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Cruickshank M, Hudson J, Hernández R, Aceves-Martins M, Quinton R, Gillies K, Aucott LS, Kennedy C, Manson P, Oliver N, Wu F, Bhattacharya S, Dhillo WS, Jayasena CN, Brazzelli M. The effects and safety of testosterone replacement therapy for men with hypogonadism: the TestES evidence synthesis and economic evaluation. Health Technol Assess 2024; 28:1-210. [PMID: 39248210 PMCID: PMC11404359 DOI: 10.3310/jryt3981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2024] Open
Abstract
Background Low levels of testosterone cause male hypogonadism, which is associated with sexual dysfunction, tiredness and reduced muscle strength and quality of life. Testosterone replacement therapy is commonly used for ameliorating symptoms of male hypogonadism, but there is uncertainty about the magnitude of its effects and its cardiovascular and cerebrovascular safety. Aims of the research The primary aim was to evaluate the safety of testosterone replacement therapy. We also assessed the clinical and cost-effectiveness of testosterone replacement therapy for men with male hypogonadism, and the existing qualitative evidence on men's experience and acceptability of testosterone replacement therapy. Design Evidence synthesis and individual participant data meta-analysis of effectiveness and safety, qualitative evidence synthesis and model-based cost-utility analysis. Data sources Major electronic databases were searched from 1992 to February 2021 and were restricted to English-language publications. Methods We conducted a systematic review with meta-analysis of individual participant data according to current methodological standards. Evidence was considered from placebo-controlled randomised controlled trials assessing the effects of any formulation of testosterone replacement therapy in men with male hypogonadism. Primary outcomes were mortality and cardiovascular and cerebrovascular events. Data were extracted by one reviewer and cross-checked by a second reviewer. The risk of bias was assessed using the Cochrane Risk of Bias tool. We performed one-stage meta-analyses using the acquired individual participant data and two-stage meta-analyses to integrate the individual participant data with data extracted from eligible studies that did not provide individual participant data. A decision-analytic Markov model was developed to evaluate the cost per quality-adjusted life-years of the use of testosterone replacement therapy in cohorts of patients of different starting ages. Results We identified 35 trials (5601 randomised participants). Of these, 17 trials (3431 participants) provided individual participant data. There were too few deaths to assess mortality. There was no difference between the testosterone replacement therapy group (120/1601, 7.5%) and placebo group (110/1519, 7.2%) in the incidence of cardiovascular and/or cerebrovascular events (13 studies, odds ratio 1.07, 95% confidence interval 0.81 to 1.42; p = 0.62). Testosterone replacement therapy improved quality of life and sexual function in almost all patient subgroups. In the testosterone replacement therapy group, serum testosterone was higher while serum cholesterol, triglycerides, haemoglobin and haematocrit were all lower. We identified several themes from five qualitative studies showing how symptoms of low testosterone affect men's lives and their experience of treatment. The cost-effectiveness of testosterone replacement therapy was dependent on whether uncertain effects on all-cause mortality were included in the model, and on the approach used to estimate the health state utility increment associated with testosterone replacement therapy, which might have been driven by improvements in symptoms such as sexual dysfunction and low mood. Limitations A meaningful evaluation of mortality was hampered by the limited number of defined events. Definition and reporting of cardiovascular and cerebrovascular events and methods for testosterone measurement varied across trials. Conclusions Our findings do not support a relationship between testosterone replacement therapy and cardiovascular/cerebrovascular events in the short-to-medium term. Testosterone replacement therapy improves sexual function and quality of life without adverse effects on blood pressure, serum lipids or glycaemic markers. Future work Rigorous long-term evidence assessing the safety of testosterone replacement therapy and subgroups most benefiting from treatment is needed. Study registration The study is registered as PROSPERO CRD42018111005. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 17/68/01) and is published in full in Health Technology Assessment; Vol. 28, No. 43. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
| | - Jemma Hudson
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Rodolfo Hernández
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Richard Quinton
- Department of Endocrinology, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Katie Gillies
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Lorna S Aucott
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Charlotte Kennedy
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Paul Manson
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Frederick Wu
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK
| | - Siladitya Bhattacharya
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | | | | | - Miriam Brazzelli
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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Xu C, Liu R, Wang J, Nicholas S. Hospitalization expenses of coronary heart disease inpatients in China: evidence from two hospitals in Ningxia Hui autonomous region. Front Public Health 2024; 12:1266456. [PMID: 38756881 PMCID: PMC11096531 DOI: 10.3389/fpubh.2024.1266456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 04/16/2024] [Indexed: 05/18/2024] Open
Abstract
Aim The increasing morbidity from coronary health disease (CHD) has imposed a significant social and economic burden in China. We analyzed the factors affecting hospitalization expenses of CHD patients. Design From 2012 to 2018, data on 16,726 CHD patients were collected from the hospital information system in Ningxia Hui Autonomous Region. Methods A multiple ordered logistic regression model was used to analyze the factors affecting hospitalization expenses. Results The average hospitalization expense was RMB30998.26 ± 29890.03. Hospital materials expenses accounted for roughly 60% of total hospitalization costs. The older adult, patients who were male, in critical health status, with longer hospital stays, unemployed, using antibiotics and undergoing an operation without incision had significantly raised hospital expenses, while those with fewer complications, no operations and self-paying for health care had reduced hospitalization costs (p < 0.05). The length of hospital stay played a partial mediator role (p < 0.05). Public contribution Controlling the increase of medical materials costs and preventing over-consumption of hospital services by insured patients are recommended.
