Editor's Choice – A Systemic Evaluation of the Costs of Elective EVAR and Open Abdominal Aortic Aneurysm Repair Implies Cost Equivalence

Abstract

WHAT THIS PAPER ADDS The cost effectiveness of endovascular aneurysm repair (EVAR), and therefore EVAR as the primary option for elective abdominal aortic aneurysm repair, remains a matter of debate. However, data used as the rationale for these conclusions are impeded by time dependent effect modification, confounded by indication and asymmetric evaluation of re-interventions after repair, with an extensive focus on graft related re-interventions. In this article an instrumental variable analysis was used to minimise these impeding factors, which showed that EVAR is not costlier than open repair. Considering the lower short term mortality, faster recovery, and equal mid and long term survival, EVAR is a good first option for repair. Objective: The suggested high costs of endovascular aneurysm repair (EVAR) hamper the choice of insurance companies and financial regulators for EVAR as the primary option for elective abdominal aortic aneurysm (AAA) repair. However, arguments used in this debate are impeded by time related aspects such as effect modification and the introduction of confounding by indication, and by asymmetric evaluation of outcomes. Therefore, a re-evaluation minimising the impact of these interferences was considered. Methods: A comparative analysis was performed evaluating a period of exclusive open repair (OR; 1998e2000) and a period of established EVAR (2010e2012). Data from four hospitals in The Netherlands were collected to estimate resource use. Actual costs were estimated by benchmark cost prices and a literature review. Costs are reported at 2019 prices. A break even approach, defining the costs for an endovascular device at which cost equivalence for EVAR and OR is achieved, was applied to cope with the large variation in endovascular device costs. Results: One hundred and eighty-six patients who underwent elective AAA repair between 1998 and 2000 (OR period) and 195 patients between 2010 and 2012 (EVAR period) were compared. Cost equivalence for OR and EVAR was reached at a break even price for an endovascular device of V13 190. The main cost difference reflected the longer duration of hospital stay (ward and Intensive Care Unit) of OR (V11 644). Re-intervention rates were similar for OR (24.2%) and EVAR (24.6%) (p ¼ .92). Conclusion: Cost equivalence for EVAR and OR occurs at a device cost of V13 000 for EVAR. Hence, for most routine repairs, EVAR is not costlier than OR until at least the five year follow up.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

“…1 Pathogenic variants in 5 genes cause Loeys-Dietz syndrome, also termed transforming growth factor-β vasculopathies. 1-3,5,6 Some pathogenic variants in Loeys-Dietz syndrome genes, in particular TGFBR1 and TGFBR2 , may have earlier onset TAD. 7 All the Loeys-Dietz syndrome genes confer a risk for aortic involvement distal to the aortic root along with branch vessel and intracranial aneurysms.…”

Has EVAR changed the outcomes of ruptured abdominal aortic aneurysms? A decades worth of experience in an Australian Teaching Hospital

“…Whilst there has been some suggestions that EVARs are associated with higher costs, a recent review by Bulder et al . demonstrated a cost equivalence between EVAR and OR 15 . One important determining factor of this was the length of post‐operative admissions, with patients who underwent OR demonstrating longer admission lengths to both ICU and surgical wards 15 .…”

“…15 One important determining factor of this was the length of postoperative admissions, with patients who underwent OR demonstrating longer admission lengths to both ICU and surgical wards. 15 Whilst our review did not find a significant difference in the length of admission to ICU, those undergoing endovascular repair did demonstrate a significantly shorter total length of admission. This inevitably has implications on the costs and resources associated with post-operative care, although this was not further explored given the scope of this review.…”

“…Whilst there has been some suggestions that EVARs are associated with higher costs, a recent review by Bulder et al demonstrated a cost equivalence between EVAR and OR. 15 One important determining factor of this was the length of postoperative admissions, with patients who underwent OR demonstrating longer admission lengths to both ICU and surgical wards. 15 Whilst our review did not find a significant difference in the length of admission to ICU, those undergoing endovascular repair did demonstrate a significantly shorter total length of admission.…”

Administrative healthcare data as an addition to the Dutch surgical aneurysm audit to evaluate mid-term reinterventions following abdominal aortic aneurysm repair: A pilot study

“…Despite the considerable number of performed studies, the exact percentages of reinterventions in literature and our study are hardly comparable since each study used other criteria for describing reinterventions [17] and reported other follow-up periods. Nevertheless, reporting reinterventions at the national level might be valuable to evaluate the nationwide impact of the reinterventions following EVAR and OSR, especially since reinterventions significantly raise the costs of AAA repair [19,20]. Although we could only report on a large sample of nationwide data within this study design, which had similar patient characteristics (age and sex) when comparing the administrative healthcare data with the DSAA, this study revealed that about 1 in 10 patients received a reintervention within 12 months following EVAR and OSR.…”