COST-EFFECTIVENESS OF CORONARY ANGIOPLASTY VERSUS MEDICAL-TREATMENT -THE IMPACT OF COST-SHIFTING

Background: Coronary angioplasty (PTCA) offers improved symptom contro l over medical treatment in patients with stable angina and single-ves sel disease. However, it is uncertain if PTCA is more cost-effective. Cost-shifting could also influence the provision of PTCA. Methods: Dat a from the only randomised trial comparing PTCA to medical therapy (AC ME study) were used with costs from an Australian teaching hospital to estimate the costs and freedom from angina in 100 patients over three years. The incremental cost-effectiveness of PTCA, and the potential for cost-shifting were also examined. Results: Although the total cost of treating 100 patients over three years with PTCA ($678,978) was hi gher than a medical strategy ($631,078), PTCA was more cost-effective ($10,930 versus $12,682 per patient free of angina). The incremental c ost-effectiveness of PTCA ($3875 per extra patient free of angina) was also substantially less than the cost of the medical strategy. These should be considered crude estimates as they were based on limited dat a on resource use. The hospital could reduce costs by pursuing a medic al strategy, but 54% of the savings would result from shifting the cos t of treating patients to the Federal Government and patients. By perf orming PTCA on privately insured rather than Medicare patients, the ho spital could shift $29,876 per 100 patients to the Federal government and private insurance funds. Conclusions: From society's perspective, PTCA may be more cost-effective than a medical strategy. However, the financial interests of the hospital are best served by limiting PTCA o r restricting PTCA to privately insured patients. Cost-shifting may ha ve a major impact on the provision of PTCA. The costs of providing med ical services need to be weighed against the cost of not providing the m.