than in 2000-2002. The improvement remained after adjustment for multiple demographic and hospital-level factors and various comorbidities (table 1).

Table 1. In-Hospital Outcomes With Elective EVAR

There were no changes in rates of stroke or postoperative shock observed (0.1% at the beginning and end of the study period for both outcomes). 

Median length of stay was reduced from 2 days to 1 day, and after adjusting costs at an inflation rate of 5% in 2011 dollars, the median cost of elective EVAR fell from $28,174 in 2000-2002 to $22,811 in 2009-2011 (P < .001).

Evolution in Outcomes Important for New Technology  

Since its introduction, EVAR has been rapidly adopted after demonstrating lower perioperative mortality, morbidity, and length of stay and higher postoperative quality of life compared with open surgical repair, the authors note. Yet “the relative balance of the benefits and costs continues to be questioned,” they write.

Some prior research has led to the conclusion that the high costs associated with EVAR, combined with a requirement for postoperative surveillance, make open repair a more cost-effective option, Dr. Meltzer and colleagues note. But more recent studies have shown costs to be comparable between EVAR and surgery. Costs did not differ between approaches in the EVAR 1 trial, for example. And in the OVER trial, hospitalization costs were lower with EVAR, with a convergence by 2 years.

“Our objective was not simply to recapitulate existing studies with respect to the cost-effectiveness of EVAR, but rather to characterize the evolution in the value of this technology—at least from the standpoint of perioperative outcomes and procedural costs,” Dr. Meltzer and colleagues write.

The observed improvement in outcomes during the study period likely can be attributed to a provider learning curve and advances in perioperative care, they say.

The findings “should help advance the debate related to reimbursement, pricing, and hospital purchasing [for EVAR],” they argue. “While the procedural costs of EVAR may appear to be comparatively high, the perioperative clinical benefit is such that it is unlikely that providers or patients will choose open AAA repair. EVAR truly represents a ‘disruptive innovation,’ and the reimbursement policy for such technologies is poorly defined.”

Acknowledging that the analysis is limited by the retrospective design, the reliance on administrative data, and the lack of detail about device costs, Dr. Meltzer and colleagues say that “any debate regarding the value of healthcare innovations should account for evolution in outcomes and costs as noted in this study.”

In addition, the focus on in-hospital outcomes and costs “prohibits analysis of long-term outcomes and costs associated with follow-up imaging and reinterventions,” they write. “From a patient care and financial standpoint, these durability concerns may prove to be the Achilles’ heel of EVAR. Costs associated with the index procedure represent only a fraction of overall costs, and long-term follow-up data is necessary to truly assess cost-effectiveness.”


Source: 
Salzler GG, Meltzer AJ, Mao J, et al. Characterizing the evolution of perioperative outcomes and costs of endovascular abdominal aortic aneurysm repair. J Vasc Surg. 2015;Epub ahead of print.

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Todd Neale is the Associate News Editor for TCTMD and a Senior Medical Journalist. He got his start in journalism at …

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Disclosures
  • Dr. Meltzer reports no relevant conflicts of interest.

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