Repeating balloon angioplasty and/or stenting procedures in elderly patients add more than $700 million a year to Medicare expenses

Repeating balloon angioplasty and/or stenting procedures to open narrowed arteries in elderly patients may add more than $700 million a year to Medicare expenses, according to a report in today’s rapid access issue of Circulation: Journal of the American Heart Association.

The study is the first to examine the rates of restenosis of percutaneous coronary interventions (PCIs) and their economic consequences in a contemporary, unselected elderly population.

Researchers used Medicare records of 9,868 patients aged 65 or older who underwent balloon angioplasty or stenting in 1998 and identified those who had repeat revascularization procedures 31 to 365 days after the initial procedure.

About 17 percent of these patients required one or more repeat procedures during the year following the first procedure — 13.2 percent had repeat PCI and 4.9 percent required bypass surgery, said David J. Cohen, M.D., M.Sc., the study’s senior author and an associate professor of medicine at Harvard Medical School.

Average one-year medical care costs increased five-fold among patients with repeat procedures. Follow-up costs in the first year were $26,186 for those who needed additional revascularization versus $5,344 for PCI patients who did not require revascularization. After adjusting for baseline differences, the added cost for each patient who required repeat revascularization was about $19,000.

In PCI procedures, a tiny catheter is threaded up into the heart from an artery in the groin or arm to the blocked or narrowed vessel. Once the catheter is in place, a tiny balloon is inflated to open the vessel. Often, a tiny, flexible tube called a stent is also deployed to help prop open the vessel in order to allow blood to flow freely. Sometimes the vessel re-narrows, which is called restenosis. If the restenosis is severe, repeat procedures are required.

“Considering both the cost of repeat interventions and their frequency in the Medicare population, we estimate that treatment of restenosis adds about $2,700 to the cost of each percutaneous coronary intervention over the following year,” Cohen said. “Given the current PCI volumes, these findings imply that the aggregate cost to the Medicare Program for treatment of restenosis is more than $700 million per year.”

He said many patients “require two or three repeat procedures or, eventually, they may need bypass surgery.”

Based on previous research indicating that 85 percent of repeat procedures in the general population are due to restenosis, researchers in this study estimated that the clinical restenosis rate at one year was 14.4 percent, “which is actually a better restenosis rate than previously reported for bare metal stents,” he said. “So the bare metal stents were actually working reasonably well, except for the high costs associated with patients who needed repeat procedures.”

Bare metal stents cost about $1,000. Newer drug-eluting stents, which reduce the rates of restenosis, are about $3,000.

Cohen and his colleagues conclude that drug-eluting stents are an unlikely cost-saving option for the general Medicare population. But, they said newer stents may be more cost-effective in patients with diabetes or kidney disease. In those patients, they project “true long-term cost savings might still be achieved…”

Co-authors are Mary Ann Clark, M.H.A.; Ameet Bakhai, M.D.; Michael J. Lacey, M.S.; and Elise M. Pelletier, M.S