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Affiliation(s)
- Chuanchuan Xu
- School of Humanities and Management, Ningxia Medical University, Yinchuan, China
| | - Rugang Liu
- School of Health Policy and Management, Nanjing Medical University, Nanjing, China
- Center for Global Health, Nanjing Medical University, Nanjing, China
- Jiangsu Provincial Institute of Health, Nanjing Medical University, Nanjing, China
- School of Public Health, Nanjing Medical University, Nanjing, China
| | - Jian Wang
- Dong Fureng Economic and Social Development School, Wuhan University, Beijing, China
- Center for Health Economics and Management at School of Economics and Management, Wuhan University, Wuhan, China
| | - Stephen Nicholas
- Health Services Research and Workforce Innovation Centre, Newcastle Business School, University of Newcastle, Newcastle, NSW, Australia
- Australian National Institute of Management and Commerce, Sydney, NSW, Australia
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Ansaripour A, Moloney E, Branagan-Harris M, Patrone L, Javanbakht M. Digital variance angiography in patients undergoing lower limb arterial recanalization: cost-effectiveness analysis within the English healthcare setting. J Comp Eff Res 2024; 13:e230068. [PMID: 38517149 PMCID: PMC11044957 DOI: 10.57264/cer-2023-0068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 02/14/2024] [Indexed: 03/23/2024] Open
Abstract
Aim: Digital variance angiography (DVA) is a recently developed image processing method capable of improving image quality compared with the traditionally used digital subtraction angiography (DSA), among patients undergoing lower limb x-ray angiography. This study aims to explore the potential cost-effectiveness of DVA from an English National Health Service perspective. Materials & methods: A two-part economic model, consisting of a decision tree and a Markov model, was developed to consider the costs and health outcomes associated with the use of DVA as part of current practice imaging, compared with x-ray angiography using standard DSA. The model explored the impact of DVA on the development of acute kidney injury (AKI), chronic kidney disease and radiation-induced cancer over a lifetime horizon. Both deterministic and probabilistic analyses were performed to assess the cost per quality-adjusted life-year (QALY). Results: Base-case results indicate that DVA results in cost savings of £309 per patient, with QALYs also improving (+0.025) over a lifetime. As shown in sensitivity analysis, a key driver of model results is the relative risk (RR) reduction of contrast-associated acute kidney injury associated with use of DVA. The intervention also decreases the risk of carcinoma over a lifetime. Scenario analyses show that cost savings range from £310 to £553, with QALY gains ranging from 0.048 to 0.109 per patient. Conclusion: The use of DVA could result in a decrease in costs and an increase in QALYs over a lifetime, compared with existing imaging practice. The potential for this technology to offer an economically viable alternative to existing image processing methods, through a reduction in contrast media volume and radiation exposure, has been demonstrated.
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Affiliation(s)
- Amir Ansaripour
- Optimax Access Ltd, Hofplein, Rotterdam, 3032AC, The Netherlands
| | - Eoin Moloney
- Optimax Access Ltd, Kenneth Dibben House, Enterprise Rd, Chilworth, Southampton Science Park, Southampton, SO16 7NS, UK
| | - Michael Branagan-Harris
- Device Access Ltd, Market Access Consultancy, University of Southampton Science Park, Southampton, SO16 7NS, UK
| | - Lorenzo Patrone
- West London Vascular & Interventional Centre, London North West University Healthcare NHS Trust, Harrow, HA1 3UJ, UK
| | - Mehdi Javanbakht
- Optimax Access Ltd, Kenneth Dibben House, Enterprise Rd, Chilworth, Southampton Science Park, Southampton, SO16 7NS, UK
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Hernández R, de Silva NL, Hudson J, Cruickshank M, Quinton R, Manson P, Dhillo WS, Bhattacharya S, Brazzelli M, Jayasena CN. Cost-effectiveness of testosterone treatment utilising individual patient data from randomised controlled trials in men with low testosterone levels. Andrology 2024; 12:477-486. [PMID: 38233215 DOI: 10.1111/andr.13597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 12/05/2023] [Accepted: 12/28/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND Testosterone is safe and highly effective in men with organic hypogonadism, but worldwide testosterone prescribing has recently shifted towards middle-aged and older men, mostly with low testosterone related to age, diabetes and obesity, for whom there is less established evidence of clinical safety and benefit. The value of testosterone treatment in middle-aged and older men with low testosterone is yet to be determined. We therefore evaluated the cost-effectiveness of testosterone treatment in such men with low testosterone compared with no treatment. METHODS A cost-utility analysis comparing testosterone with no treatment was conducted following best practices in decision modelling. A cohort Markov model incorporating relevant care pathways for individuals with hypogonadism was developed for a 10-year-time horizon. Clinical outcomes were obtained from an individual patient meta-analysis of placebo-controlled, double-blind randomised studies. Three starting age categories were defined: 40, 60 and 75 years. Cost utility (quality-adjusted life years) accrued and costs of testosterone treatment, monitoring and cardiovascular complications were compared to estimate incremental cost-effectiveness ratios and cost-effectiveness acceptability curves for selected scenarios. RESULTS Ten-year excess treatment costs for testosterone compared with non-treatment ranged between £2306 and £3269 per patient. Quality-adjusted life years results depended on the instruments used to measure health utilities. Using Beck depression index-derived quality-adjusted life years data, testosterone was cost-effective (incremental cost-effectiveness ratio <£20,000) for men aged <75 years, regardless of morbidity and mortality sensitivity analyses. Testosterone was not cost-effective in men aged >75 years in models assuming increased morbidity and/or mortality. CONCLUSIONS AND FUTURE RESEARCH Our data suggest that testosterone is cost-effective in men <75 years when Beck depression index-derived quality-adjusted life years data are considered; cost-effectiveness in men >75 years is dependent on cardiovascular safety. However, more robust and longer-term cost-utility data are needed to verify our conclusion.
