CHICAGO—Coronary artery surgery performed "off-pump", i.e., keeping the heart beating and not using the cardiopulmonary bypass machine, has similar outcomes after one year, and costs less, when compared to conventional coronary artery bypass grafting (CABG) using cardiopulmonary bypass, according to a study in the April 21 issue of the Journal of the American Medical Association (JAMA).

To try to avoid some of the complications attributable to cardiopulmonary bypass, U.S. surgeons performed approximately 21 percent of coronary artery bypass operations off-pump in 2002, according to background information in the article. In off-pump operations, the heart is kept beating, and with the help of a device, the beating heart is stabilized while the surgeon places the bypass grafts around the blocked arteries. During a conventional CABG surgery, a heart-lung machine allows the heart to stop and pumps blood throughout the body, and keeps the body stabilized. Concerns remains about the technical difficulty of off-pump coronary artery bypass (OPCAB), including the possibility of imprecise grafting and incomplete revascularization compromising patient outcomes, and long-term graft patency (keeping the graft open).

John D. Puskas, M.D., M.Sc., of the Emory University School of Medicine and Emory Center for Outcomes Research, Atlanta, and colleagues conducted the Surgical Management of Arterial Revascularization Therapies (SMART) trial, designed to compare graft patency, clinical outcomes, health-related quality of life, and costs in unselected patients referred for elective, isolated CABG surgery and randomized to OPCAB or CABG with cardiopulmonary bypass. The study included 197 patients who had follow-up at 30 days; 185 of those had follow-up at 1 year. The study was conducted between March 10, 2000, and August 20, 2001, at a U.S. academic center.

The researchers found that graft patency was similar for OPCAB and conventional CABG with cardiopulmonary bypass at 30 days and at 1 year. Rates of death, stroke, heart attack, angina, and reintervention were similar at 30 days and 1 year. "There were no significant differences in health-related quality of life. Mean total hospitalization cost per patient at hospital discharge was $2,272 less for OPCAB and $1,955 less at 1 year," the authors write.

CHICAGO—A new study suggests that donor livers are not always distributed according to a patient's need, but may be retained by some organ procurement organizations with smaller waiting lists and transplanted into less sick patients, according to a study in the April 21 issue of the Journal of the American Medical Association (JAMA).

According to background information in the article, the Model for Endstage Liver Disease (MELD) score was implemented in February 2002 to serve as the basis for the liver allocation system used by the United Network for Organ Sharing. The MELD score is an objective scoring system of medical characteristics predictive of prognosis, with minimal emphasis on waiting time as a priority for transplantation. However, recommendations to increase and standardize the size of the area of organ allocation has not been implemented. Consequently, there is great disparity in the patient populations served by organ procurement organizations (OPOs) across the country. In some regions of the United States, an OPO may serve as few as 1.2 million people, whereas in other areas, the population covered by the OPO is nearly 18 million. The smallest OPO has fewer than 10 patients listed for liver transplantation, whereas the largest has more than 2000.

James F. Trotter, M.D., and Michael J. Osgood, B.S., of the University of Colorado Health Sciences Center, Denver, conducted a study to determine whether there is a difference in MELD scores for liver transplant recipients receiving transplants in small vs. large OPOs. The researchers reviewed data from the U.S. Scientific Registry of Transplant Recipients between February 28, 2002, and March 31, 2003. Transplant recipients (n=4,798) had end-stage liver disease and received deceased-donor (DD) livers. The authors examined MELD score distribution (range, 6-40), graft survival, and patient survival for liver transplant recipients in small (less than 100) and large (100 or greater on the waiting list) OPOs.

The researchers found that the distribution of patients' MELD scores listed for transplantation was the same in large and small OPOs; 92 percent had a MELD score of 18 or less, 7 percent had a MELD score between 19 and 24, and only 2 percent of listed patients had a MELD score higher than 24. The proportion of patients receiving transplants in small OPOs and with a MELD score higher than 24 was significantly lower than that in large OPOs (19 percent vs. 49 percent). Patient survival rates at 1 year after transplantation for small OPOs (86.4 percent) and large OPOs (86.6 percent) were not statistically different, and neither were graft survival rates in small OPOs (80.1 percent) and large OPOs (81.3 percent).

CHICAGO—Adherence to evidence-based prescribing guidelines for hypertension (high blood pressure) could result in substantial savings in prescription costs for elderly patients, and up to $1.2 billion nationally, according to a study in the April 21 issue of the Journal of the American Medical Association (JAMA).

"More than 60 percent of Americans aged 65 years and older have hypertension," the authors provide as background information in the article. "Estimates of the cost of its treatment have ranged from $7 billion to $15.5 billion per year." The authors also note that costs of medications for chronic conditions continue to escalate, particularly for the elderly and that the proportion of seniors without insurance coverage has increased in recent years, as well.

Michael A. Fischer, M.D., M.S., and Jerry Avorn, M.D., from Brigham and Women's Hospital, Harvard Medical School, Boston, analyzed medication use patterns in 133,624 hypertensive patients in a state drug assistance program for elderly patients in Pennsylvania during 2001. The researchers "evaluated every antihypertensive regimen in light of the clinical history of each patient and then estimated the potential cost savings to the health care delivery system that could have been realized through adherence to evidence-based recommendations."

"The patients studied filled more than 2.05 million prescriptions for antihypertensive medications in 2001, at an annual program cost of $48.5 million ($363 per patient)," the researchers found. "We identified 815,316 prescriptions (40 percent) for which an alternative regimen appeared more appropriate according to evidence-based recommendations. Such changes would have reduced the costs to payers in 2001 by $11.6 million (nearly a quarter of program spending on antihypertensive medications), as well as being more clinically appropriate overall."

The researchers found that "calcium channel blockers had the highest average cost ($33.39 per prescription) and the highest total spending ($17 million); ACE inhibitors were the second costliest class ($10.5 million). Beta-blockers were the most commonly prescribed antihypertensive drug, but average cost ($15.62) and total spending ($8 million) were lower than for ACE inhibitors or calcium channel blockers. Thiazides (diuretics) were among the least expensive medications ($5.33 per prescription) but accounted for only 4.3 percent of prescriptions."

BEATING HEART SURGERY EVALUATED