Influence of age on revascularization related costs of hospitalization among patients of stable coronary artery disease

Airway Remodeling in Asthma

Asthma is an inflammatory disease of the airways that may result from exposure to allergens or other environmental irritants, resulting in bronchoconstriction, wheezing, and shortness of breath. The structural changes of the airways associated with asthma, broadly referred to as airway remodeling, is a pathological feature of chronic asthma that contributes to the clinical manifestations of the disease. Airway remodeling in asthma constitutes cellular and extracellular matrix changes in the large and small airways, epithelial cell apoptosis, airway smooth muscle cell proliferation, and fibroblast activation. These pathological changes in the airway are orchestrated by crosstalk of different cell types within the airway wall and submucosa. Environmental exposures to dust, chemicals, and cigarette smoke can initiate the cascade of pro-inflammatory responses that trigger airway remodeling through paracrine signaling and mechanostimulatory cues that drive airway remodeling. In this review, we explore three integrated and dynamic processes in airway remodeling: (1) initiation by epithelial cells; (2) amplification by immune cells; and (3) mesenchymal effector functions. Furthermore, we explore the role of inflammaging in the dysregulated and persistent inflammatory response that perpetuates airway remodeling in elderly asthmatics.

Aging and Outcome in Patients With Peripheral Artery Disease and Critical Limb Ischemia

BACKGROUND, OBJECTIVES, DESIGN

Aging of the population is one of the major challenges facing public health systems. The impact of aging on acute and long-term outcome of patients with peripheral artery disease (PAD) and critical limb ischemia (CLI) is currently not sufficiently clarified. This analysis consists of comprehensive, anonymized data obtained from the largest public health insurance in Germany.

RESULTS

A total of 41,740 PAD patients with an index hospitalization between January 1, 2009, and December 31, 2011, and a follow-up time up to 4 years were included (40-49 years: n = 1179; 50-59 years: n = 5415; 60-69 years: n = 10,565; 70-79 years: n = 13,313; 80-89 years: n = 9714; and 90-100 years: n = 1554). Advanced age was associated with female gender (men-women ratio up to 1:3.3), less smoking, less frequent obesity, more often chronic heart failure (up to 9-fold), chronic kidney disease (up to 4-fold), fewer angiographies (up to 0.8-fold), fewer endovascular (up to 0.5-fold) and surgical revascularizations (up to 0.9-fold), higher rates of amputation (up to 2.5-fold), acute renal failure (up to 3.7-fold), in-hospital mortality (up to 12-fold), myocardial infarction (up to 2.8-fold), ischemic stroke (up to 1.5-fold), infection (up to 1.4-fold), and sepsis (up to 1.8-fold) (each P < .001). During follow-up, advanced age was a highly significant independent predictor of long-term mortality, myocardial infarction, and stroke (each P < .001). Lengths of hospital stay (up to 1.3-fold longer) and reimbursement costs (up to 1.1-fold higher) were clearly associated with advanced age (each P < .001).

CONCLUSIONS

This study demonstrates the impact of aging on morbidity, in-hospital treatment, complications, and acute and long-term outcome of PAD patients.

Cost-utility analysis of genotype-guided antiplatelet therapy in patients with moderate-to-high risk acute coronary syndrome and planned percutaneous coronary intervention

BACKGROUND

Prasugrel is recommended over clopidogrel in poor/intermediate CYP2C19 metabolizers with acute coronary syndrome (ACS) and planned percutaneous coronary intervention (PCI), reducing the risk of ischemic events. CYP2C19 genetic testing can guide antiplatelet therapy in ACS patients.

OBJECTIVE

The purpose of this study was to evaluate the cost-utility of genotype-guided treatment, compared with prasugrel or generic clopidogrel treatment without genotyping, from the US healthcare provider's perspective.

METHODS

A decision model was developed to project lifetime economic and humanistic burden associated with clinical outcomes (myocardial infarction [MI], stroke and major bleeding) for the three strategies in patients with ACS. Probabilities, costs and age-adjusted quality of life were identified through systematic literature review. Incremental cost-utility ratios (ICURs) were calculated for the treatment strategies, with quality-adjusted life years (QALYs) as the primary effectiveness outcome. Relative risk of developing myocardial infarction and stroke between patients with and without variant CYP2C19 when receiving clopidogrel were estimated to be 1.34 and 3.66, respectively. One-way and probabilistic sensitivity analyses were performed.