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Affiliation(s)
- Rodolfo Hernández
- Health Economics Research Unit, University of Aberdeen, Foresterhill, Aberdeen, UK
| | - Nipun Lakshitha de Silva
- Faculty of Medicine, General Sir John Kotelawala Defence University, Colombo, Sri Lanka
- Department of Metabolism, Digestion and Reproduction, Imperial College, London, UK
| | - Jemma Hudson
- Health Service Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Richard Quinton
- Department of Metabolism, Digestion and Reproduction, Imperial College, London, UK
- Translational & Clinical Research Institute, University of Newcastle upon Tyne, Newcastle Upon Tyne, UK
- Department of Endocrinology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Paul Manson
- Health Service Research Unit, University of Aberdeen, Aberdeen, UK
| | - Waljit S Dhillo
- Department of Metabolism, Digestion and Reproduction, Imperial College, London, UK
| | - Siladitya Bhattacharya
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Foresterhill, Aberdeen, UK
| | - Miriam Brazzelli
- Health Service Research Unit, University of Aberdeen, Aberdeen, UK
| | - Channa N Jayasena
- Department of Metabolism, Digestion and Reproduction, Imperial College, London, UK
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Guthrie B, Rogers G, Livingstone S, Morales DR, Donnan P, Davis S, Youn JH, Hainsworth R, Thompson A, Payne K. The implications of competing risks and direct treatment disutility in cardiovascular disease and osteoporotic fracture: risk prediction and cost effectiveness analysis. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2024; 12:1-275. [PMID: 38420962 DOI: 10.3310/kltr7714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
Background Clinical guidelines commonly recommend preventative treatments for people above a risk threshold. Therefore, decision-makers must have faith in risk prediction tools and model-based cost-effectiveness analyses for people at different levels of risk. Two problems that arise are inadequate handling of competing risks of death and failing to account for direct treatment disutility (i.e. the hassle of taking treatments). We explored these issues using two case studies: primary prevention of cardiovascular disease using statins and osteoporotic fracture using bisphosphonates. Objectives Externally validate three risk prediction tools [QRISK®3, QRISK®-Lifetime, QFracture-2012 (ClinRisk Ltd, Leeds, UK)]; derive and internally validate new risk prediction tools for cardiovascular disease [competing mortality risk model with Charlson Comorbidity Index (CRISK-CCI)] and fracture (CFracture), accounting for competing-cause death; quantify direct treatment disutility for statins and bisphosphonates; and examine the effect of competing risks and direct treatment disutility on the cost-effectiveness of preventative treatments. Design, participants, main outcome measures, data sources Discrimination and calibration of risk prediction models (Clinical Practice Research Datalink participants: aged 25-84 years for cardiovascular disease and aged 30-99 years for fractures); direct treatment disutility was elicited in online stated-preference surveys (people with/people without experience of statins/bisphosphonates); costs and quality-adjusted life-years were determined from decision-analytic modelling (updated models used in National Institute for Health and Care Excellence decision-making). Results CRISK-CCI has excellent discrimination, similar to that of QRISK3 (Harrell's c = 0.864 vs. 0.865, respectively, for women; and 0.819 vs. 0.834, respectively, for men). CRISK-CCI has systematically better calibration, although both models overpredict in high-risk subgroups. People recommended for treatment (10-year risk of ≥ 10%) are younger when using QRISK-Lifetime than when using QRISK3, and have fewer observed events in a 10-year follow-up (4.0% vs. 11.9%, respectively, for women; and 4.3% vs. 10.8%, respectively, for men). QFracture-2012 underpredicts fractures, owing to under-ascertainment of events in its derivation. However, there is major overprediction among people aged 85-99 years and/or with multiple long-term conditions. CFracture is better calibrated, although it also overpredicts among older people. In a time trade-off exercise (n = 879), statins exhibited direct treatment disutility of 0.034; for bisphosphonates, it was greater, at 0.067. Inconvenience also influenced preferences in best-worst scaling (n = 631). Updated cost-effectiveness analysis generates more quality-adjusted life-years among people with below-average cardiovascular risk and fewer among people with above-average risk. If people experience disutility when taking statins, the cardiovascular risk threshold at which benefits outweigh harms rises with age (≥ 8% 10-year risk at 40 years of age; ≥ 38% 10-year risk at 80 years of age). Assuming that everyone experiences population-average direct treatment disutility with oral bisphosphonates, treatment is net harmful at all levels of risk. Limitations Treating data as missing at random is a strong assumption in risk prediction model derivation. Disentangling the effect of statins from secular trends in cardiovascular disease in the previous two decades is challenging. Validating lifetime risk prediction is impossible without using very historical data. Respondents to our stated-preference survey may not be representative of the population. There is no consensus on which direct treatment disutilities should be used for cost-effectiveness analyses. Not all the inputs to the cost-effectiveness models could be updated. Conclusions Ignoring competing mortality in risk prediction overestimates the risk of cardiovascular events and fracture, especially among older people and those with multimorbidity. Adjustment for competing risk does not meaningfully alter cost-effectiveness of these preventative interventions, but direct treatment disutility is measurable and has the potential to alter the balance of benefits and harms. We argue that this is best addressed in individual-level shared decision-making. Study registration This study is registered as PROSPERO CRD42021249959. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 15/12/22) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 4. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Bruce Guthrie
- Advanced Care Research Centre, Centre for Population Health Sciences, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Gabriel Rogers
- Manchester Centre for Health Economics, The University of Manchester, Manchester, UK
| | - Shona Livingstone
- Population Health and Genomics Division, University of Dundee, Dundee, UK
| | - Daniel R Morales
- Population Health and Genomics Division, University of Dundee, Dundee, UK
| | - Peter Donnan
- Population Health and Genomics Division, University of Dundee, Dundee, UK
| | - Sarah Davis
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | | | - Rob Hainsworth
- Manchester Centre for Health Economics, The University of Manchester, Manchester, UK
| | - Alexander Thompson
- Manchester Centre for Health Economics, The University of Manchester, Manchester, UK
| | - Katherine Payne
- Manchester Centre for Health Economics, The University of Manchester, Manchester, UK
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6
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Ferko N, Priest S, Almuallem L, Walczyk Mooradally A, Wang D, Oliva Ramirez A, Szabo E, Cabra A. Economic and healthcare resource utilization assessments of PET imaging in Coronary Artery Disease diagnosis: a systematic review and discussion of opportunities for future economic evaluations. J Med Econ 2024; 27:715-729. [PMID: 38650543 DOI: 10.1080/13696998.2024.2345507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 04/17/2024] [Indexed: 04/25/2024]
