title: Fixed and variable cost of carotid endarterectomy and stenting in the United States: A comparative study.
abstract: Despite multiple landmark clinical trials, little data exists on real-world cost of carotid artery stenting (CAS) and carotid endarterectomy (CEA) to the United States healthcare system. We aim to study differences in actual hospitalization cost between patients who underwent CAS vs CEA in a nationally representative database.
  
  
  
  We studied hospital discharge and billing records of all patients, in the Premier Perspective Database, who underwent CEA or CAS between the third quarter of 2009 and the first quarter of 2015. Nearest-neighbor 1:1 propensity score matching was performed, to account for differences in patient and hospital characteristics as well as clinical comorbidities of patients who underwent both procedures, for both symptomatic and asymptomatic cohorts using 32 variables. Pearson χ2, Student t-test, and nonparametric K-sample equality-of-medians tests were used to analyze the data, as appropriate. The primary outcome was total in-hospital cost, including fixed (administrative, capital and utilities) and variable costs (labor and supply). Cost data were presented as medians, inflation-adjusted for 2015 U.S. dollar and rounded to the nearest dollar.
  
  
  
  A total of 115,548 procedures were identified. The mean age was 71 and 69 years; 58% and 57% were male patients; and 81% and 77% were white among asymptomatic and symptomatic patients, respectively. After propensity score matching, 25,812 asymptomatic (12,906 CEA and 12,906 CAS) and 3864 symptomatic (1932 CEA and 1932 CAS) patients were included. Total hospitalization cost per CAS was 40% ($11,814 vs $8378; P < .001) and 37% ($19,426 vs $14,190; P < .001) higher than CEA among asymptomatic and symptomatic patients, respectively. Patients who underwent CAS incurred significantly higher total hospitalization cost despite stratifying by type of cost (fixed and variable), U.S. census regions and symptomatic status. Moreover, asymptomatic patients who underwent CAS performed by any surgical specialty incurred an average of $2717 to $4918 higher total hospitalization cost compared with patients who underwent CEA (all P < 001). Among symptomatic patients, those who underwent CAS performed by vascular, cardiac, and neurologic surgeons, incurred $2108 ($16,114 vs $14,006; P = .006), $7055 ($17,351 vs $10,296; P = .023) and $6479 ($27,290 vs $20,811; P = .002) higher total hospitalization cost compared with patients who underwent CEA, respectively.
  
  
  
  The total hospitalization cost incurred by patients who underwent CAS was significantly higher than for those who underwent CEA, despite matching cohort based on patient and hospital characteristics, and stratifying by symptomatic status, type of cost, hospital region, and surgeon specialty. Our findings could provide additional important information giving the ongoing controversy regarding the appropriate indication for CAS.
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Johns Hopkins Medical Institution, Baltimore, Md.
authors.forename: Tammam
authors.initials: T
authors.lastname: Obeid
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Johns Hopkins Medical Institution, Baltimore, Md.
authors.forename: Husain
authors.initials: H
authors.lastname: Alshaikh
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Johns Hopkins Medical Institution, Baltimore, Md.
authors.forename: Besma
authors.initials: B
authors.lastname: Nejim
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Johns Hopkins Medical Institution, Baltimore, Md.
authors.forename: Isibor
authors.initials: I
authors.lastname: Arhuidese
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Johns Hopkins Medical Institution, Baltimore, Md.
authors.forename: Satinderjit
authors.initials: S
authors.lastname: Locham
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Johns Hopkins Medical Institution, Baltimore, Md. Electronic address: bmalas1@jhmi.edu.
authors.forename: Mahmoud
authors.initials: M
authors.lastname: Malas
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017130:Angioplasty / Q000009:adverse effects / Q000191:economics* / Q000295:instrumentation; D058070:Asymptomatic Diseases; D016893:Carotid Stenosis / Q000000981:diagnostic imaging / Q000191:economics* / Q000628:therapy*; D016009:Chi-Square Distribution; D016208:Databases, Factual; D003661:Decision Support Techniques; D016894:Endarterectomy, Carotid / Q000009:adverse effects / Q000191:economics*; D005260:Female; D017721:Hospital Costs; D006801:Humans; D008297:Male; D008875:Middle Aged; D018803:Models, Economic; D018579:Patient Selection; D017064:Process Assessment, Health Care / Q000191:economics*; D057216:Propensity Score; D012189:Retrospective Studies; D015607:Stents / Q000191:economics*; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States