A Systematic Review of Direct Cardiovascular Event Costs: An International Perspective

Impact of New Cardiovascular Events on Quality of Life and Hospital Costs in People With Cardiovascular Disease in the United Kingdom and United States

BACKGROUND

Despite optimized risk factor control, people with prior cardiovascular disease remain at high cardiovascular disease risk. We assess the immediate- and longer-term impacts of new vascular and nonvascular events on quality of life (QoL) and hospital costs among participants in the REVEAL (Randomized Evaluation of the Effects of Anacetrapib Through Lipid Modification) trial in secondary prevention.

METHODS AND RESULTS

Data on demographic and clinical characteristics, health-related quality of life (QoL: EuroQoL 5-Dimension-5-Level), adverse events, and hospital admissions during the 4-year follow-up of the 21 820 participants recruited in Europe and North America informed assessments of the impacts of new adverse events on QoL and hospital costs from the UK and US health systems' perspectives using generalized linear regression models. Reductions in QoL were estimated in the years of event occurrence for nonhemorrhagic stroke (-0.067 [United Kingdom], -0.069 [US]), heart failure admission (-0.072 [United Kingdom], -0.103 [US]), incident cancer (-0.064 [United Kingdom], -0.068 [US]), and noncoronary revascularization (-0.071 [United Kingdom], -0.061 [US]), as well as in subsequent years following these events. Myocardial infarction and coronary revascularization (CRV) procedures were not found to affect QoL. All adverse events were associated with additional hospital costs in the years of events and in subsequent years, with the highest additional costs in the years of noncoronary revascularization (£5830 [United Kingdom], $14 133 [US Medicare]), of myocardial infarction with urgent CRV procedure (£5614, $24722), and of urgent/nonurgent CRV procedure without myocardial infarction (£4674/£4651 and $15 251/$17 539).

CONCLUSIONS

Stroke, heart failure, and noncoronary revascularization procedures substantially reduce QoL, and all cardiovascular disease events increase hospital costs. These estimates are useful in informing cost-effectiveness of interventions to reduce cardiovascular disease risk in secondary prevention.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT01252953; https://www.Isrctn.com. Unique identifier: ISRCTN48678192; https://www.clinicaltrialsregister.eu. Unique identifier: 2010-023467-18.

Identifying and comparing low-value care recommendations for coronary heart disease prevention, diagnosis, and treatment in the US and China

BACKGROUND

Low-value care provides little or no benefit, causes harm and incurs unnecessary costs. Low-value care for coronary heart disease (CHD) is particularly prevalent in the US and China. Identifying low-value care services is the first step in reducing these services. There is currently limited data on identifying a comprehensive CHD low-value care list in the US and China. We aimed to identify and compare low-value care recommendations for CHD prevention, diagnosis, and treatment in the US and China.

METHODS

Clinical practice guidelines (CPGs) related to CHD in the US and China were screened for do-not-do recommendations stating that specific services should be avoided. The similarities and discrepancies of low-value care recommendations for CHD between the two countries were then compared.

RESULTS

We found a total of 38 low-value care recommendations in 6 Chinese CPGs and 98 recommendations in 11 US CPGs. In the US, the most common types of low-value care recommendations were therapeutic medications (44, 44.9%), followed by therapeutic procedures (27, 27.6%), diagnostic imaging (16, 16.3%), diagnostic testing (9, 9.2%) and primary prevention (2, 2.0%). In China, the most common types were therapeutic medications (18, 47.4%), followed by therapeutic procedures (13, 34.2%), diagnostic testing (4, 10.5%), and diagnostic imaging (3, 7.9%).

CONCLUSION

In this study, a comprehensive list of low-value care for CHD in the US and China was established and potentially become the important targets for de-implementation for both countries. The findings may have important implications for other countries, especially low-and middle-income countries, to reduce low-value care for CHD.

Predicting high health-cost users among people with cardiovascular disease using machine learning and nationwide linked social administrative datasets

OBJECTIVES

To optimise planning of public health services, the impact of high-cost users needs to be considered. However, most of the existing statistical models for costs do not include many clinical and social variables from administrative data that are associated with elevated health care resource use, and are increasingly available. This study aimed to use machine learning approaches and big data to predict high-cost users among people with cardiovascular disease (CVD).

