No Clear Winner on Cost-effectiveness for EVAR vs. Open Repair of AAA

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In patients who undergo elective treatment for abdominal aortic aneurysm (AAA), hospital expenses required for open repair surpass the higher initial graft cost of endovascular aortic aneurysm repair (EVAR). But by 2 years, costs are similar between the treatments, according to findings derived from an earlier randomized trial that were published online May 26, 2012, ahead of print in the Journal of Vascular Surgery.

For the OVER (Open Versus Endovascular Repair) trial, Frank A. Lederle, MD, of the Veterans Affairs (VA) Medical Center (Minneapolis, MN), and colleagues randomized 881 patients being treated at 42 VA hospitals to either EVAR (n = 444) or surgery (n = 437). Patients enrolled between October 2002 and April 2008. Results published in the Journal of the American Medical Association in 2009 showed similar mortality for both treatments at 2 years, with EVAR holding the advantage during the perioperative period.

The current analysis used health care utilization and cost data derived from patients, national VA and CMS sources, or billing details to look at whether EVAR or surgery was more expensive overall. Researchers also considered quality-of-life data derived from the EuroQol (EQ)-5D questionnaire, which was conducted at baseline and annually thereafter.

Nearly the Same by 2 Years

Procedure costs were higher for EVAR due to the need for pricier grafts; yet this expense was offset by the fact that open repair required longer mean stays in the intensive care unit (5.6 vs. 1.9 days with EVAR) and hospital (10.5 vs. 5.0 days with EVAR; P < 0.001 for both comparisons). The overall cost of hospital admission, therefore, was higher for surgical patients. By 2 years, a trend toward lower health care costs was still apparent in the EVAR group (table 1).

Table 1. Mean Costs: Endovascular vs. Open Repair of AAA

^a Including graft.

In addition, mean quality-of-life years were almost exactly the same for both treatments at 2 years (1.462 with EVAR and 1.461 with open surgery; P = 0.78), even after adjusting for baseline EQ-5D score.

Though results have been mixed, “[m]ost previous studies have found endovascular repair to be a more expensive strategy despite the shorter hospital and intensive care length of stay,” Dr. Lederle and colleagues note. They cite 2 randomized European trials, EVAR 1 and DREAM, as well as a nonrandomized US-based study. Possible reasons for this discrepancy include:

• OVER considered more recent procedures than earlier reports
• Hospital stays are longer in the United States, a factor that would make open repair more expensive here than in Europe
• The VA system may more thoroughly capture hospitalization costs than other health care systems

The investigators also point out that the costs observed in OVER may not be generalizable, since the VA may be able to obtain medications and grafts at lower prices than would other institutions.

 

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Source:
Stroupe KT, Lederle FA, Matsumura JS, et al. Cost-effectiveness of open vs. endovascular repair of abdominal aortic aneurysm: Results of a multicenter randomized trial. J Vasc Surg. 2012;Epub ahead of print.

 

 

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