Abstract
AIMS This systematic literature review (SLR) consolidated economic and healthcare resource utilization (HCRU) evidence for positron emission tomography (PET) and single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) to inform future economic evaluations. MATERIALS AND METHODS An electronic search was conducted in MEDLINE, Embase, and Cochrane databases from 2012-2022. Economic and HCRU studies in adults who underwent PET- or SPECT-MPI for coronary artery disease (CAD) diagnosis were eligible. A qualitative methodological assessment of existing economic evaluations, HCRU, and downstream cardiac outcomes was completed. Exploratory meta-analyses of clinical outcomes were performed. RESULTS The search yielded 13,439 results, with 71 records included. Economic evaluations and comparative clinical trials were limited in number and outcome types (HCRU, downstream cardiac outcomes, and diagnostic performance) assessed. No studies included all outcome types and only one economic evaluation linked diagnostic performance to HCRU. The meta-analyses of comparative studies demonstrated significantly higher rates of early- and late-invasive coronary angiography and revascularization for PET- compared to SPECT-MPI; however, the rate of repeat testing was lower with PET-MPI. The rate of acute myocardial infarction was lower, albeit non-significant with PET- vs. SPECT-MPI. LIMITATIONS AND CONCLUSIONS This SLR identified economic and HCRU evaluations following PET- and SPECT-MPI for CAD diagnosis and determined that existing studies do not capture all pertinent outcome parameters or link diagnostic performance to downstream HCRU and cardiac outcomes, thus, resulting in simplified assessments of CAD burden. A limitation of this work relates to heterogeneity in study designs, patient populations, and follow-up times of existing studies. Resultingly, it was challenging to pool data in meta-analyses. Overall, this work provides a foundation for the development of comprehensive economic models for PET- and SPECT-MPI in CAD diagnosis, which should link diagnostic outcomes to HCRU and downstream cardiac events to capture the full CAD scope.
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Affiliation(s)
| | | | | | | | - Di Wang
- EVERSANA, Burlington, Canada
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Hayajneh AA, Alhusban IM, Rababa M, Al-sabbah S, Bani-Hamad D, Al-Mugheed K, Al-Nusour EA, Alsatari ES. The association of traditional obesity parameters with the length of stay among patients with coronary artery disease: A cross-sectional study. Medicine (Baltimore) 2023; 102:e36731. [PMID: 38134084 PMCID: PMC10735059 DOI: 10.1097/md.0000000000036731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 11/29/2023] [Indexed: 12/24/2023] Open
Abstract
There is a strong association between obesity and coronary artery disease (CAD). Obesity is measured using traditional obesity parameters, such as body mass index, body adiposity index, waist circumference (WC), and hip circumference. The aim of this study is to explore the association between traditional obesity parameters and the length of stay (LOS) among hospitalized CAD patients. An original correlative descriptive study was carried out using secondary data analysis, in which 220 hospitalized Jordanian CAD patients were recruited from Jordan northern and middle regions. Age, WC, triglycerides, and high- sensitivity C-reactive protein were all positive predictors of the total hospital LOS among hospitalized patients with CAD. The WC, age, triglycerides, and high-sensitivity C-reactive protein levels were significantly positively associated with total LOS. Healthcare providers, including nurses, should take into account these significant positive predictors of LOS to achieve better health outcomes and improve patient satisfaction.
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Affiliation(s)
- Audai A. Hayajneh
- Adult Health-Nursing Department, Faculty of Nursing, Jordan University of Science and Technology, Irbid, Jordan
| | - Islam M. Alhusban
- Adult Health-Nursing Department, Faculty of Nursing, Jordan University of Science and Technology, Irbid, Jordan
| | - Mohammad Rababa
- Adult Health-Nursing Department, Faculty of Nursing, Jordan University of Science and Technology, Irbid, Jordan
| | - Shatha Al-sabbah
- Faculty of Nursing, Jordan University of Science and Technology, Irbid, Jordan
| | - Dania Bani-Hamad
- Faculty of Nursing, Jordan University of Science and Technology, Irbid, Jordan
| | - Khalid Al-Mugheed
- Adult Health Nursing Department, College of Nursing, Riyadh Elm University, Riyadh, Saudi Arabia
| | - Esraa A. Al-Nusour
- Prince Al Hussein Bin Abdullah II Academy for Civil Protection, AlBalqa Applied University, King Saud University Medical City, Amman, Jordan
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8
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Won MH, Shim J. Combined effect of left ventricular ejection fraction and obesity on sedentary behavior in patients with coronary artery disease. Medicine (Baltimore) 2023; 102:e35839. [PMID: 37960741 PMCID: PMC10637509 DOI: 10.1097/md.0000000000035839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 10/06/2023] [Indexed: 11/15/2023] Open
Abstract
Sedentary behavior has been associated with poor adherence to treatment in patients with coronary artery disease. Low left ventricular ejection fraction and obesity have been separately linked to increased sedentary behavior in patients with coronary artery disease. However, the combined effect of low left ventricular ejection fraction and obesity on sedentary behavior in patients with coronary artery disease has not been thoroughly investigated. Therefore, this study aimed to examine the combined influence of left ventricular ejection fraction and obesity on sedentary behavior in patients with coronary artery disease. This descriptive cross-sectional study enrolled 200 inpatients aged ≥ 20 years who were diagnosed with coronary artery disease at a tertiary hospital in Korea between March and August 2022. Data were collected using structured questionnaires, and multivariate logistic regression analysis was performed to determine the combined effect of left ventricular ejection fraction and obesity on sedentary behavior in patients with coronary artery disease. Among the 111 patients with sedentary behavior, 38 (34.2%) had both low left ventricular ejection fraction and obesity, whereas only 11 (12.4%) of the 89 patients without sedentary behavior had both low left ventricular ejection fraction and obesity. In multivariate logistic regression analysis, patients with coronary artery disease who had both low left ventricular ejection fraction and obesity had the highest risk of sedentary behavior compared to those without either low left ventricular ejection fraction or obesity (odds ratio = 13.98, 95% confidence interval = 5.19-37.69, P < .001). The co-existence of low left ventricular ejection fraction and obesity in patients with coronary artery disease may be associated with sedentary behavior. Therefore, evaluating both left ventricular ejection fraction and obesity when assessing sedentary behavior in patients with coronary artery disease may be valuable in implementing patient-centered approaches for the secondary prevention and management of sedentary behavior in patients with coronary artery disease. However, further prospective cohort studies with larger sample sizes are required to establish causal relationships and explore interventions to mitigate sedentary behavior in this population.
