Abstract P20: One-Year Hospitalization Costs Associated with Carotid Stenting Versus Endarterectomy: Results from the CREST Trial
Authors: Vilain Katherine , Magnuson Elizabeth , Li Haiyan , Sternbergh Charles , Clark Wayne M , Begg Richard J , Sam Albert D , Weaver Fred A , Brott Thomas G , Cohen David J 
Published: July 2021

Background:
The CREST trial demonstrated that for patients at standard risk of surgical complications, there was no significant difference in the primary composite outcome of periprocedural death, MI, or stroke, or late ipsilateral stroke between carotid artery stenting (CAS) and carotid endarterectomy (CEA), although CAS had a higher rate of stroke, and CEA had a higher rate of MI. The economic implications of these two strategies are unknown.

Methods:
We performed a prospective health economic study alongside the CREST trial. Costs were assessed from the perspective of the US health care system in 2008 dollars using a combination of resource-based and event-based methods. Costs for carotid revascularization procedures were based on measured resource use and unit costs derived from a sample of study hospitals. Non-procedural costs for these hospitalizations were estimated using hospital billing data (charges) and cost-center-specific cost-to-charge-ratios. Costs for follow-up events were estimated using national average DRG reimbursements. The primary analysis was based on a modified intention-to-treat population for which the assigned procedure was attempted (n=1212 CAS; 1193 CEA).

Results:
CAS was associated with higher total procedural costs (Δ=$675, see Table), driven mainly by higher costs for disposable supplies. Length of stay was shorter for CAS, with associated reductions in non-procedural hospital costs (Δ = -$436). Total cost for the index hospitalization remained slightly higher for CAS (Δ=$239) with similar differences at 1 year.

Conclusions:
For patients at standard risk of surgical complications, total 1-year costs are slightly higher for CAS vs. CEA, driven largely by higher initial procedural costs. Cost-utility analysis will be performed to determine whether differences in quality of life observed in CREST render CAS an economically attractive strategy.

CAS (n= 1212)
CEA (n=1193)
Δ CAS - CEA (95% CI via bootstrap)

Index Procedure Costs, $

    Excluding MD Fees
6782 ± 1412
5743 ± 1370
1039 (926, 1148)

    MD Fees
1114 ± 240
1478 ± 108
-364 (-379, -349)

    Total
7896 ± 1551
7221 ± 1450
675 (555, 800)

Index Hospital Stay
7159 ± 5108
7595 ± 7482
-436 (-951, -59)

TOTAL Index Hosp Costs
15055 ± 5539
14816 ± 7709
239 (-302, 778)

Index Hosp LOS (days)

    ICU LOS
0.7 ± 1.1
0.8 ± 1.4
-0.1 (-0.24, -0.04)

    Non-ICU LOS
1.9 ± 3.2
2.2 ± 4.1
-0.2 (-0.55, 0.06)

TOTAL LOS
2.6 ± 3.3
3.0 ± 4.5
-0.4 (-0.7, -0.06)

1-year Rehosp Costs:

    Repeat Revasc - CAS
295 ± 2097
273 ± 2126
-21 (-142, 201)

    Repeat Revasc - CEA
287 ± 2088
477 ± 2510
-190 (-371, -11)

    Ipsilateral Stroke
556 ± 3273
384 ± 2580
172 (-75, 402)

    TIA
48 ± 520
33 ± 487
16 (-25, 56)

    Death
63 ± 846
45 ± 779
18 (-49, 85)

TOTAL Rehosp costs
1321 ± 4827
1293± 4502
28 (-334, 396)

TOTAL 1-year costs
16375 ± 7730
16108 ± 9030
267 (-366, 961)