Open versus endovascular repair of abdominal aortic aneurysms: What does each really cost?

Endovascular repair (EVAR) of abdominal aortic aneurysm (AAA) has emerged as an alternative to open repair (OR). The aim of this study was to compare the clinical outcomes and specific costs of these procedures since commercialization. A retrospective analysis of 119 consecutive infrarenal AAA repaired via an EVAR or an OR between July 2000 and September 2001 was performed. Patient charts were reviewed. Diagnostic-related group (DRG) classification and payer mix were identified. The hospital cost accounting system was accessed to obtain actual variable direct cost (AVDC) for the two groups. Percentages of the mean AVDC for the two groups were compared in the following cost categories: graft, operating room, radiology procedures and supplies, pharmacy, respiratory therapy, clinical laboratories, surgical floor, and monitored unit. Hospital profit margins were determined. Fifty-five patients underwent EVAR and 64 patients underwent OR. Mean aneurysm size was 5.5 cm (EVAR) and 6.1 cm (OR). Mean intensive care unit (ICU) stay was 0.09 days for EVAR vs. 3.5 days for OR (p < 0.05). Mean length of stay (LOS) was 1.96 days for EVAR vs. 7.3 days for OR (p < 0.05). Reimbursement was based on DRG 110, 47.3% in the EVAR and 79.7% in the OR group (p < 0.05), and DRG 111, 50.9% in the EVAR group and 12.5% in the OR group (p < 0.05). The payer mix showed no significant differences between the two groups. Mean AVDC for EVAR was 1.74 times that of OR. Significant differences in the distribution of costs were found in the following: graft costs (58% vs. 6.3%, p < 0.05), radiology procedures and supplies (3.9% vs. 0.1%, p < 0.05), pharmacy (1.9% vs. 10.5%, p < 0.05), and monitored unit (7.3% vs. 24.65%, p < 0.05) comparing EVAR vs. OR, respectively. Median cost of an endovascular graft was 22.4 times that of the standard graft for OR. Average hospital profit margins for an EVAR case was 49.5% vs. 88.6% for OR. Despite significant differences in monitored unit utilization, pharmacy services, and respiratory therapy services by the OR group, the cost of EVAR is appreciably more expensive. Furthermore, increased DRG reimbursement, and decreased ICU use and LOS do not compensate for the cost of EVAR. The main cost of EVAR is the cost of the graft itself. Hospital profit margins are acceptable with both the EVAR and OR procedures at this time; however, with proposed reductions in reimbursement, the ability to cover the cost of this new technology may be threatened.