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Affiliation(s)
- Mi Hwa Won
- Department of Nursing, Wonkwang University, Iksan, South Korea
| | - JaeLan Shim
- College of Nursing, Dongguk University, Gyeongju, South Korea
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Qureshi N, Woods B, Neves de Faria R, Saramago Goncalves P, Cox E, Leonardi Bee J, Condon L, Weng S, Akyea RK, Iyen B, Roderick P, Humphries SE, Rowlands W, Watson M, Haralambos K, Kenny R, Datta D, Miedzybrodzka Z, Byrne C, Kai J. Alternative cascade-testing protocols for identifying and managing patients with familial hypercholesterolaemia: systematic reviews, qualitative study and cost-effectiveness analysis. Health Technol Assess 2023; 27:1-140. [PMID: 37924278 PMCID: PMC10658348 DOI: 10.3310/ctmd0148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2023] Open
Abstract
Background Cascade testing the relatives of people with familial hypercholesterolaemia is an efficient approach to identifying familial hypercholesterolaemia. The cascade-testing protocol starts with identifying an index patient with familial hypercholesterolaemia, followed by one of three approaches to contact other relatives: indirect approach, whereby index patients contact their relatives; direct approach, whereby the specialist contacts the relatives; or a combination of both direct and indirect approaches. However, it is unclear which protocol may be most effective. Objectives The objectives were to determine the yield of cases from different cascade-testing protocols, treatment patterns, and short- and long-term outcomes for people with familial hypercholesterolaemia; to evaluate the cost-effectiveness of alternative protocols for familial hypercholesterolaemia cascade testing; and to qualitatively assess the acceptability of different cascade-testing protocols to individuals and families with familial hypercholesterolaemia, and to health-care providers. Design and methods This study comprised systematic reviews and analysis of three data sets: PASS (PASS Software, Rijswijk, the Netherlands) hospital familial hypercholesterolaemia databases, the Clinical Practice Research Datalink (CPRD)-Hospital Episode Statistics (HES) linked primary-secondary care data set, and a specialist familial hypercholesterolaemia register. Cost-effectiveness modelling, incorporating preceding analyses, was undertaken. Acceptability was examined in interviews with patients, relatives and health-care professionals. Result Systematic review of protocols: based on data from 4 of the 24 studies, the combined approach led to a slightly higher yield of relatives tested [40%, 95% confidence interval (CI) 37% to 42%] than the direct (33%, 95% CI 28% to 39%) or indirect approaches alone (34%, 95% CI 30% to 37%). The PASS databases identified that those contacted directly were more likely to complete cascade testing (p < 0.01); the CPRD-HES data set indicated that 70% did not achieve target treatment levels, and demonstrated increased cardiovascular disease risk among these individuals, compared with controls (hazard ratio 9.14, 95% CI 8.55 to 9.76). The specialist familial hypercholesterolaemia register confirmed excessive cardiovascular morbidity (standardised morbidity ratio 7.17, 95% CI 6.79 to 7.56). Cost-effectiveness modelling found a net health gain from diagnosis of -0.27 to 2.51 quality-adjusted life-years at the willingness-to-pay threshold of £15,000 per quality-adjusted life-year gained. The cost-effective protocols cascaded from genetically confirmed index cases by contacting first- and second-degree relatives simultaneously and directly. Interviews found a service-led direct-contact approach was more reliable, but combining direct and indirect approaches, guided by index patients and family relationships, may be more acceptable. Limitations Systematic reviews were not used in the economic analysis, as relevant studies were lacking or of poor quality. As only a proportion of those with primary care-coded familial hypercholesterolaemia are likely to actually have familial hypercholesterolaemia, CPRD analyses are likely to underestimate the true effect. The cost-effectiveness analysis required assumptions related to the long-term cardiovascular disease risk, the effect of treatment on cholesterol and the generalisability of estimates from the data sets. Interview recruitment was limited to white English-speaking participants. Conclusions Based on limited evidence, most cost-effective cascade-testing protocols, diagnosing most relatives, select index cases by genetic testing, with services directly contacting relatives, and contacting second-degree relatives even if first-degree relatives have not been tested. Combined approaches to contact relatives may be more suitable for some families. Future work Establish a long-term familial hypercholesterolaemia cohort, measuring cholesterol levels, treatment and cardiovascular outcomes. Conduct a randomised study comparing different approaches to contact relatives. Study registration This study is registered as PROSPERO CRD42018117445 and CRD42019125775. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 16. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Nadeem Qureshi
- PRISM Research Group, Centre for Academic Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - Bethan Woods
- Centre for Health Economics, University of York, York, UK
| | | | | | - Edward Cox
- Centre for Health Economics, University of York, York, UK
| | - Jo Leonardi Bee
- PRISM Research Group, Centre for Academic Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - Laura Condon
- PRISM Research Group, Centre for Academic Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - Stephen Weng
- Cardiovascular and Metabolism, Janssen Research and Development, High Wycombe, UK
| | - Ralph K Akyea
- PRISM Research Group, Centre for Academic Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - Barbara Iyen
- PRISM Research Group, Centre for Academic Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - Paul Roderick
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Steve E Humphries
- Centre for Cardiovascular Genetics, Institute for Cardiovascular Science, University College London, London, UK
| | | | - Melanie Watson
- Wessex Clinical Genetics Service, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Kate Haralambos
- Familial Hypercholesterolaemia Service, University Hospital of Wales, Cardiff, UK
| | - Ryan Kenny
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Dev Datta
- Lipid Unit, University Hospital Llandough, Penarth, UK
| | | | - Christopher Byrne
