A model of the direct and indirect effects of aprotinin administration on the overall costs of coronary revascularization surgery in a university teaching hospital cardiothoracic unit.
BACKGROUND
Cardiac patients sometimes bleed postoperatively and consequently require rethoracotomy, necessitating a longer stay in the intensive care unit (ICU) of the cardiothoracic unit (CTU). When ICU capacity is limited, rethoracotomy necessitates postponing treatment of the next patient. Aprotinin, a bovine lung-derived proteinase inhibitor, has been shown to reduce the frequency of rethoracotomies in cardiac patients.


OBJECTIVE
This study was undertaken to quantify the reduction of potentially avoidable cost to the CTU of postoperative bleeding, both directly and indirectly, by administering aprotinin before and during coronary artery bypass graft (CABG).


METHODS
A novel, validated operational research model was developed, featuring the principal CABG-related health care resource parameters believed to influence waiting lists and times. Factors and costs were derived from both local data from a CTU and relevant recent literature.


RESULTS
According to the model, aprotinin therapy reduced the waiting list by approximately 3% by reducing the number of rethoracotomies. Using data from the literature, for an annual throughput of 431 patients who would receive aprotinin costing 97,333 pounds per year, the annual net savings to the CTU would be 46,586 pounds, which comprised direct savings on blood products of 35,036 pounds and indirect marginal savings of 11,550 pounds derived from 3.2% fewer rethoracotomies (each at a marginal cost of 837 pounds). By reason, then, reinvesting savings in increasing CTU capacity would yield further waiting-list reductions and improve patient morbidity. These results had 2 major limitations. First, it was assumed that all operations would have the same duration and all surgeons would perform operations in the same manner. Second, nonurgent patients were assumed to have been treated in order of strict referral sequence, which may not be done in real-world practice.


CONCLUSIONS
Aprotinin reduced costs in CABG directly by reducing the use of blood products and indirectly by reducing waiting lists, as well as by reducing morbidity and mortality associated with waiting time.
Robinson
David
D
Richardson Research, Manchester, United Kingdom. david.robinson@richardsonresearch.co.uk
Bliss
Edward
E
D007611:Aprotinin / Q000191:economics* / Q000627:therapeutic use; D001026:Coronary Artery Bypass / Q000191:economics*; D003325:Coronary Care Units / Q000191:economics*; D003365:Costs and Cost Analysis; D004334:Drug Administration Schedule; D017723:Drug Utilization Review; D006490:Hemostatics / Q000191:economics* / Q000627:therapeutic use; D006785:Hospitals, University; D006801:Humans; D018803:Models, Economic; D019106:Postoperative Hemorrhage / Q000517:prevention & control; D012086:Reoperation; D015842:Serine Proteinase Inhibitors / Q000191:economics* / Q000627:therapeutic use; D014850:Waiting Lists
D006490:Hemostatics; D015842:Serine Proteinase Inhibitors; D007611:Aprotinin