Commentary: Hospital Costs for PAD Patients in the Endovascular Era: Has the Taxi’s Meter Slowed?

A hospital bed is a parked taxi with the meter running.

Tang et al ¹ provide a retrospective analysis of the initial treatment costs for patients who present with vascular conditions in a single-payer healthcare system, comparing open surgery, endovascular interventions, and primary amputation during the time frame of 2013 to 2016. The study, being observational in nature, carries the selection bias any surgeon would understand, that is, surgical and amputation patients are more likely to have more complex presentations than the endovascular group. To wit, critical limb ischemia was far more common in the open surgery group (88.6%) vs the endovascular group (37.2%). The study clearly shows the costs associated with patients treated with endovascular techniques, or more accurately phrased treatable with endovascular techniques, is far less than surgery and amputation.

While this is intuitive on some level, the observation of how healthcare delivery has changed in the past decade is remarkable. To the remark of Professor Groucho, the dramatic decrease via endovascular techniques in length of stay (LOS), operating room charges, and intensive care unit utilization drive the costs of care downward, as evidenced by Dr Tang and colleagues. In comparison to the BASIL trial, ² in which the LOS was nearly equal by 2 years postrandomization, the nonrandomized study of Tang et al shows a major difference in LOS for endovascular vs open vs amputation groups. While Tang et al could not capture readmissions in this dataset, I believe advances in antiplatelet management after intervention and better optimal medical management may reduce the readmission rate and the “catch-up” in LOS seen in BASIL’s endovascular group over time. Anecdotally, although our vascular service at Johns Hopkins Hospital performs 5% to 10% more endovascular procedures per annum over annum, our daily inpatient census has fallen dramatically in the past 10 years.

Arguments about the costs of endovascular devices pale in comparison to the daily charges of a modern healthcare setting, a reality we as vascular surgeons engage daily with our practice administrators. To argue equipoise may still exist on the notion of treatment efficacy between equally weighted surgery and endovascular procedures divorces the sentiment of cost of care, which is a major consideration of how we elect treatment decisions in the modern healthcare systems.

In the state of Maryland, under a “grand” experiment initiated by the Affordable Care Act, we now operate under a global hospital budget enacted by an all-payer rate-setting model. ³ Endovascular procedures and noninvasive imaging will continue to move out of the hospital setting to fully outpatient settings. This may represent the next level of “cost-shifting,” as the most recent year of analysis suggested $110 million of the $486 million savings in Maryland hospital spending was due to a shift to outpatient procedures. This trend will undoubtedly persist, as 12 more office-based laboratories open in Maryland in 2018. Tang and colleagues’ modern view of healthcare spending will provide useful evidence of just how fast the landscape of vascular surgery has changed and how fast the meter runs in the hospital.