Annual cost of stable coronary artery disease in France: A modeling study.

BACKGROUND: Few studies have analyzed the cost of treatment of chronic angina pectoris, especially in European countries. AIM: To determine, using a modeling approach, the cost of care in 2012 for 1year of treatment of patients with stable angina, according to four therapeutic options: optimal medical therapy (OMT); percutaneous coronary intervention with bare-metal stent (PCI-BMS); PCI with drug-eluting stent (PCI-DES); and coronary artery bypass graft (CABG). METHODS: Six different clinical scenarios that could occur over 1year were defined: clinical success; recurrence of symptoms without hospitalization; myocardial infarction (MI); subsequent revascularization; death from non-cardiac cause; and cardiac death. The probability of a patient being in one of the six clinical scenarios, according to the therapeutic options used, was determined from a literature search. A direct medical cost for each of the therapeutic options was calculated from the perspective of French statutory health insurance. RESULTS: The annual costs per patient for each strategy, according to their efficacy results, were, in our models, €1567 with OMT, €5908 with PCI-BMS, €6623 with PCI-DES and €16,612 with CABG. These costs were significantly different (P<0.05). A part of these costs was related to management of complications (recurrence of symptoms, MI and death) during the year (between 3% and 38% depending on the therapeutic options studied); this part of the expenditure was lowest with the CABG therapeutic option. CONCLUSION: OMT appears to be the least costly option, and, if reasonable from a clinical point of view, might achieve appreciable savings in health expenditure.

Clinical and economic outcomes of liberal versus selective drug-eluting stent use: insights from temporal analysis of the multicenter Evaluation of Drug Eluting Stents and Ischemic Events (EVENT) registry.

BACKGROUND: Although the benefits of drug-eluting stents (DES) for reducing restenosis after percutaneous coronary intervention are well established, the impact of alternative rates of DES use on population-level outcomes is unknown. METHODS AND RESULTS: We used data from the Evaluation of Drug Eluting Stents and Ischemic Events (EVENT) registry to examine the clinical impact and cost-effectiveness of varying DES use rates in routine care. Between 2004 and 2007, 10,144 patients undergoing percutaneous coronary intervention were enrolled in the EVENT registry at 55 US centers. Clinical outcomes and cardiovascular-specific costs were assessed prospectively over 1 year of follow-up. Use of DES decreased from 92 in 2004 to 2006 (liberal use era; n=7587) to 68 in 2007 (selective use era; n=2557; P<0.001). One-year rates of death or myocardial infarction were similar in both eras. Over this time period, the incidence of target lesion revascularization increased from 4.1 to 5.1, an absolute increase of 1.0 (95 confidence interval, 0.1 to 1.9; P=0.03), whereas total cardiovascular costs per patient decreased by $401 (95 confidence interval, 131 to 671; P=0.004). The risk-adjusted incremental cost-effectiveness ratio for the liberal versus selective DES era was $16,000 per target lesion revascularization event avoided, $27,000 per repeat revascularization avoided, and $433 000 per quality-adjusted life-year gained. CONCLUSIONS: In this prospective registry, a temporal reduction in DES use was associated with a small increase in target lesion revascularization and a modest reduction in total cardiovascular costs. These findings suggest that although clinical outcomes are marginally better with unrestricted DES use, this approach represents a relatively inefficient use of healthcare resources relative to several common benchmarks for cost-effective care.

Health and cost consequences of early versus late invasive strategy after thrombolysis for acute myocardial infarction.

UNLABELLED: The NORwegian study on DIstrict treatment of ST-Elevation Myocardial Infarction showed an improved clinical outcome with early transfer for percutaneous coronary intervention (PCI) compared to a more conservative approach after thrombolysis. The aim of this substudy was to compare the 12-month quality-adjusted life years (QALYs) and costs of these alternative strategies. METHODS: Patients with ST-elevation myocardial infarction <6 h duration and >90 min expected delay to PCI, received full-dose tenecteplase and were randomized to either early or late invasive strategy (n = 266). Detailed quality of life and resource use data were registered prospectively for a period of 12 months. Health outcomes were measured as quality of life using a generic instrument (15D). Quality of life scores were translated into QALYs. Unit costs were based on hospital accounts, fee schedules, and market prices. RESULTS: After 12 months of follow-up, patients in the early invasive group had 0.008 (95% CI -0.027 to 0.043) more QALYs compared to the late invasive group. The mean total costs were €18,201 in the early versus €17,643 in the late invasive group, with a mean difference of €558 (95% CI -2258 to 3484). Cost/QALY was €69,750 while cost/avoided clinical endpoint was €5636. CONCLUSION: Early and late invasive strategies after thrombolysis resulted in similar quality of life and similar costs in ST-elevation myocardial infarction patients living far from a PCI centre (NCT00161005).

