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Department of Medicine, Division of Cardiovascular Medicine, University of Pennsylvania Medical Center, 3400 Spruce St, 6 Penn Tower, Philadelphia, PA 19104
(Email: alexander.opotowsky{at}uphs.upenn.edu).
We read with interest the article by Karamlou and colleagues [1] on patent foramen ovale/atrial septal defect (PFO/ASD) closure utilization. We previously published a report on trends in percutaneous and surgical PFO/ASD closure using the same database [2]. Their excellent article presents important data on this increasingly common procedure. There are two points we would like to address.
First is the assertion that the development of percutaneous techniques is driving utilization. Percutaneous ASD closure (and, with modifications, PFO closure) has become possible and popular only in the last decade. Although advances in technology have been important in the growth of procedural volume, we would submit that a more important factor has been the recent appreciation that paradoxical emboli through a PFO may be an important source of cryptogenic stroke.
The first epidemiologic report suggesting that PFOs confer increased stroke risk was published in 1988, and dissemination of this idea took many years [3]. It seems improbable that physicians close these defects because they happen to have devices at hand. More likely, these conceptual changes, and the resultant identification of a large population who might benefit from PFO/ASD closure, drove advances in device development. Nonetheless, it remains unclear whether percutaneous closure is appropriate and effective for patients with PFO and cryptogenic stroke or for other proposed indications. Current trials hopefully will provide answers to address the controversy surrounding the appropriate indications for these procedures.
Second, the data on charges associated with admissions for percutaneous closure are difficult to interpret. Most surgical procedures in the sample were performed before 2000, whereas almost all of the percutaneous closures were performed after 2000. Without controlling for health care inflation, a direct comparison is impossible. Using the Healthcare Cost and Utilization Project online query system to analyze the Nationwide Inpatient Sample, we found that mean total charges in 2005 for patients with a principal procedure of surgical closure were $72,802 ± $7630 compared with $41,833 ± $3199 for percutaneous closure, a much larger difference than the authors report [4].
In addition, major changes have occurred in reimbursement schemes [5]. Before 2005, Medicare reimbursed percutaneous PFO/ASD closure under Diagnosis-related group (DRG) 108 (Other Cardiothoracic Procedures), the same DRG as surgical closure. From 2006 on, this procedure has been reassigned to DRG 518 (Percutaneous Cardiovascular Procedure without Coronary Artery Stent or Acute Myocardial Infarction). The national average Medicare Fee Schedule amount in 2005 for DRG 108 was $25,891.27 compared with $8703.36 for DRG 518 [6]. Perhaps as a result, total hospital charges for percutaneous PFO/ASD closure actually declined from $41,833 ± $3199 in 2005 to $36,231 ± $2288 in 2006. Average total charges for surgical closure increased to $75,262 ± $8832 in 2006, more than twice the charges for a percutaneous approach [4].
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  T. Karamlou, B. S. Diggs, B. W. McCrindle, R. M. Ungerleider, and K. F. Welke Reply Ann. Thorac. Surg., October 1, 2009; 88(4): 1386 - 1387. [Full Text] [PDF]
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