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Comparison of Economic Impact of Endovascular Procedures: An Interview With Brian G. DeRubertis, MD, FACS

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Comparison of Economic Impact of Endovascular Procedures: An Interview With Brian G. DeRubertis, MD, FACS

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Interview by Jennifer Ford

At the 2015 VIVA meeting, data were presented from a study investigating economic impact of various endovascular interventions compared to the Supera stent from Abbott Vascular. Vascular Disease Management spoke with Brian G. DeRubertis, MD, about details from the study.

Q:Please describe the methodology of the economic analysis – what data were analyzed?

A: We evaluated the 3-year economic impact of five endovascular strategies – percutaneous transluminal angioplasty (PTA), bare metal stents (BMS), drug eluting stents (DES), drug-coated balloons (DCB), and the interwoven nitinol stent (Supera) – for the treatment of femoropopliteal peripheral artery disease (PAD). 

This analysis evaluated the clinical and economic impact of these treatment strategies from the perspective of the patient, the United States payer (Medicare), and the hospital. Data from US investigational device exemption (IDE) studies were identified in peer-reviewed journals where target lesion revascularization (TLR) were observed for PTA, BMS, DES, and DCB. These data were compared to the SUPERB trial TLR rates, which provided the risk of reinterventions for patients treated with the Supera stent. Only IDE studies were chosen to ensure high quality and consistent clinical trial methodology.

The economic impact of various endovascular treatment strategies is influenced by the cost of the initial procedure, the associated risk of revascularization, and the costs associated with having repeat revascularization procedures.

A decision analytic model was developed to estimate the costs associated with each strategy. 

The risk of revascularization was used to derive the expected number of reinterventions for each strategy over 3 years. The economic impact to payers was estimated as the per-patient cost for each strategy over 3 years, determined by combining the reimbursement for the index procedure and the reimbursement for the projected number of revascularizations associated with each strategy. The economic impact to hospitals was assessed as the remaining payment, defined as the institution’s reimbursement from payers minus the device costs for each procedure. 

Q: What are some highligts of the results?

A: This 3-year economic model of the costs associated with various treatment strategies revealed that different modalities are associated with widely discrepant rates of reintervention, and Abbott’s Supera stent reduces the rate of reinterventions for patients, saves money for Medicare, and is an economically attractive treatment strategy for hospitals. Supera reduced patient risk of having reintervention procedures, resulting in fewer reintervention procedures over 3 years. For every 100 patients, we estimated 7 reintervention procedures for Supera compared to 51 for PTA, which was associated with the highest number of reinterventions. Supera is an economically attractive (i.e., cost-saving) strategy for Medicare compared to PTA, BMS, DES, and DCB. Over a 3-year period, the cost to Medicare was estimated as follows per patient:

  • Supera: $13,097
  • DCB: $13,898
  • DES: $14,918
  • PTA: $15,045
  • BMS: $16,254

In addition, Supera is economically attractive for hospitals and health systems. It resulted in the greatest remaining payment per procedure for hospitals when the total reimbursement per 100 patients was normalized to the number of procedures patients experienced.

Q: Tell us in your own words what this means for vascular specialists.

A: This type of economic analysis is becoming increasingly important in our changing healthcare environment, in which our emphasis is beginning to shift away from the finite cost of a single procedure and more toward the quality of care offered by different treatment options, each of which have important economic ramifications. As newer technologies have emerged, we are finding that these modalities are associated with differing intermediate and long-term outcomes. 

What is most interesting about this analysis is that it demonstrates that choosing new high-quality treatment options, which are typically thought of as being more expensive, not only benefits the patient, but is also economically preferable for payers and health care systems when those costs are assessed over broader time horizons. In this model, Supera was demonstrated to be the modality that was most likely to provide both quality outcomes for patients and economic advantages for payers and providers.

Q: What patient population will this benefit?

A: PAD affects 12 to 20 percent of Americans age 65 or older, and can result in both claudication and limb loss in severe cases.1 The gold standard for revascularization is surgical bypass, which is generally considered a more durable option than interventional procedures but unfortunately comes with an increased risk of morbidity and perioperative mortality compared to percutaneous interventions. The risk of complications is a serious concern in these elderly and oftentimes frail patients who require revascularization, and therefore these less-invasive treatment strategies are attractive options. These are the types of patients who are most likely to benefit from devices like Supera, especially as these newer devices with lower reintervention rates begin to approach the long-term patency of surgical bypass.

Q: Anything surprising about the data?

A: In my opinion, the most surprising result from this analysis is the recognition that some of our newer and potentially more expensive technologies can be best for the patient from a quality perspective (fewer reinterventions) while at the same time being economically attractive (cost saving) from a payer perspective. Conversely, when some of the older and less expensive modalities, such as PTA alone, result in higher reimbursements to providers or hospitals, they do so at the expense of the patient who suffers additional re-interventions due to the high TLR rates associated with these modalities. 

Currently, there is a tendency for hospitals to focus on the initial cost of the device or the index intervention in efforts to control spending, with less attention paid to the quality and long-term durability of the intervention. Luckily, in recent years this focus has begun to shift toward quality outcomes, and the results of this analysis highlight the importance of long-term outcomes when balancing the quality and cost of more effective therapies. While a device may cost more, it may save money over the long term.

Q: How could this information benefit future developments in vascular interventional technologies?

A: Focusing on the cost of devices over the clinical benefits offered by new technology has the potential to stifle research and development of new treatment modalities because of concerns regarding the economic burden these new devices may bring to the health care system. While it will always be important to be cost conscious when selecting devices for treating our patients, this analysis demonstrates that newer technologies can be more efficacious and cost saving, primarily because it is the cost associated with the failed interventions that actually drives the economic burden in treating PAD. From a health economics perspective, the market can support somewhat more expensive technologies provided they offer better patient outcomes and fewer reinterventions, and a recognition of this fact is likely to allow industry to continue to invest in these exciting new technologies.

Q: Anything else you think is important for vascular specialists to know about the data or the Supera stent?

A: Supera is a unique, proprietary interwoven wire technology that is quite different than laser-cut nitinol stents we’ve previously implanted in the SFA. Its novel design offers considerably improved crush resistance and flexibility compared to other stents, and it is uniquely suited to areas of torsion and twisting without the same susceptibility to stent fractures seen with other stents.2 Supera is FDA approved for the treatment of occlusive disease in the superficial femoral artery (SFA) and the proximal popliteal artery (PPA). The Supera stent’s excellent outcomes are likely a result of the stent’s ability to mimic the artery’s natural movement. The SUPERB trial has demonstrated the long-term effectiveness of the Supera stent with remarkably low rates of TLR over 3 years and an impressive primary patency of 86% at 1 year.

Brian G. DeRubertis, MD, FACS, is Associate Professor of Surgery and Director of the Gonda Ambulatory Procedure Unit in the UCLA Division of Vascular Surgery, David Geffen School of Medicine at UCLA in Los Angeles, California. Dr. DeRubertis reports consultancy to Abbott Vascular, Medtronic, Boston Scientific, and Cook Medical.

References

  1. Roger VL, Go AS, Lloyd-Jones DM, et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart Disease and Stroke Statistics—2011 Update: A report from the American Heart Association. Circulation. 2011;123(4):e18-e209. 
  2. Data on file at Abbott.
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