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Ann Thorac Surg 2004;77:635-642
© 2004 The Society of Thoracic Surgeons
a Division of Thoracic Surgery, Duke University Medical Center, Durham, North Carolina, USA
b Duke Center for Clinical Health Policy Research, Duke University Medical Center, Durham, North Carolina, USA
c Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
d Bayer Corporation, West Haven, Connecticut, USA
e National Cancer Institute, Bethesda, Maryland, USA
Accepted for publication June 23, 2003.
* Address reprint requests to Dr Smith, Department of Surgery, Duke University Medical Center, Box 3442, Durham, NC 27710, USA.
e-mail: smith058{at}mc.duke.edu
BACKGROUND: The full kallikrein-inhibiting dose of aprotinin has been shown to reduce blood loss, transfusion requirements, and the systemic inflammatory response associated with cardiopulmonary bypass graft surgery (CABG). A half-dose regimen, although having a reduced delivery cost, inhibits plasmin and fibrinolysis without substantially effecting kallikrein-mediated inflammation associated with bypass surgery. The differing pharmacologic effects of the two regimens impact the decision-making process. The current study assessed the medical cost offset of full-dose and half-dose aprotinin from short- and long-term perspectives to provide a rational decision-making framework for clinicians.
METHODS: To estimate CABG admission costs, resource utilization and clinical data from aprotinin clinical trials were combined with unit costs estimated from a Duke University–based cost model. Lifetime medical costs of stroke and acute myocardial infarction were based on previous research.
RESULTS: Relative to placebo, the differences in total perioperative cost for primary CABG patients receiving full-dose or half-dose aprotinin were not significant. When lifetime medical costs of complications were considered, total costs in full-dose and half-dose aprotinin-treated patients were not different relative to that of placebo. Total perioperative cost was significantly lower for repeat CABG patients treated with aprotinin, with savings of $2,058 for full-dose and $2,122 for half-dose patients when compared with placebo. Taking lifetime costs of stroke and acute myocardial infarction into consideration, the cost savings estimates were $6,044 for full-dose patients and $4,483 for half-dose patients, due to substantially higher lifetime stroke costs incurred by the placebo patients.
CONCLUSIONS: Using this cost model, use of full-dose and half-dose aprotinin in primary CABG patients was cost neutral during hospital admission, whereas both dosing regimens were significantly cost saving in reoperative CABG patients. Additional lifetime cost savings were realized relative to placebo due to reduced complication costs, particularly with the full-dose regimen. As the full kallikrein-inhibiting dose of aprotinin has been shown to be safe and effective, the current results support its use in both primary and repeat CABG surgery. No demonstrable economic advantage was observed with the half-dose aprotinin regimen.
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