METHODS

We used nationally representative linked datasets in New Zealand to predict CVD prevalent cases with the most expensive cost belonging to the top quintiles by cost. We compared the performance of four popular machine learning models (L1-regularised logistic regression, classification trees, k-nearest neighbourhood (KNN) and random forest) with the traditional regression models.

RESULTS

The machine learning models had far better accuracy in predicting high health-cost users compared with the logistic models. The harmony score F1 (combining sensitivity and positive predictive value) of the machine learning models ranged from 30.6% to 41.2% (compared with 8.6-9.1% for the logistic models). Previous health costs, income, age, chronic health conditions, deprivation, and receiving a social security benefit were among the most important predictors of the CVD high-cost users.

CONCLUSIONS

This study provides additional evidence that machine learning can be used as a tool together with big data in health economics for identification of new risk factors and prediction of high-cost users with CVD. As such, machine learning may potentially assist with health services planning and preventive measures to improve population health while potentially saving healthcare costs.

Dyslipidemia treatment strategies in primary and secondary prevention. Dyslipemia Registry of the Spanish Arteriosclerosis Society

INTRODUCTION

Clinical studies show that patients with high cardiovascular risk are still far from reaching the therapeutic objectives, especially of the levels of LDL cholesterol. If the management of these patients in specialized units differs from other scenarios is known.

PATIENTS AND METHODS

61 certified Lipid Units were selected in the Registry of Dyslipemias of the Spanish Arteriosclerosis Society for the collection of study data. The study included 3958 subjects >18 years of age who met the criteria for hypercholesterolemia (LDL cholesterol ≥160 mg/dL or non-HDL cholesterol ≥190 mg/dL) without familial hypercholesterolemia. A total 1,665 subjects were studied with a mean follow-up time of 4.2 years.

RESULTS AND CONCLUSIONS

A total of 42 subjects had a cardiovascular event since their inclusion in the Registry, which represents 0.6%. There were no differences in the treatment used at follow-up, but 50% of the patients did not reach the therapeutic goals at the visit end of follow-up. An increase in the potency of the lipid-lowering treatment was observed, including PCSK9 inhibitors use in 16.7% of subjects with recurrences.

Association between patient activation, self-management behaviours and clinical outcomes in adults with diabetes or related metabolic disorders: a systematic review and meta-analysis protocol

INTRODUCTION

Diabetes and related metabolic disorders such as obesity and cardiovascular diseases (CVD) are a growing global issue. Equipping individuals with the necessary 'knowledge, skills and confidence to self-manage their health' (ie, patient activation (PAct)) may lead to improvements in health outcomes. It is unclear whether existing evidence allows us to assume a causal relationship. We aim to synthesise and critically appraise evidence on the relationship between PAct and self-management behaviours and clinical outcomes of people living with diabetes and related metabolic disorders.

METHODS AND ANALYSIS

The protocol is based on guidance on Preferred Reporting Items for Systematic Review and Meta-analysis Protocols. We will search Medline, Embase, CENTRAL, PsycInfo, Web of Science and CINAHL using search terms related to PAct, diabetes, pre-diabetes, obesity and CVD. Any quantitative study design is eligible provided studies assess the association between PAct and clinical outcomes and/or self-management behaviours of diabetes and related metabolic disorders. Outcomes include behavioural (eg, diet) and clinical (eg, blood pressure) outcomes. Two reviewers will independently screen titles/abstracts and full texts and assess risk of bias using the revised Cochrane risk-of-bias tool for randomised trials or the Risk of Bias Assessment Tool for Nonrandomised Studies (RoBANS).One reviewer will extract data, with independent checking by a second reviewer. We will critically assess the level of evidence available for assuming a causal association between PAct and outcomes. Data permitting, we will use the Hunter-Schmidt random-effects method to meta-analyse correlations across studies.

ETHICS AND DISSEMINATION

Ethical approval is not required. The review will be disseminated in the form of a peer-reviewed journal article, at conferences and other presentations. The findings of the review will be of interest to clinical commissioning groups, policymakers and intervention deliverers/developers.

PROSPERO REGISTRATION NUMBER

CRD42021230727.

Trends in survival of Swedish men and women with heart failure from 1987 to 2014: a population-based case-control study

AIMS

To compare trends in short-term and long-term survival of patients with heart failure (HF) compared with controls from the general population.