- Southampton National Institute for Health and Care Research Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Joe Kai
- PRISM Research Group, Centre for Academic Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
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10
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Cho SMJ, Koyama S, Honigberg MC, Surakka I, Haidermota S, Ganesh S, Patel AP, Bhattacharya R, Lee H, Kim HC, Natarajan P. Genetic, sociodemographic, lifestyle, and clinical risk factors of recurrent coronary artery disease events: a population-based cohort study. Eur Heart J 2023; 44:3456-3465. [PMID: 37350734 PMCID: PMC10516626 DOI: 10.1093/eurheartj/ehad380] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 05/07/2023] [Accepted: 05/25/2023] [Indexed: 06/24/2023] Open
Abstract
AIMS Complications of coronary artery disease (CAD) represent the leading cause of death among adults globally. This study examined the associations and clinical utilities of genetic, sociodemographic, lifestyle, and clinical risk factors on CAD recurrence. METHODS AND RESULTS Data were from 7024 UK Biobank middle-aged adults with established CAD at enrolment. Cox proportional hazards regressions modelled associations of age at enrolment, age at first CAD diagnosis, sex, cigarette smoking, physical activity, diet, sleep, Townsend Deprivation Index, body mass index, blood pressure, blood lipids, glucose, lipoprotein(a), C reactive protein, estimated glomerular filtration rate (eGFR), statin prescription, and CAD polygenic risk score (PRS) with first post-enrolment CAD recurrence. Over a median [interquartile range] follow-up of 11.6 [7.2-12.7] years, 2003 (28.5%) recurrent CAD events occurred. The hazard ratio (95% confidence interval [CI]) for CAD recurrence was the most pronounced with current smoking (1.35, 1.13-1.61) and per standard deviation increase in age at first CAD (0.74, 0.67-0.82). Additionally, age at enrolment, CAD PRS, C-reactive protein, lipoprotein(a), glucose, low-density lipoprotein cholesterol, deprivation, sleep quality, eGFR, and high-density lipoprotein (HDL) cholesterol also significantly associated with recurrence risk. Based on C indices (95% CI), the strongest predictors were CAD PRS (0.58, 0.57-0.59), HDL cholesterol (0.57, 0.57-0.58), and age at initial CAD event (0.57, 0.56-0.57). In addition to traditional risk factors, a comprehensive model improved the C index from 0.644 (0.632-0.654) to 0.676 (0.667-0.686). CONCLUSION Sociodemographic, clinical, and laboratory factors are each associated with CAD recurrence with genetic risk, age at first CAD event, and HDL cholesterol concentration explaining the most.
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Affiliation(s)
- So Mi Jemma Cho
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, 415 Main St., Cambridge, MA 02142, USA
- Cardiovascular Research Center and Center for Genomic Medicine, Massachusetts General Hospital, 185 Cambridge St., Boston, MA 02114, USA
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Satoshi Koyama
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, 415 Main St., Cambridge, MA 02142, USA
- Cardiovascular Research Center and Center for Genomic Medicine, Massachusetts General Hospital, 185 Cambridge St., Boston, MA 02114, USA
| | - Michael C Honigberg
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, 415 Main St., Cambridge, MA 02142, USA
- Cardiovascular Research Center and Center for Genomic Medicine, Massachusetts General Hospital, 185 Cambridge St., Boston, MA 02114, USA
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114, USA
- Department of Medicine, Harvard Medical School, 25 Shattuck St., Boston, MA 02114, USA
| | - Ida Surakka
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, 415 Main St., Cambridge, MA 02142, USA
- Division of Cardiology, Department of Internal Medicine, University of Michigan, 1500 E Medical Center Dr., Ann Arbor, MI 48109, USA
| | - Sara Haidermota
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, 415 Main St., Cambridge, MA 02142, USA
- Cardiovascular Research Center and Center for Genomic Medicine, Massachusetts General Hospital, 185 Cambridge St., Boston, MA 02114, USA
| | - Shriienidhie Ganesh
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, 415 Main St., Cambridge, MA 02142, USA
- Cardiovascular Research Center and Center for Genomic Medicine, Massachusetts General Hospital, 185 Cambridge St., Boston, MA 02114, USA
| | - Aniruddh P Patel
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, 415 Main St., Cambridge, MA 02142, USA
- Cardiovascular Research Center and Center for Genomic Medicine, Massachusetts General Hospital, 185 Cambridge St., Boston, MA 02114, USA
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114, USA
- Department of Medicine, Harvard Medical School, 25 Shattuck St., Boston, MA 02114, USA
| | - Romit Bhattacharya
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, 415 Main St., Cambridge, MA 02142, USA
- Cardiovascular Research Center and Center for Genomic Medicine, Massachusetts General Hospital, 185 Cambridge St., Boston, MA 02114, USA
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114, USA
- Department of Medicine, Harvard Medical School, 25 Shattuck St., Boston, MA 02114, USA
| | - Hokyou Lee
- Department of Preventive Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Hyeon Chang Kim
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
- Department of Preventive Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
- Institute for Innovation in Digital Healthcare, Yonsei University Health System, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Pradeep Natarajan
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, 415 Main St., Cambridge, MA 02142, USA
- Cardiovascular Research Center and Center for Genomic Medicine, Massachusetts General Hospital, 185 Cambridge St., Boston, MA 02114, USA
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114, USA
- Department of Medicine, Harvard Medical School, 25 Shattuck St., Boston, MA 02114, USA
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11
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Zito A, Galli M, Biondi-Zoccai G, Abbate A, Douglas PS, Princi G, D'Amario D, Aurigemma C, Romagnoli E, Trani C, Burzotta F. Diagnostic Strategies for the Assessment of Suspected Stable Coronary Artery Disease : A Systematic Review and Meta-analysis. Ann Intern Med 2023; 176:817-826. [PMID: 37276592 DOI: 10.7326/m23-0231] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/07/2023] Open
Abstract