Hyperbaric oxygen preconditioning improves myocardial function, reduces length of intensive care stay, and limits complications post coronary artery bypass graft surgery.

OBJECTIVE: The objective of this study was to determine whether preconditioning coronary artery disease (CAD) patients with HBO(2) prior to first-time elective on-pump cardiopulmonary bypass (CPB) coronary artery bypass graft surgery (CABG) leads to improved myocardial left ventricular stroke work (LVSW) post CABG. The primary end point of this study was to demonstrate that preconditioning CAD patients with HBO(2) prior to on-pump CPB CABG leads to a statistically significant (P<.05) improvement in myocardial LVSW 24 h post CABG. METHODS: This randomised control study consisted of 81 (control group=40; HBO(2) group=41) patients who had CABG using CPB. Only the HBO(2) group received HBO(2) preconditioning for two 30-min intervals separated 5 min apart. HBO(2) treatment consisted of 100% oxygen at 2.4 ATA. Pulmonary artery catheters were used to obtain perioperative hemodynamic measurements. All routine perioperative clinical outcomes were recorded. Venous blood was taken pre HBO(2), post HBO(2) (HBO(2) group only), and during the perioperative period for analysis of troponin T. RESULTS: Prior to CPB, the HBO(2) group had significantly lower pulmonary vascular resistance (P=.03). Post CPB, the HBO(2) group had increased stroke volume (P=.01) and LVSW (P=.005). Following CABG, there was a smaller rise in troponin T in HBO(2) group suggesting that HBO(2) preconditioning prior to CABG leads to less postoperative myocardial injury. Post CABG, patients in the HBO(2) group had an 18% (P=.05) reduction in length of stay in the intensive care unit (ICU). Intraoperatively, the HBO(2) group had a 57% reduction in intraoperative blood loss (P=.02). Postoperatively, the HBO(2) group had a reduction in blood loss (11.6%), blood transfusion (34%), low cardiac output syndrome (10.4%), inotrope use (8%), atrial fibrillation (11%), pulmonary complications (12.7%), and wound infections (7.6%). Patients in the HBO(2) group saved US$116.49 per ICU hour. CONCLUSION: This study met its primary end point and demonstrated that preconditioning CAD patients with HBO(2) prior to on-pump CPB CABG was capable of improving LVSW. Additionally, this study also showed that HBO(2) preconditioning prior to CABG reduced myocardial injury, intraoperative blood loss, ICU length of stay, postoperative complications, and saved on cost, post CABG.

Recent developments in pharmacologic prophylaxis of atrial fibrillation in patients undergoing surgical revascularization.

Atrial fibrillation is a frequent complication after CABG. It occurs in 20-50% of patients, most often between the 2nd and 3rd postoperative day. About 40 % of patients experience more than 1 episode. Postoperative AF (POAF) is associated with an increase in adverse events and hospital stay and, therefore, costs of care. The incidence of POAF is not influenced by the technique of CABG with or without cardiopulmonary by-pass Neurohormonal activation, electrolyte imbalance, fluid overload, surgical practices and finally an exaggerated inflammatory response has been proposed to be etiological factor. Advanced age, history of AF or heart failure, COPD, postoperative withdrawal of beta-blockers are independent risk factors of postoperative AF. Conversely, postoperative administration of beta-blockers, ACE inhibitors, potassium supplementation and NSAID were associated with a reduced risk of POAF. Pharmacological strategies for prevention of POAF may be divided in two main groups : the first one encompasses the use of antiarrhythmic drugs (amiodarone, metoprolol, sotalol) before and /or after surgery and has been extensively investigated in the last two decades. Recently an Italian study has shown that PUFA administration during hospitalization in patients undergoing CABG significantly decreased the incidence of POAF and was associated with a shorter hospital stay. Since an exaggerated inflammatory reaction may play a significant role in POAF, treatments directed to antagonize inflammation are presently under investigation. Despite different action mechanisms both hydrocortisone and statins have been shown to decrease post-operative AF risk. These two prophylactic regimens are not mutually exclusive and some data suggest that their association may be useful to further decrease the risk of POAF.

"ProvenCareSM": a provider-driven pay-for-performance program for acute episodic cardiac surgical care.

