In-hospital and one-year economic outcomes after coronary stenting or balloon angioplasty. Results from a randomized clinical trial. Stent Restenosis Study Investigators.

BACKGROUND: Coronary stenting has been shown to improve initial success, reduce angiographic restenosis, and reduce the need for repeat revascularization compared with conventional balloon angioplasty (PTCA). Although previous studies have demonstrated that initial hospital costs for stenting are considerably higher than those for conventional PTCA, the impact of coronary stenting on long-term medical care costs remains unknown. METHODS AND RESULTS: Between January 1991 and June 1993, 207 consecutive patients with symptomatic coronary disease requiring revascularization of a single coronary lesion were randomized to receive initial treatment by either PTCA (n = 105) or Palmaz-Schatz coronary stent implantation (n = 102) in the multicenter STRESS trial. Detailed resource utilization and cost data were collected for each patient's initial hospitalization and for any subsequent hospital visits for 1 year after randomization. Compared with conventional angioplasty, coronary stenting resulted in additional catheterization laboratory costs, increased vascular complications, and longer length of stay. Initial hospital costs were thus approximately $2200 higher for stenting than for PTCA ($9738 +/- 3248 versus $7505 +/- 5015; P < .001). Over the first year of follow-up, however, patients assigned to initial stenting were less likely to require rehospitalization for a cardiac condition and underwent fewer subsequent revascularization procedures. Follow-up medical care costs thus tended to be lower for stenting than for conventional angioplasty ($1918 +/- 4841 versus $3359 +/- 7100, P = .21). Nonetheless, cumulative 1-year medical care costs remained higher for patients undergoing initial stenting ($11,656 +/- 5674 versus $10,865 +/- 9073, P < .001). Even after adjustment for the higher incidence of vascular complications in the stent group, total 1-year costs were $300 higher for stenting than for balloon angioplasty. CONCLUSIONS: Elective coronary stenting, as performed in the randomized STRESS trial, increased total 1-year medical care costs by approximately $800 per patient compared with conventional angioplasty. Future studies will be necessary to determine whether ongoing refinements in stent design, implantation techniques, and anticoagulation regimens can narrow this cost difference further by reducing stent-related vascular complications or length of stay.

Decision-support systems in health care. Factors influencing the development and transfer of technology.

National concern about escalating health care costs and inefficiencies in delivery systems has created demand for informatics technology such as decision-support systems. This paper discusses the pressing need for better cost information in health care and how decision-support technology meets this need. Future directions for the technology also are discussed.

Cost accounting, management control, and planning in health care.

Advantages and pharmacy applications of computerized hospital management-control and planning systems are described. Hospitals must define their product lines; patient cases, not tests or procedures, are the end product. Management involves operational control, management control, and strategic planning. Operational control deals with day-to-day management on the task level. Management control involves ensuring that managers use resources effectively and efficiently to accomplish the organization's objectives. Management control includes both control of unit costs of intermediate products, which are procedures and services used to treat patients and are managed by hospital department heads, and control of intermediate product use per case (managed by the clinician). Information from the operation and management levels feeds into the strategic plan; conversely, the management level controls the plan and the operational level carries it out. In the system developed at New England Medical Center, Boston, Massachusetts, the intermediate product-management system enables managers to identify intermediate products, develop standard costs, simulate changes in departmental costs, and perform variance analysis. The end-product management system creates a patient-level data-base, identifies end products (patient-care groupings), develops standard resource protocols, models alternative assumptions, performs variance analysis, and provides concurrent reporting. Examples are given of pharmacy managers' use of such systems to answer questions in the areas of product costing, product pricing, variance analysis, productivity monitoring, flexible budgeting, modeling and planning, and comparative analysis.(ABSTRACT TRUNCATED AT 250 WORDS)