Weighing the costs: In an analysis that will track 392 patients over an eight-year period, Patrick Mauldin and a team of researchers compare the costs of angioplasty versus those of coronary bypass surgery, creating the most complete econ omic analysis to date.

s the 103rd session of the US Congress came to a close in the fall, legislators left the Capitol, having failed at the biggest challenge of their careers. They had passed no new legislation on health care ref orm as the Administration had hoped. While some politicians blamed the opposite party members for defeat, others applauded the lack of legislation, arguing that voters supported long-term solutions rather than quick-fix laws governing health care. The tas k proved too large, the problem too complicated, the issues too broad for one session of lawmaking. Patrick Mauldin, assistant professor of Health Policy and Management at the Rollins School of Public Health, believes that would-be reformers must first fully understand the problems and costs associated with health care before they can create effectiv e policies. "If you want to contain costs, first you must figure out what works," Dr. Mauldin says. That understanding, however, is not a simple matter. Even with America's most expensive and deadliest of chronic conditions, cardiovascular disease, researchers have yet to fully uncover the comprehensive costs. Heart disease and stroke cause some 39% of deaths in the United States each year. According to Dr. Mauldin, procedures to treat cardiovascular problems account for around 10% of all medical expenses in the United States, approximately $120 billion. Of those procedures, coronary bypass surgery a nd angioplasty make up some $20 billion in expenses. Yet until recently, there has been no comprehensive study of the costs associated with those two treatments nor of the effects of those treatments on quality of life. Dr. Mauldin, collaborating with other researchers and physicians in the Schools of Public Health and of Medicine, is trying to remedy that lack of data with the Emory Angioplasty vs. Surgery Trial (EAST). A randomized trial led by cardiologist Spencer B. King III, EAST compared coronary angioplasty with coronary artery bypass surgery in 392 patients with multiple vessel coronary artery disease. The three-year results recently appeared in the New England Journal of Medicine. In the late 1980s, the researchers expanded EAST to include an economic analysis. Cardiologist William Weintraub recruited Mauldin, then a doctoral student, to assist him in the development and analysis of the economic study. Recently Edmund Becker bro ught his experience with physician profiling to the team. The task of the group is to capture all the costs associated with bypass surgery and angioplasty and then to interpret those data. They also hope to analyze the impact of the procedures on patients ' quality of life. Since EAST began, other trials have gotten under way in Britain, Germany, and the United States that address the relative efficacy of bypass surgery and angioplasty. However, "no other study has been able to analyze the problem from an economic perspec tive with such detail," Dr. Mauldin says. The researchers had some theories about what they'd find, but some surprises awaited them.

Dr. Spencer King III, who directs the EAST study, performs an angioplasty procedure on a patient with multiple vessel coronary artery disease. EAST findings place the combined costs over a three-year period for each angioplasty procedure at $23,734. Quiet! Economists at work: Cardiologist William Weintraub (left) discusses data from the EAST study with Patrick Mauldin and Edmund Becker, whose backgrounds in mathematical modeling and physician profiling bring several perspectives to t he economic analysis.

