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Diabetics Benefit More In Long Term From Heart Bypass Than Stents

Diabetics with more than one clogged heart artery are more likely to benefit in the longer term from heart bypass surgery than drug-coated stents, according to a late-breaking clinical trial whose results were presented at a meeting in the US over the weekend.

The trial investigators suggest that at first, fitting a stent to prop the clogged vessels open seems like a cheaper option, but say their study found fewer deaths and heart attacks in the longer term in diabetic patients who had the more expensive option of bypass surgery instead. They say from a quality of life point of view, the bypass option is more cost-effective and worth the larger up-front cost.

The study was the work of lead investigator Elizabeth A Magnuson and colleagues, and was presented at the American Heart Association's (AHA's) Scientific Sessions 2012 in Los Angeles on 4 November.

Magnuson, who is director of health economics and technology assessment at Saint Luke's Mid-America Heart Institute in Kansas City, Missouri, says in an AHA statement:

"Our results demonstrate that bypass surgery is not only beneficial from a clinical standpoint, but also economically attractive from the perspective of the US healthcare system."

"The economic data are important because of the large number of people with diabetes who are in need of procedures to unblock clogged arteries," she explains. The Study The sub-study that compared heart bypass versus stent in patients with diabetes is part of a larger trial called the FREEDOM trial.

Magnuson and colleagues examined clinical and costings data from more than 1,900 patients with diabetes and more than one clogged heart artery, who had either bypass surgery and or were implanted with drug-coated stents to keep the clogged vessels propped open.

The study covered patients living in more than 16 countries: 19% of them were residents of the US. Stents Are the Cheaper Option At first, bypass surgery appeared to be more expensive, costing $8,622 more per procedure. This was mainly because a bypass patient has a longer stay in hospital, and there tend to be more complications just after the surgery.

When the researchers looked at the five years following the procedure, they found the follow-up costs of treating patients who had stents implanted were higher than for patients who had bypasses. But even accounting for these, the cost of bypass surgery, with follow up, on average cost about $3,600 more. But Quality of Life Favors Bypass Sugery The researchers then looked on the other side of the cost-versus-effectiveness equation: quality of life. Here, the data showed that patients who received bypass surgery had a lower risk of dying or having a heart attack in the five years after their procedure.

To plug that factor into their equation, they converted the data into QALY units gained, (QALY stands for quality-adjusted life-year). This measure takes into account both the difference in how long patients can be expected to live after the procedure, plus the quality of life they have in those years.

Turning that into dollars, the researchers calculated that bypass surgery represented a lifetime cost-effectiveness figure of $8,132 per QALY gained, which is well below $50,000 per QALY gained, which is used as a threshold for deciding if medical procedures are worth the cost. Findings Affirm AHA Position Magnuson, who is also professor of medicine at the University of Missouri's Kansas City School of Medicine, says their findings affirm the AHA's guidelines that have been in place since the 1990s. These recommend patients with diabetes who have more than one clogged heart artery should receive bypass surgery.

She says amid growing concerns about the rising cost of healthcare, it is important to ensure policymakers are fully aware of the long term benefit of adding more cost to treatments.

"This is especially true in cardiovascular disease where many interventions tend to be very costly up front," she adds.

However, she and her colleagues point out there is still a need to investigate if the cost-effectiveness of bypass surgery extends beyond the 5-year horizon they looked at in their study.

The National Heart, Lung and Blood Institute helped fund the study, and a number of commercial organizations provided stents, drugs, and a research grant.

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