OBJECTIVE: To test whether an integrated delivery system could successfully implement an evidence-based pay-for-performance program for coronary artery bypass graft (CABG) surgery. METHODS: The program consisted of 3 components: (1) establishing implementable best practices; (2) developing risk-based pricing; (3) establishing a mechanism for patient engagement. Surgeons reviewed all class I and IIa "2004 American Heart Association/American College of Cardiology Guidelines for CABG Surgery" and translated them into 40 verifiable behaviors. These were imbedded within a new ProvenCareSM program and "hardwired" within the electronic health record system, including order sets, templates, and "time outs". Concurrently preoperative, inpatient, and postoperative care within 90 days was packaged into a fixed price. A Patient Compact was developed to highlight the importance of patient activation. All elective CABG patients treated between February 2, 2006 and February 2, 2007 were included (ProvenCareSM Group) and compared with 137 patients treated in 2005 (Conventional Care Group). RESULTS: Initially, only 59% of patients received all 40 best practice components. At 3 months, program compliance reached 100%, but fell transiently to 86% over the next 3 months. Reliability subsequently increased to 100% and was sustained for the remainder of the study period. The overall trend in reliability was significant at P=0.001. Thirty-day clinical outcomes showed improved trends () but only the likelihood of discharge to home reached statistical significance. Length of stay decreased by 16% and mean hospital charges fell 5.2%.(Table is included in full-text article.) CONCLUSION: A provider-driven pay-for-performance process for CABG, enabled by an electronic health record system, can reliably deliver evidence-based care, fundamentally alter reimbursement incentives, and may ultimately improve outcomes and reduce resource use.

Economic analysis of treatments reducing coronary heart disease mortality in England and Wales, 2000-2010.

BACKGROUND: Coronary heart disease (CHD) in the UK affects approximately 3 million people, with >100,000 deaths annually. Mortality rates have halved since the 1980s, but annual NHS treatment costs for CHD exceed 2 billion pounds. AIM: To examine the cost-effectiveness of specific CHD treatments in England and Wales. METHODS: The IMPACT CHD model was used to calculate the number of life-years gained (LYG) from specific cardiological interventions from 2000 to 2010. Cost-effectiveness ratios (costs per LYG) were generated for each specific intervention, stratified by age and sex. The robustness of the results was tested using sensitivity analyses. RESULTS: In 2000, medical and surgical treatments together prevented or postponed approximately 25,888 deaths in CHD patients aged 25-84 years, thus generating approximately 194,929 extra life-years between 2000 and 2010 (range 143,131-260,167). Aspirin and beta-blockers for secondary prevention following myocardial infarction or revascularisation, for angina and heart failure were highly cost-effective (< 1000 pounds per LYG). Other secondary prevention therapies, including cardiac rehabilitation, ACE inhibitors and statins, were reasonably cost-effective (1957 pounds, 3398 pounds and 4246 pounds per LYG, respectively), as were CABG surgery (3239 pounds-4601 pounds per LYG) and angioplasty (3845 pounds-5889 pounds per LYG). Primary angioplasty for myocardial infarction was intermediate (6054 pounds-12,057 pounds per LYG, according to age), and statins in primary prevention were much less cost-effective (27,828 pounds per LYG, reaching 69,373 pounds per LYG in men aged 35-44). Results were relatively consistent across a wide range of sensitivity analyses. DISCUSSION: The cost-effectiveness ratios for standard CHD treatments varied by over 100-fold. Large amounts of NHS funding are being spent on relatively less cost-effective interventions, such as statins for primary prevention, angioplasty and CABG surgery. This merits debate.

Cost effectiveness analysis of minimally invasive internal thoracic artery bypass versus percutaneous revascularisation for isolated lesions of the left anterior descending artery.