METHODS AND RESULTS

We used data from the Swedish National Inpatient Registry to identify all patients aged ≥18 years with a first recorded diagnosis of HF between 1 January 1987 and 31 December 2014 and compared them with controls matched on age and sex from the Total Population Register. We included 702 485 patients with HF and 1 306 183 controls. In patients with HF aged 18-64 years, short-term (29 days to 6 months) and long-term mortality (>11 years) decreased from 166 and 76.6 per 1000 person-years in 1987 to 2000 to 99.6 and 49.4 per 1000 person-years, respectively, in 2001 to 2014. During the same period, mortality improved marginally, in those aged ≥65 years: short-time mortality from 368.8 to 326.2 per 1000 person-years and long-term mortality from 219.6 to 193.9 per 1000 person-years. In 1987-2000, patients aged <65 years had more than three times higher risk of dying at 29 days to 6 months, with an hazard ratio (HR) of 3.66 [95% confidence interval (CI) 3.46-3.87], compared with controls (P < 0.0001) but substantially higher in 2001-2014 with an HR of 11.3 (95% CI 9.99-12.7, P < 0.0001). HRs for long-term mortality (6-10 and >11 years) increased moderately from 2.49 (95% CI 2.41-2.57) and 3.16 (95% CI 3.07-3.24) in 1987-2000 to 4.35 (95% CI 4.09-4.63) and 4.11 (95% CI 3.49-4.85) in 2001-2014, largely because survival among controls improved more than that among patients with HF (P < 0.0001).

CONCLUSIONS

Absolute survival improved in HF patients aged <65 years, but only marginally so in those aged ≥65 years. Compared with controls, both short-term and long-term relative risk of dying increased, especially in younger patients with HF.

A non-invasive nanoparticles for multimodal imaging of ischemic myocardium in rats

BACKGROUND

Ischemic heart disease (IHD) is the leading cause of morbidity and mortality worldwide, and imposes a serious economic load. Thus, it is crucial to perform a timely and accurate diagnosis and monitoring in the early stage of myocardial ischemia. Currently, nanoparticles (NPs) have emerged as promising tools for multimodal imaging, because of their advantages of non-invasion, high-safety, and real-time dynamic imaging, providing valuable information for the diagnosis of heart diseases.

RESULTS

In this study, we prepared a targeted nanoprobe (termed IMTP-Fe3O4-PFH NPs) with enhanced ultrasound (US), photoacoustic (PA), and magnetic resonance (MR) performance for direct and non-invasive visual imaging of ischemic myocardium in a rat model. This successfully designed nanoprobe had excellent properties such as nanoscale size, good stability, phase transformation by acoustic droplet vaporization (ADV), and favorable safety profile. Besides, it realized obvious targeting performance toward hypoxia-injured cells as well as model rat hearts. After injection of NPs through the tail vein of model rats, in vivo imaging results showed a significantly enhanced US/PA/MR signal, well indicating the remarkable feasibility of nanoprobe to distinguish the ischemic myocardium.

CONCLUSIONS

IMTP-Fe3O4-PFH NPs may be a promising nanoplatform for early detection of ischemic myocardium and targeted treatment under visualization for the future.

Schizophrenia Treatment with Second-Generation Antipsychotics: A Multi-Country Comparison of the Costs of Cardiovascular and Metabolic Adverse Events and Weight Gain

PURPOSE

Cardiovascular and metabolic adverse events are costly to treat, and their incidence is increased amongst people with schizophrenia, with different rates observed for second-generation antipsychotics. To inform treatment choice, this study sought to estimate the lifetime costs associated with antipsychotic choice, and how these costs varied across European countries.

METHODS

Systematic searches were conducted to identify evidence on effectiveness and costs. A Markov model was developed to assess the costs of ten antipsychotics: aripiprazole, brexpiprazole, cariprazine, lumateperone, lurasidone, olanzapine, paliperidone, quetiapine, risperidone and ziprasidone. Costs were obtained for seven countries: Italy, Hungary, France, Slovenia, Spain, Sweden and the UK. The costs considered were adverse events (including diabetes, myocardial infarction, stroke and weight gain), drug costs, relapse, treatment discontinuation and schizophrenia management. Two adult populations were modelled; initiating either acute or maintenance treatment, with a lifetime horizon for both.

RESULTS

Lurasidone was associated with the lowest lifetime costs amongst patients initiating acute treatment compared to all other atypical antipsychotics considered. The second lowest costs were for ziprasidone. These results were observed for all seven countries. The main drivers of cost differences were rates of diabetes and cardiovascular diseases, which were lowest for lurasidone, followed by ziprasidone then lumateperone. Costs for managing weight gain were lowest for lurasidone and ziprasidone. Similar results were observed for patients initiating maintenance treatment.