RESULTS

Clopidogrel cost USD19,147 and provided 10.03 QALYs versus prasugrel (USD21,425, 10.04 QALYs) and genotype-guided therapy (USD19,231, 10.05 QALYs). The ICUR of genotype-guided therapy compared with clopidogrel was USD4,200. Genotype-guided therapy provided more QALYs at lower costs compared with prasugrel. Results were sensitive to the cost of clopidogrel and relative risk of myocardial infarction and stroke between CYP2C19 variant vs. non-variant. Net monetary benefit curves showed that genotype-guided therapy had at least 70% likelihood of being the most cost-effective alternative at a willingness-to-pay of USD100,000/QALY. In comparison with clopidogrel, prasugrel therapy was more cost-effective with <21% certainty at willingness-to-pay of >USD170,000/QALY.

CONCLUSIONS

Our modeling analyses suggest that genotype-guided therapy is a cost-effective strategy in patients with acute coronary syndrome undergoing planned percutaneous coronary intervention.

Predictive value of exercise myocardial perfusion imaging in the Medicare population: the impact of the ability to exercise

BACKGROUND

Although the prognostic value of quantitative single photon emission computed tomography myocardial perfusion imaging (MPI) with exercise and pharmacologic stress is well established, the prognostic and management value in the Medicare age population is less clear.

METHODS

The prospectively populated Cleveland Clinic nuclear cardiology database was used to identify 5,994 consecutive pateints, age >65 years [1,664 (28%) exercise MPI, mean age 72.4±5.1, 74% male], who underwent MPI between January 2004 and January 2008. Clinical baseline variables, post test 90 days revascularization and MPI variables were analyzed. Overall and stratified nonparametric survival estimates were obtained by Kaplan-Meier method. Median follow-up time was 2.4 years. Parametric hazard modeling with bootstrap bagging methods was used to determine prognostic variables predicting mortality.

RESULTS

There was no difference in mortality in patients with an abnormal MPI vs. those with normal MPI. Amongst the patients who underwent exercise MPI, there were 103 (6%) deaths and 121 (8.2%) revascularizations. Only lower exercise capacity (<7 METs) and higher end systolic volume (ESV) predicted mortality. Although a larger amount of ischemia influenced down stream revascularization ischemia, revascularization of patients with an abnormal exercise MPI did not offer a survival benefit (log rank P value=0.01).

CONCLUSIONS

In the a Medicare age population, exercise MPI perfusion variables influenced rates of revascularization but failed to provide incremental significant risk-stratification beyond exercise capacity. Maximum METs achieved appears to be a better predictor of survival.

Outcomes and cost of cardiac surgery in octogenarians is related to type of operation: a multiinstitutional analysis

BACKGROUND

Given recent economic implications in caring for an aging population, we sought to determine if postoperative complications and costs for octogenarians differed based on the type of cardiac operation.

METHODS

From 2003 to 2008, patients who underwent cardiac operations at 16 different centers were identified from the Virginia Cardiac Surgery Quality Initiative and selected into two cohorts (<80 years and ≥80 years). Octogenarians (≥80 years) were stratified into isolated primary coronary bypass graft, aortic valve, mitral valve, or combined operation. Preoperative risks, outcomes, and costs were analyzed. Case-mix adjusted models for mortality and major complication rate were developed.

RESULTS

We examined 45,731 patients, of which 3,079 were octogenarians (82.7 ± 2.5 years). Compared with younger patients, octogenarians incurred higher mortality (6.5% vs 3.1%, p < 0.001) and major complication rates (13.2% vs 8.4%, p < 0.001) with only incrementally higher total costs (p < 0.001). Among octogenarians mortality was similar despite the operation. Cross-clamp and cardiopulmonary bypass time (p < 0.001), hospital length of stay (p = 0.001), and major complication rate (p = 0.002) were highest for combined operation. Despite the fewest complications, mitral valve operation had the highest total costs (p < 0.001). Type of operation was not predictive of mortality or major complication rate. However, age, female gender, emergent status, and prolonged cardiopulmonary bypass time were independently associated with death despite risk-adjustment.

CONCLUSIONS

Advanced age confers increased risks and incrementally higher costs in patients undergoing cardiac operations. Isolated mitral and combined procedures have the highest complications and costs. Any proposed cardiac operation in octogenarians mandates careful consideration of resource utilization.