OBJECTIVE: To compare the cost effectiveness of percutaneous transluminal coronary artery stenting with minimally invasive internal thoracic artery bypass for isolated lesions of the left anterior descending artery. DESIGN: Cost effectiveness analysis. DATA SOURCES: Embase, Medline, Cochrane, Google Scholar, and Health Technology Assessment databases (1966-2005), and reference sources for utility values and economical variables. METHODS: Decision analytical modelling and Markov simulation were used to model medium and long term costs, quality of life, and cost effectiveness after either intervention using data from referenced sources. Probabilistic sensitivity and alternative analyses were used to investigate the effect of uncertainty about the value of model variables and model structure. RESULTS: Stenting was the dominant strategy in the first two years, being both more effective and less costly than bypass surgery. In the third year bypass surgery still remained more expensive but became marginally more effective. As the incremental cost effectiveness was 1,108,130.40 pounds sterling (1 682,146.00 euros; $2,179,194) per quality adjusted life year (QALY), the additional effectiveness could not be said to justify the additional cost at this stage. By five years, however, the incremental cost effectiveness ratio of 28,042.95 pounds sterling per QALY began to compare favourably with other interventions. At 10 years the additional effectiveness of 0.132 QALYs (range -0.166 to 0.430) probably justified the additional cost of 829.02 pounds sterling (range 205.56 pounds sterling to 1452.48 pounds sterling), with an incremental cost effectiveness of 6274.02 pounds sterling per QALY. Sensitivity and alternative analysis showed the results were sensitive to the time horizon and stent type. CONCLUSIONS: Minimally invasive left internal thoracic artery bypass may be a more cost effective medium and long term alternative to percutaneous transluminal coronary artery stenting.

Cost-effectiveness of cell salvage and alternative methods of minimising perioperative allogeneic blood transfusion: a systematic review and economic model.

OBJECTIVES: To compare patient outcomes, resource use and costs to the NHS and NHS Blood Transfusion Authority (BTA) associated with cell salvage and alternative methods of minimising perioperative allogeneic blood transfusion. DATA SOURCES: Electronic databases covering the period 1996-2004 for systematic reviews and 1994-2004 for economic evidence. REVIEW METHODS: Existing systematic reviews were updated with data from selected randomised controlled trials (RCTs) that involved adults scheduled for elective non-urgent surgery. Any resource use or cost data were extracted for potential use in populating an economic model. Relative risks or weighted mean difference of each outcome for each intervention were assessed, taking into account the number of RCTs included in each outcome and intervention and the presence of any heterogeneity. This allowed indirect comparison of the relative effectiveness of each intervention when the intervention is compared with allogeneic blood transfusion. A decision analytic model synthesised clinical and economic data from several sources, to estimate the relative cost-effectiveness of cell salvage for people undergoing elective surgery with moderate to major expected blood loss. The perspective of the NHS and patients and a time horizon of 1 month were used. The economic model was developed from reviews of effectiveness and cost-effectiveness and clinical experts. Secondary analysis explored the robustness of the results to changes in the timing and costs of cell salvage equipment, surgical procedure, use of transfusion protocols and time horizon of analysis. RESULTS: Overall, 668 studies were identified electronically for the update of the two systematic reviews. This included five RCTs, of which two were cell salvage and three preoperative autologous donation (PAD). Five published systematic reviews were identified for antifibrinolytics, fibrin sealants and restrictive transfusion triggers, PAD plus erythropoietin, erythropoietin alone and acute normovolaemic haemodilution (ANH). Twelve published studies reported full economic evaluations. All but two of the transfusion strategies significantly reduced exposure to allogeneic blood. The relative risk of exposure to allogeneic blood was 0.59 for the pooled trials of cell salvage (95% confidence interval: 0.48 to 0.73). This varied by the type and timing of cell salvage and type of surgical procedure. For cell salvage, the relative risk of allogeneic blood transfusion was higher in cardiac surgery than in orthopaedic surgery. Cell salvage had lower costs and slightly higher quality-adjusted life years compared with all of the alternative transfusion strategies except ANH. The likelihood that cell salvage is cost-effective compared with strategies other than ANH is over 50%. Most of the secondary analyses indicated similar results to the primary analysis. However, the primary and secondary analyses indicated that ANH may be more cost-effective than cell salvage. CONCLUSIONS: The available evidence indicates that cell salvage may be a cost-effective method to reduce exposure to allogeneic blood transfusion. However, ANH may be more cost-effective than cell salvage. The results of this analysis are subject to the low quality and reliability of the data used and the use of indirect comparisons. This may affect the reliability and robustness of the clinical and economic results. There is a need for further research that includes adequately powered high-quality RCTs to compare directly various blood transfusion strategies. These should include measures of health status, health-related quality of life and patient preferences for alternative transfusion strategies. Observational and tracking studies are needed to estimate reliably the incidence of adverse events and infections transmitted during blood transfusion and to identify the lifetime consequences of the serious hazards of transfusion on mortality, health status and health-related quality of life.

Long-term effects of integrated rehabilitation in patients with advanced angina pectoris: a nonrandomized comparative study.