CONCLUSION

Diabetes and cardiovascular events are large drivers of lifetime costs for people with schizophrenia. Lurasidone is predicted to have the lowest rates of these adverse events, and so the lowest costs amongst patients initiating acute treatment in seven European countries compared to nine other antipsychotics. Future research should investigate the individual costs of relapse management, including differences in the costs and proportions of hospitalizations.

Major bleed costs of atrial fibrillation patients treated with factor Xa inhibitor anticoagulants

OBJECTIVE

To examine the healthcare economic burden of atrial fibrillation (AF) patients treated with factor Xa inhibitor (FXaI) anticoagulants who were hospitalized in the US with a major bleed (MB).

METHODS

Adult AF patients treated with FXaIs and hospitalized with an MB were selected from MarketScan databases (1 January 2015-30 April 2018). Patients were grouped into cohorts based on type of MB: intracranial hemorrhage (ICH), gastrointestinal (GI), other types of MB. Healthcare costs in 2019 USD were evaluated for index hospitalizations and during a variable follow-up period in unadjusted and adjusted analyses.

RESULTS

Of the overall AF patient population treated with FXaIs and hospitalized with an MB (n = 7,577), 9.9% had ICH (mean age: 77.9 years; 58% male), 55.9% had GI (mean age: 76.8 years; 52% male), and 34.2% had other types of MB (mean age: 74.4 years; 61% male). Mean index hospitalization costs for ICH, GI, and other type of MB were $54,163, $26,901, and $36,645, respectively; from adjusted analyses, patients with ICH vs. GI spent 1.6 more days in the hospital; mean cost was $15,630 higher. Patients with other types of MB vs. GI spent 0.6 more days in the hospital; mean cost was $5,859 higher. Index hospitalization cost in addition to total all-cause healthcare costs incurred in the follow-up period were $34,522 higher per ICH patient and $11,584 higher per other type of MB patient vs. a GI MB patient.

LIMITATIONS

Since this study was a retrospective observational study using a claims database analysis, a causal relationship between treatment with FXaIs and MB events cannot be established.

CONCLUSIONS

Although all of the evaluated MB types were associated with high hospitalization costs, ICH was associated with the most substantial short- and long-term healthcare economic burden.

Percussion assisted radiation therapy in Hodgkin lymphoma allows a marked reduction in heart dose

BACKGROUND AND PURPOSE

Early-stage Hodgkin lymphoma (HL) is a highly curable disease but the treatment can induce late complications many years later. Irradiation of the healthy heart is inevitable during radiation treatment of mediastinal sites. We developed a novel method to induce a prolonged apnea-like state that can help decrease the dose to organs at risk during radiation therapy. We present the results of the first 8 HL patients treated routinely with percussion assisted radiation therapy (PART) in our clinic.

MATERIAL AND METHODS

We used a newly developed high-frequency non-invasive ventilation system to suppress respiratory motion for prolonged periods and push the heart away from the treated volume.

RESULTS

All 8 patients were able to rapidly learn the technique and had an advantage to be treated by PART. We lowered the mean heart dose by an average of 3 Gy with similar target coverage compared to a classical free breathing treatment plan. They were all treated for 15 radiotherapy sessions by PART without any notable side effects.

CONCLUSIONS

Percussion assisted radiation therapy can be used routinely to reduce the dose to the heart in Hodgkin lymphoma.

Recommendations to improve lipid control. Consensus document of the Spanish Society of Cardiology

T***he current control of low-density lipoprotein cholesterol among patients with atherosclerotic cardiovascular disease is very low and this is associated with an increase of cardiovascular outcomes. In addition, the latter this happens, the risk will be greater. This is mainly due to an insufficient use of the lipid-lowering therapy currently available. In fact, with current treatments (statins, ezetimibe and PCSK9 inhibitors), the majority of patients in secondary prevention should achieve low-density lipoprotein cholesterol goals. For these reasons, in this manuscript promoted by the Spanish Society of Cardiology we propose three simple and feasible decision-making algorithms that include the majority of clinical scenarios among patients with ischemic heart disease, with the double aim of attaining therapeutic goals in the majority of patients as soon as possible; in secondary prevention the magnitude of the benefit is risk- and time-dependent.