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J Thorac Cardiovasc Surg 2003;125:618-624
© 2003 The American Association for Thoracic Surgery

Surgery for Acquired Cardiovascular Disease

Comparative economic analyses of minimally invasive direct coronary artery bypass surgery

From the Department of Community Research and Community Education, The Hope Heart Institute,^a and the Center for Cost and Outcomes Research^b and the Pharmaceutical Outcomes Research and Policy Program,^c University of Washington, Seattle, Wash.

Funded in part by the American Heart Association Grant-in-Aid Program and the National Institutes of Health.

Presented in part at the annual meeting of the International Society of Technology Assessment in Health Care, Philadelphia, Pa, June 2001.

Received for publication July 1, 2002. Revisions requested Aug 19, 2002; revisions received Aug 21, 2002. Accepted for publication Aug 26, 2002. Address for reprints: Darryl T. Gray, MD, ScD, University of Washington Box 358853, Center for Cost and Outcomes Research, 146 N Canal St, Suite 300, Seattle, WA 98103 (E-mail: tolvadtg{at}u.washington.edu).

Objective: This study was undertaken to assess the degree to which published cost comparisons of minimally invasive direct coronary artery bypass through a thoracotomy versus conventional coronary artery bypass grafting, off-pump bypass surgery through a sternotomy, or angioplasty with or without stenting adhered to existing guidelines for performing economic analyses.
Methods: We used minimally invasive direct coronary artery bypass (MIDCAB), off-pump bypass surgery, cost-effectiveness, economic analysis, and related keywords to search MEDLINE, other literature databases and article reference lists for English-language economic analyses of minimally invasive direct coronary artery bypass procedures versus other procedures that were published from 1990 to February 2002. We critically appraised article adherence to a 10-item methodologic checklist modified to address issues particularly relevant to minimally invasive direct coronary artery bypass evaluations. Assessment discordance was reconciled by consensus.
Results: Ten articles published from June 1997 to March 2001 compared costs and (generally) outcomes of minimally invasive direct coronary artery bypass with those of other procedures. All were nonrandomized comparisons, generally of concurrent intrainstitutional clinical series. Stated results generally favored minimally invasive direct coronary artery bypass, angioplasty, or off-pump bypass surgery through a sternotomy relative to conventional coronary artery bypass grafting. Studies adequately addressed an average of only 24% of applicable checklist items (range 0%-67%). Few studies adequately ensured the comparability of treatment groups, clearly performed intent-to-treat analyses, comprehensively and credibly measured costs that were considered, or clearly addressed costs and results of preprocedural angiography or postprocedural imaging. Only 1 study compared success of revascularization between minimally invasive direct coronary artery bypass and competing alternatives. No studies specified the cost-analysis perspective or included costs of physician or physician assistant care.
Conclusions: Most published comparative economic analyses of minimally invasive direct coronary artery bypass have failed to adequately address issues crucial to such evaluations. Future studies should more closely follow well-described principles of clinical epidemiology and cost-effectiveness analysis.

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