BACKGROUND There is uncertainty about which diagnostic strategy for detecting coronary artery disease (CAD) provides better outcomes. PURPOSE To compare the effect on clinical management and subsequent health effects of alternative diagnostic strategies for the initial assessment of suspected stable CAD. DATA SOURCES PubMed, Embase, and Cochrane Central Register of Controlled Trials. STUDY SELECTION Randomized clinical trials comparing diagnostic strategies for CAD detection among patients with symptoms suggestive of stable CAD. DATA EXTRACTION Three investigators independently extracted study data. DATA SYNTHESIS The strongest available evidence was for 3 of the 6 comparisons: coronary computed tomography angiography (CCTA) versus invasive coronary angiography (ICA) (4 trials), CCTA versus exercise electrocardiography (ECG) (2 trials), and CCTA versus stress single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) (5 trials). Compared with direct ICA referral, CCTA was associated with no difference in cardiovascular death and myocardial infarction (relative risk [RR], 0.84 [95% CI, 0.52 to 1.35]; low certainty) but less index ICA (RR, 0.23 [CI, 0.22 to 0.25]; high certainty) and index revascularization (RR, 0.71 [CI, 0.63 to 0.80]; moderate certainty). Moreover, CCTA was associated with a reduction in cardiovascular death and myocardial infarction compared with exercise ECG (RR, 0.66 [CI, 0.44 to 0.99]; moderate certainty) and SPECT-MPI (RR, 0.64 [CI, 0.45 to 0.90]; high certainty). However, CCTA was associated with more index revascularization (RR, 1.78 [CI, 1.33 to 2.38]; moderate certainty) but less downstream testing (RR, 0.56 [CI, 0.45 to 0.71]; very low certainty) than exercise ECG. Low-certainty evidence compared SPECT-MPI versus exercise ECG (2 trials), SPECT-MPI versus stress cardiovascular magnetic resonance imaging (1 trial), and stress echocardiography versus exercise ECG (1 trial). LIMITATION Most comparisons primarily rely on a single study, many studies were underpowered to detect potential differences in direct health outcomes, and individual patient data were lacking. CONCLUSION For the initial assessment of patients with suspected stable CAD, CCTA was associated with similar health effects to direct ICA referral, and with a health benefit compared with exercise ECG and SPECT-MPI. Further research is needed to better assess the relative performance of each diagnostic strategy. PRIMARY FUNDING SOURCE None. (PROSPERO: CRD42022329635).
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Affiliation(s)
- Andrea Zito
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Rome, Italy (A.Z., G.P.)
| | - Mattia Galli
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy (M.G.)
| | - Giuseppe Biondi-Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Rome, Italy (G.B.)
| | - Antonio Abbate
- Mediterranea Cardiocentro, Napoli, Italy (G.B.); Robert M. Berne Cardiovascular Research Center, Division of Cardiovascular Medicine, University of Virginia School of Medicine, Charlottesville, Virginia (A.A.)
| | - Pamela S Douglas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina (P.S.D.)
| | - Giuseppe Princi
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Rome, Italy (A.Z., G.P.)
| | - Domenico D'Amario
- Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy (D.D.)
| | - Cristina Aurigemma
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy (C.A., E.R.)
| | - Enrico Romagnoli
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy (C.A., E.R.)
| | - Carlo Trani
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, and Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy (C.T., F.B.)
| | - Francesco Burzotta
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, and Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy (C.T., F.B.)
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12
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Xie P, Li X, Guo F, Zhang D, Zhang H. Direct medical costs of ischemic heart disease in urban Southern China: a 5-year retrospective analysis of an all-payer health claims database in Guangzhou City. Front Public Health 2023; 11:1146914. [PMID: 37228711 PMCID: PMC10203198 DOI: 10.3389/fpubh.2023.1146914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 04/11/2023] [Indexed: 05/27/2023] Open
Abstract
Introduction This study aimed to estimate the direct medical costs and out-of-pocket (OOP) expenses associated with inpatient and outpatient care for IHD, based on types of health insurance. Additionally, we sought to identify time trends and factors associated with these costs using an all-payer health claims database among urban patients with IHD in Guangzhou City, Southern China. Methods Data were collected from the Urban Employee-based Basic Medical Insurance (UEBMI) and the Urban Resident-based Basic Medical Insurance (URBMI) administrative claims databases in Guangzhou City from 2008 to 2012. Direct medical costs were estimated in the entire sample and by types of insurance separately. Extended Estimating Equations models were employed to identify the potential factors associated with the direct medical costs including inpatient and outpatient care and OOP expenses. Results The total sample included 58,357 patients with IHD. The average direct medical costs per patient were Chinese Yuan (CNY) 27,136.4 [US dollar (USD) 4,298.8] in 2012. The treatment and surgery fees were the largest contributor to direct medical costs (52.0%). The average direct medical costs of IHD patients insured by UEBMI were significantly higher than those insured by the URBMI [CNY 27,749.0 (USD 4,395.9) vs. CNY 21,057.7(USD 3,335.9), P < 0.05]. The direct medical costs and OOP expenses for all patients increased from 2008 to 2009, and then decreased during the period of 2009-2012. The time trends of direct medical costs between the UEBMI and URBMI patients were different during the period of 2008-2012. The regression analysis indicated that the UEBMI enrollees had higher direct medical costs (P < 0.001) but had lower OOP expenses (P < 0.001) than the URBMI enrollees. Male patients, patients having percutaneous coronary intervention operation and intensive care unit admission, patients treated in secondary hospitals and tertiary hospitals, patients with the LOS of 15-30 days, 30 days and longer had significantly higher direct medical costs and OOP expenses (all P < 0.001). Conclusions The direct medical costs and OOP expenses for patients with IHD in China were found to be high and varied between two medical insurance schemes. The type of insurance was significantly associated with direct medical costs and OOP expenses of IHD.
