Cost comparison of transcatheter and operative closures of ostium secundum atrial septal defects

Abstract

Background: Clinical outcomes for transcatheter and operative closures of atrial septal defects (ASDs) are similar. Economic cost for each method has not been well described.

Methods: A single-center retrospective cohort study of children and adults<30 years of age undergoing closure for single secundum ASD from January 1, 2007, to April 1, 2012, was performed to measure differences in inflation-adjusted cost of operative and transcatheter closures of ASD. A propensity score weight-adjusted multivariate regression model was used in an intention-to-treat analysis. Costs for reintervention and crossover admissions were included in primary analysis.

Results: A total of 244 subjects were included in the study (64% transcatheter and 36% operative), of which 2% (n = 5) were ≥18 years. Crossover rate from transcatheter to operative group was 3%. Risk of reintervention (P = .66) and 30-day mortality (P = .37) were not significantly different. In a multivariate model, adjusted cost of operative closure was 2012 US $60,992 versus 2012 US $55,841 for transcatheter closure (P < .001). Components of total cost favoring transcatheter closure were length of stay, medications, and follow-up radiologic and laboratory testing, overcoming higher costs of procedure and echocardiography. Professional costs did not differ. The rate of 30-day readmission was greater in the operative cohort, further increasing the cost advantage of transcatheter closure. Sensitivity analyses demonstrated that costs of follow-up visits influenced relative cost but that device closure remained favorable over a broad range of crossover and reintervention rates.

Conclusion: For single secundum ASD, cost comparison analysis favors transcatheter closure over the short term. The cost of follow-up regimens influences the cost advantage of transcatheter closure.

Figure 1

Study population.

Figure 2

Effect of crossover, reintervention, and 30-day readmission rates on cost. Graphs depict total cost of closure of ASD (2012 US$) over a range of possible event rates (percentages) for crossover to from transcatheter to operative closure (A), device embolization and repeat catheterization (B), acute care after device closure (C), and acute care after operative closure (D). Adjusted costs of device closure (dotted line) and operative closure (dashed line) are identified. The cost of transcatheter closure as risk ascends is depicted (solid line). In D, the cost of operative closure as risk of readmission increases is depicted (dash-dot line) rather than the cost of transcatheter closure. The risk at which the 2 procedures are cost equivalent is marked with red dotted line. In C and D, there is no risk of readmission that results in cost equivalence.

Figure 3

Effect of cost of follow-up visits on total cost. Graphs depict total cost of closure of ASD (2012 US$) over a range of possible costs for follow-up visits. In both analyses, total cost of transcatheter closure (solid line) and operative closure (dashed line) are depicted. The cost of follow-up visit at which there is cost equivalence is depicted (red dotted line). Panel A depicts the most conservative model in which the operative cohort does not receive follow-up and transcatheter cohort receives follow-up for 5 years as per FDA recommendations. Cost equality is reached at a cost of 2012 US $1,559 per visit. Panel B depicts a model in which operative cohort receives 1-week, 1-year, and 5-year follow-up visits. Cost equality is reached at a cost of 2012 US $2,494 per visit.