title: The financial implications of endovascular aneurysm repair in the cost containment era.
abstract: OBJECTIVE
  Endovascular aneurysm repair (EVAR) is associated with significant direct device costs. Such costs place EVAR at odds with efforts to constrain healthcare expenditures. This study examines the procedure-associated costs and operating margins associated with EVAR at a tertiary care academic medical center.
  
  
  METHODS
  All infrarenal EVARs performed from April 2011 to March 2012 were identified (n = 127). Among this cohort, 49 patients met standard commercial instruction for use guidelines, were treated using a single manufacturer device, and billed to Medicare diagnosis-related group (DRG) 238. Of these 49 patients, net technical operating margins (technical revenue minus technical cost) were calculated in conjunction with the hospital finance department. EVAR implant costs were determined for each procedure. DRG 238-associated costs and length of stay were benchmarked against other academic medical centers using University Health System Consortium 2012 data.
  
  
  RESULTS
  Among the studied EVAR cohort (age 75, 82% male, mean length of stay, 1.7 days), mean technical costs totaled $31,672. Graft implants accounted for 52% of the allocated technical costs. Institutional overhead was 17% ($5495) of total technical costs. Net mean total technical EVAR-associated operating margins were -$4015 per procedure. Our institutional costs and length of stay, when benchmarked against comparable centers, remained in the lowest quartile nationally using University Health System Consortium costs for DRG 238. Stent graft price did not correlate with total EVAR market share.
  
  
  CONCLUSIONS
  EVAR is currently associated with significant negative operating margins among Medicare beneficiaries. Currently, device costs account for over 50% of EVAR-associated technical costs and did not impact EVAR market share, reflecting an unawareness of cost differential among surgeons. These data indicate that EVAR must undergo dramatic care delivery redesign for this practice to remain sustainable.
authors.affiliation: Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH. Electronic address: david.h.stone@hitchcock.org.
authors.forename: David H
authors.initials: DH
authors.lastname: Stone
authors.affiliation: Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
authors.forename: Alexander J
authors.initials: AJ
authors.lastname: Horvath
authors.affiliation: Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; The Dartmouth Institute for Health Policy and Clinical Practice, Center for Leadership and Improvement, Lebanon, NH.
authors.forename: Philip P
authors.initials: PP
authors.lastname: Goodney
authors.affiliation: Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
authors.forename: Eva M
authors.initials: EM
authors.lastname: Rzucidlo
authors.affiliation: Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; The Dartmouth Institute for Health Policy and Clinical Practice, Center for Leadership and Improvement, Lebanon, NH.
authors.forename: Brian W
authors.initials: BW
authors.lastname: Nolan
authors.affiliation: Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
authors.forename: Daniel B
authors.initials: DB
authors.lastname: Walsh
authors.affiliation: Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
authors.forename: Robert M
authors.initials: RM
authors.lastname: Zwolak
authors.affiliation: Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
authors.forename: Richard J
authors.initials: RJ
authors.lastname: Powell
mesh_terms: D000046:Academic Medical Centers / Q000191:economics; D000368:Aged; D000783:Aneurysm / Q000191:economics* / Q000601:surgery*; D019985:Benchmarking / Q000191:economics; D001807:Blood Vessel Prosthesis / Q000191:economics; D019917:Blood Vessel Prosthesis Implantation / Q000191:economics* / Q000295:instrumentation; D003363:Cost Control; D003362:Cost-Benefit Analysis; D057510:Endovascular Procedures / Q000191:economics* / Q000295:instrumentation; D005260:Female; D005102:Health Expenditures; D017721:Hospital Costs; D006801:Humans; D007902:Length of Stay / Q000191:economics; D008297:Male; D006278:Medicare / Q000191:economics; D062606:Tertiary Care Centers / Q000191:economics; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States