ith traditional economics, a consumer buys an apple, eats the apple, and enjoys it. In health care, however, consumers don't necessarily pay for medical care directly. They often don't make the consumption decisions. But they do receive the benefits." Dr. Mauldin is sharing his interest in the shape economics take when they confront health care. Currently, in addition to his appointment at the School of Public Health, Dr. Mauldin works as a health economist for both Emory's School of Medicine and th e Centers for Disease Control and Prevention (CDC). In the EAST trial, his particular assignment was to develop a rigorous mathematical model that would demonstrate the relative effectiveness and costs of bypass surgery and angioplasty. Traditionally, economists use cost-effectiveness, cost-benefit, or cost-utility analyses to evaluate whether one procedure has benefit over another. However, those methods do not provide the level of sophistication needed to incorporate multiple costs and outcome indicators. "From a medical decision-making perspective," Dr. Mauldin says, "uncertainty can arise when two possible procedures suggest several endpoints, suggesting the value of one or the other." On the other hand, an ideal model, he suggests, would be one that demonstrates the value of health improvement to the patient relative to cost. Dr. Mauldin's model is a complex tool that relates multiple patient variables to outcomes to determine which procedure offers more increases in quality health as compared with i ncreases in provider costs. The EAST economic team used the model to help answer three sets of questions. What were the costs of the two procedures at different points in time? How did the costs of the procedures relate to the outcomes? And, how do repeat angioplasty revasculariz ations affect costs and outcomes? The researchers began their collection of data by electronically downloading the hospital and physician charges made to patients participating in the trial. To collect information about direct and indirect patient costs, such as time lost from work or out-of-pocket prescription charges, they interviewed the 198 people in the study who had received angioplasty and the 194 who had bypass surgery. In these interviews, the economic team hoped to discover not only direct and indirect costs to patients but also the patients' perceptions about their resulting quality of life. "It was amazing how willing patients were to answer some very personal que stions," Dr. Mauldin says. "If they felt they had some say-so, some power to direct their health outcome, they opened up and shared some very intimate perspectives." The team suspected that clinical outcomes and patient satisfaction would significantly influence those patients' perceptions of each procedure's success. They surmised that angioplasty patients might be more satisfied with their procedure than bypass p atients because angioplasty is less invasive and requires less medical intervention than does bypass surgery. They also hypothesized that the procedures' costs would be inversely related to patient satisfaction but positively associated with clinical outc omes. In other words, higher costs for both procedures would lead to lower patient satisfaction but better clinical outcomes. In evaluating the data at the three-year interval (the study has been extended to eight years), EAST clinical researchers found no differences between the two groups in mortality, myocardial infarctions, or large, reversible thallium defects. The econo mic team, however, discovered what they describe as "a clear and striking utilization pattern" in hospital and professional charges. Although bypass surgery patients had higher initial costs for their treatment, cumulative costs over three years to angiop lasty and bypass patients were roughly equivalent. Initially, angioplasty hospital costs were about $11,684, with physician charges totalling around $4,538, compared with a hospital cost for coronary surgery of $14,579 and physician charges of $9,426. How ever, after three years, combined hospital and physician charges for angioplasty were up to $23,734, just short of combined charges for surgery of $25,310. The main reason for the increasing costs associated with angioplasty was the need for repeat revascularizations. Some 50% of the patients who had angioplasty needed repeat procedures, making their costs climb to the range of costs for surgery. The quality-of-life measures also revealed some interesting patterns, Dr. Mauldin says. Despite the fact that the angioplasty group experienced some continuing angina, or chest pain, they remained more optimistic than the surgery patients that their re covery would eventually be complete. Because these findings reveal no significant differences in death rates, myocardial infarction, or costs, the researchers suggest that physicians and medical personnel work closely with patients and families to make their best choice. "Some patients ma y seek to avoid surgery and would prefer the less invasive approach of angioplasty," report the researchers in a recent article. "Conversely, other patients may prefer the coronary surgery procedures over angioplasty because of the lower probability of re peat revascularization procedures, at least in the short term." The findings of the three-year analysis of EAST, however, are "moving targets," Dr. Mauldin says. During the fifth and eighth years of EAST, the clinical and economic teams will supplement their data with new information that may change findings again. For example, as bypass patients near the ten-year mark, their need for repeat angioplasty or surgery will probably increase. This, however, is only a hypothesis. At the next collection of data, researchers may once again be surprised. But rather than disturbing the researchers, the pioneering nature of their work underscores the importance of the health care debate and the critical need for credible analysis. "The blending of powerful new analytical techniques to integrate clinical, economic, and patient quality-of-life data," says Dr. Mauldin, "promises to provide physicians an analysis with more meaningful answers." Answers not only to the economics of the heart but also to other medical and surgical services.