OBJECTIVES: An evaluation of Integrative Rehabilitation (IR) of patients with angina pectoris with respect to death rate, the need for invasive treatment, and cost effectiveness. DESIGN: A report from a clinical database. Death rates were compared to those of the general Danish population matched for age, gender, and observation period, as well as with data from the literature concerning medical and invasive treatments. SETTING: The treatment was carried out as an ambulatory treatment in a private clinic. SUBJECTS: One hundred and sixty-eight (168) patients with angina pectoris, of whom 103 were candidates for invasive treatment and 65 for whom this had been rejected. INTERVENTIONS: Integrated rehabilitation consists of acupuncture, a self-care program including acupressure, Chinese health philosophy, stress management techniques, and lifestyle adjustments. OUTCOME MEASURES: Death rate from any cause, the need for invasive treatment, and health care expenses. RESULTS: The 3-year accumulated risk of death was 2.0% (95% confidence limits: 0.0%-4.7%) for the 103 candidates for invasive treatment, 6.4% for the general Danish population, 5.4% (4.7%-6.1%), and 8.4% (7.7%-9.1%) for patients who underwent percutaneous transluminal balloon angioplasty and coronary artery bypass grafting, respectively, in New York. For the 65 inoperable patients the risk of death due to heart disease was 7.7% (3.9%-11.5%), compared to 16% (10%-34%) and 25% (18%-36%) for American patients, who were treated with laser revascularization or medication, respectively. Of the 103 candidates for invasive treatment, only 19 (18%) still required surgery. Cost savings over 3 years were US 36,000 dollars and US 22,000 dollars for surgical and nonsurgical patients, respectively. These were mainly achieved by the reduction in the use of invasive treatment and a 95% reduction in in-hospital days. CONCLUSIONS: Integrated rehabilitation was found to be cost effective, and added years to the lives of patients with severe angina pectoris. The results invite further testing in a randomized trial.

[Economic evaluation of off-pump coronary artery bypass grafting; compared to conventional coronary artery bypass grafting].

This study was undertaken to compare economic outcomes of off-pump coronary artery bypass grafting (off-pump CABG: OPCAB) and conventional CABG (CCABG). We reviewed the medical records of 5 patients with ischemic coronary disease (IHD) who underwent OPCAB and 5 patients with IHD who underwent CCABG. A hospital income which was based on a current Japanese health insurance system was indicated. There were significant differences in total cost (OPCAB = 208,200 +/- 7,383 yen versus CCABG = 324,300 +/- 10,290 yen, 35.8% decreased), costs of medical materials and transfusions (OPCAB = 14,760 +/- 3,270 yen versus CCABG = 87,540 +/- 3,326, 81.3% decreased) and charges of surgery and anesthesia (OPCAB = 130,400 +/- 1,853 yen versus CCABG = 147,650 +/- 4,167 yen, 12% decreased) OPCAB markedly reduces the cost of hospitalization. But charges of surgery and anesthesia of OPCAB seems to be valued properly in a current Japanese health insurance system.

Cost-effectiveness of spinal cord stimulation versus coronary artery bypass grafting in patients with severe angina pectoris--long-term results from the ESBY study.

The present study is a 2-year follow-up of the 104 patients participating in the ESBY study (Electrical Stimulation versus Coronary Artery Bypass Surgery in Severe Angina Pectoris), a randomised prospective study including patients with increased surgical risk and no prognostic benefit from revascularisation. Hospital care costs, morbidity and causes of death after spinal cord stimulation (SCS) and coronary artery bypass grafting (CABG) were assessed, as well as the complication rate of SCS treatment. SCS proved to be a less expensive symptomatic treatment modality of angina pectoris than CABG (p < 0.01). The SCS group had fewer hospitalisation days related to the primary intervention (p < 0.0001) and fewer hospitalisation days due to cardiac events (p < 0.05). The groups did not differ with regard to causes of death. There were no serious complications related to the SCS treatment.

Health care for the elderly: two cases of technology diffusion.

Diffusion of medical technology and the growing proportion of elderly people in the population are generally regarded as major contributors to the increasing health care expenditure in the industrialised world. This study explores the importance of one specific factor in this process, the change in the use of technology among elderly patients. In some instances, a new technology is first used among younger patients and then gradually extended to the elderly. Two such cases are studied, both representing costly procedures: coronary bypass surgery (treatment of coronary heart disease) and dialysis (treatment of uraemia). In both cases, we demonstrate significant diffusion to older age groups. It is also tentatively concluded that the diffusion of technology could have an important effect on per capita health care expenditure among the oldest of the old.

