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Comparative Study
. 2015 Aug;150(2):304-2.e2.
doi: 10.1016/j.jtcvs.2015.03.041. Epub 2015 Apr 1.

Coronary artery bypass grafting in diabetics: A growing health care cost crisis

Sajjad Raza  1 , Joseph F Sabik 3rd  2 , Ponnuthurai Ainkaran  3 , Eugene H Blackstone  4
Affiliations
Comparative Study

Coronary artery bypass grafting in diabetics: A growing health care cost crisis

Sajjad Raza et al. J Thorac Cardiovasc Surg. 2015 Aug.

Abstract

Objectives: To determine 4-decade temporal trends in the prevalence of diabetes and cardiovascular risk factors among patients undergoing coronary artery bypass grafting (CABG) and to compare in-hospital outcomes, resource utilization, and long-term survival after CABG in diabetics versus nondiabetics.

Methods: From January 1972 to January 2011, 10,362 pharmacologically treated diabetics and 45,139 nondiabetics underwent first-time CABG. Median follow-up was 12 years. Direct technical cost data were available from 2003 onward (n = 4679). Propensity matching by diabetes status was used for outcome comparisons. Endpoints were in-hospital adverse events, resource utilization, and long-term survival.

Results: Diabetics undergoing CABG increased from 7% in the 1970s to 37% in the 2000s. Their outcomes were worse, with more (P < .05) in-hospital deaths (2.0% vs 1.3%), deep sternal wound infections (2.3% vs 1.2%), strokes (2.2% vs 1.4%), renal failure (4.0% vs 1.3%), and prolonged postoperative hospital stay (9.6% vs 6.0%); and their hospital costs were 9% greater (95% confidence interval 7%-11%). Survival after CABG among diabetics versus nondiabetics at 1, 5, 10, and 20 years was also worse: 94% versus 94%, 80% versus 84%, 56% versus 66%, and 20% versus 32%, respectively. Propensity-matched patients incurred similar costs, but the prevalence of postoperative deep sternal wound infections and stroke, as well as long-term survival, remained worse in diabetics.

Conclusions: Diabetes is both a marker for high-risk, resource-intensive, and expensive care after CABG and an independent risk factor for reduced long-term survival. These issues, coupled with the increasing proportion of patients needing CABG who have diabetes, are a growing challenge in reining in health care costs.

Keywords: Coronary artery bypass grafting; diabetes; health care costs.

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Conflict of interest statement

Statement Dr Sabik is the North American principal investigator for the Abbott Laboratories–sponsored left main coronary disease randomized trial (EXCEL), is on the Society of Thoracic Surgeons Board of Directors, and is on the scientific advisory board of Medtronic. All other authors have nothing to disclose with regard to commercial support.

Figures

FIGURE 1
FIGURE 1
Four-decade trends in prevalence of diabetes and cardiovascular risk factors among patients undergoing primary isolated coronary artery bypass grafting. Each circle is a yearly percentage or mean value, and solid lines are loess estimates. The factors shown are: (A) age; (B) body mass index; (C) stroke; (D) hypertension; (E) PAD; (F) total cholesterol; (G) HDL cholesterol; (H) triglycerides; and (I) percentage with 3-system disease. PAD, Peripheral arterial disease; HDL, high-density lipoprotein.
FIGURE 2
FIGURE 2
Median (triangles) ratio of total direct technical costs (overall and propensity matched) in diabetics versus nondiabetics. Error bars are 95% confidence intervals.
FIGURE 3
FIGURE 3
Time-related death after primary isolated coronary artery bypass grafting in diabetics and nondiabetics. Solid lines are parametric estimates enclosed within dashed 68% confidence bands equivalent to ±1 SE. The panels show: (A) instantaneous risk of death (overall); (B) survival (overall); (C) instantaneous risk of death (propensity-matched cohort); and (D) survival (propensity-matched cohort). Each symbol represents a death; vertical bars are confidence limits equivalent to ±1 SE; and values in parentheses are numbers of patients remaining at risk.
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Comment in

References

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