DATA: a decision aid for management of the patient with stable angina pectoris.

OBJECTIVE: The patient with stable disabling angina must choose between bypass surgery, coronary angioplasty, or medical therapy. Estimation of comparative outcomes of these alternative therapies is difficult. DESIGN: Utilizing Artificial Intelligence, an expert-system computerized decision aid, DATA (Decision Aid for Therapy of Angina), was developed to run on a personal computer and to calculate the probability of each possible clinical event based on individual patient characteristics. For each therapeutic option, relative clinical outcomes and anticipated charges are computed. Ten patients were evaluated retrospectively by DATA and by a group of cardiologists. RESULTS: DATA agreed with the primary therapy given to all patients. The physician group underestimated the value of alternative therapies and underestimated charges for all therapies. CONCLUSIONS: This decision aid allows comparison of alternative therapies in terms of relative patient outcome and anticipated costs can be better estimated.

Cost-effectiveness of epoetin and autologous blood donationin reducing allogeneic blood transfusions incoronary artery bypass graft surgery.

BACKGROUND: Coronary artery bypass graft (CABG) surgery accounts for a substantial portion of all allogeneic units of blood transfused. Drugs and autologous blood donation (ABD) are alternative or adjunctive methods for reducing complications and costs induced by allogeneic blood transfusions. Recombinant human erythropoietin (epoetin) has the potential to decrease perioperative need for allogeneic blood during CABG, but its high cost calls for a careful economic evaluation before it can be recommended for widespread use. STUDY DESIGN AND METHODS: A decision tree was used to compare a hypothetical strategy of no epoetin with one in which epoetin was utilized to control blood transfusion needs in CABG; each strategy was tested with and without ABD. The impact of these strategies on both the quality-adjusted life years (QALYs) and costs ($US) was calculated. RESULTS: Using epoetin alone and with ABD, respectively, avoided the transfusion of 0.61 and 1.35 units of allogeneic blood per patient and saved 0.000086 and 0.000146 QALYs per patient. This made cost-effectiveness (CE) higher than $7 million and $5 million for each QALY saved, respectively. ABD alone cost more than $1 million per QALY saved. If the risk of bacterial infections following allogeneic transfusions was included in the model, epoetin alone cost $6288 per QALY saved, while ABD, both alone and with epoetin, saved money. CONCLUSION: On the basis of the existing evidence, neither of the blood-saving strategies modeled was a cost-effective means of avoiding the deleterious health effects of perioperative blood transfusions in CABG. However, if allogeneic blood-related infections were to be considered, both ABD and epoetin would be acceptable interventions.

[Cost savings with autotransfusion in connection with coronary surgery]. / Kostnadsbesparelse ved autotransfusjon i forbindelse med koronarkirurgi.

The main purpose of this study was to estimate the costs and savings related to a consistent autotransfusion programme. More than 8,000,000 ml of autologous blood or blood-containing fluid were collected from 3,637 consecutive patients undergoing coronary artery bypass and returned to the patients during and after the operation. Economic analyses revealed a price of NOK 13 million (approximately 2 million USD) for this amount of autologous blood, or NOK 3,500 (600 USD) per patient. In the present series the need for bank blood or blood products was modest, since 69 patients (1.9%) received packed red cells, with or without plasma, 76 patients (2.1%) were given plasma transfusions only, and 11 patients (0.3%) received platelets. Thus, 95.7% of the patients were not exposed to any homologous blood products during the stay in hospital. Absence of morbidity related to the low homologous blood transfusion rate was assumed to save costs substantially, although this saving was difficult to calculate in terms of currency. Post-operative complications were few, and the total in-hospital mortality rate was 0.4%.

Epidemiologic study of candidates for coronary artery bypass surgery.

Simplified estimates of the potential patients eligible for coronary artery bypass surgery are presented. Various means of identification are discussed, as well as effects of two levels of stenosis. Although ultimate operability is not directly considered, the results demonstrate a substantial and growing pool of eligible patients. Data from the National Center for Health Statistics characterizes the trend toward more arteriograms and bypass procedures and more procedures being performed in smaller hospitals. Unexplained patterns exist with regard to racial and geographic differences. Factors that contribute to the increase of bypass procedures include more catheterizations being performed, declining mortality, the aging of the U.S. population, less reluctance to perform surgery, repeat operations, and increased availability of surgical teams and facilities. Factors discouraging an increase in the number of procedures include cost, equivocal results relative to increased survival in certain stages of disease, and improved alternative therapies.