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Affiliation(s)
- Peixuan Xie
- Department of Health Policy and Management, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Xuezhu Li
- Department of Health Policy and Management, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Feifan Guo
- Department of Health Policy and Management, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Donglan Zhang
- Division of Health Services Research, New York University Long Island School of Medicine, Mineola, NY, United States
| | - Hui Zhang
- Department of Health Policy and Management, School of Public Health, Sun Yat-sen University, Guangzhou, China
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13
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Zhou J, Wu R, Williams C, Emberson J, Reith C, Keech A, Robson J, Wilkinson K, Armitage J, Gray A, Simes J, Baigent C, Mihaylova B. Prediction Models for Individual-Level Healthcare Costs Associated with Cardiovascular Events in the UK. PHARMACOECONOMICS 2023; 41:547-559. [PMID: 36826687 PMCID: PMC10085892 DOI: 10.1007/s40273-022-01219-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 11/06/2022] [Indexed: 05/10/2023]
Abstract
OBJECTIVES The aim of this study was to develop prediction models for the individual-level impacts of cardiovascular events on UK healthcare costs. METHODS In the UK Biobank, people 40-70 years old, recruited in 2006-2010, were followed in linked primary (N = 192,983 individuals) and hospital care (N = 501,807 individuals) datasets. Regression models of annual primary and annual hospital care costs (2020 UK£) associated with individual characteristics and experiences of myocardial infarction (MI), stroke, coronary revascularization, incident diabetes mellitus and cancer, and vascular and nonvascular death are reported. RESULTS For both people without and with previous cardiovascular disease (CVD), primary care costs were modelled using one-part generalised linear models (GLMs) with identity link and Poisson distribution, and hospital costs with two-part models (part 1: logistic regression models the probability of incurring costs; part 2: GLM with identity link and Poisson distribution models the costs conditional on incurring any). In people without previous CVD, mean annual primary and hospital care costs were £360 and £514, respectively. The excess primary care costs were £190 and £360 following MI and stroke, respectively, whereas excess hospital costs decreased from £4340 and £5590, respectively, in the year of these events, to £190 and £410 two years later. People with previous CVD had more than twice higher annual costs, and incurred higher excess costs for cardiovascular events. Other characteristics associated with higher costs included older age, female sex, south Asian ethnicity, higher socioeconomic deprivation, smoking, lower level of physical activities, unhealthy body mass index, and comorbidities. CONCLUSIONS These individual-level healthcare cost prediction models could inform assessments of the value of health technologies and policies to reduce cardiovascular and other disease risks and healthcare costs. An accompanying Excel calculator is available to facilitate the use of the models.
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Affiliation(s)
- Junwen Zhou
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, OX3 7LF, Oxford, UK
| | - Runguo Wu
- Health Economics and Policy Research Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Claire Williams
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, OX3 7LF, Oxford, UK
| | - Jonathan Emberson
- MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Christina Reith
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Anthony Keech
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - John Robson
- Clinical Effectiveness Group, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | | | - Jane Armitage
- MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Alastair Gray
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, OX3 7LF, Oxford, UK
| | - John Simes
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - Colin Baigent
- MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Borislava Mihaylova
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, OX3 7LF, Oxford, UK.
- Health Economics and Policy Research Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, UK.
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14
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Salih A, Boscolo Galazzo I, Gkontra P, Lee AM, Lekadir K, Raisi-Estabragh Z, Petersen SE. Explainable Artificial Intelligence and Cardiac Imaging: Toward More Interpretable Models. Circ Cardiovasc Imaging 2023; 16:e014519. [PMID: 37042240 DOI: 10.1161/circimaging.122.014519] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
Abstract
Artificial intelligence applications have shown success in different medical and health care domains, and cardiac imaging is no exception. However, some machine learning models, especially deep learning, are considered black box as they do not provide an explanation or rationale for model outcomes. Complexity and vagueness in these models necessitate a transition to explainable artificial intelligence (XAI) methods to ensure that model results are both transparent and understandable to end users. In cardiac imaging studies, there are a limited number of papers that use XAI methodologies. This article provides a comprehensive literature review of state-of-the-art works using XAI methods for cardiac imaging. Moreover, it provides simple and comprehensive guidelines on XAI. Finally, open issues and directions for XAI in cardiac imaging are discussed.
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Affiliation(s)
- Ahmed Salih
- William Harvey Research Institute, NIHR Barts Biomedical Research Centre, Queen Mary University of London, United Kingdom (A.S., A.M.L., Z.R.-E., S.E.P.)
| | | | - Polyxeni Gkontra
- Department of de Matemàtiques i Informàtica, University of Barcelona, Spain (P.G., K.L.)
| | - Aaron Mark Lee
- William Harvey Research Institute, NIHR Barts Biomedical Research Centre, Queen Mary University of London, United Kingdom (A.S., A.M.L., Z.R.-E., S.E.P.)
| | - Karim Lekadir
- Department of de Matemàtiques i Informàtica, University of Barcelona, Spain (P.G., K.L.)
| | - Zahra Raisi-Estabragh
- William Harvey Research Institute, NIHR Barts Biomedical Research Centre, Queen Mary University of London, United Kingdom (A.S., A.M.L., Z.R.-E., S.E.P.)
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom (Z.R.-E., S.E.P.)
| | - Steffen E Petersen
- William Harvey Research Institute, NIHR Barts Biomedical Research Centre, Queen Mary University of London, United Kingdom (A.S., A.M.L., Z.R.-E., S.E.P.)
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom (Z.R.-E., S.E.P.)
- Health Data Research UK, London (S.E.P.)
- Alan Turing Institute, London, United Kingdom (S.E.P.)
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15
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Faria R, Saramago P, Cox E, Weng S, Iyen B, Akyea RK, Humphries SE, Qureshi N, Woods B. How does cholesterol burden change the case for investing in familial hypercholesterolaemia? A cost-effectiveness analysis. Atherosclerosis 2023; 367:40-47. [PMID: 36642658 DOI: 10.1016/j.atherosclerosis.2022.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 11/19/2022] [Accepted: 12/06/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND AIMS This study aimed to ascertain how the long-term benefits and costs of diagnosis and treatment of familial hypercholesterolaemia (FH) vary by prognostic factors and 'cholesterol burden', which is the effect of long-term exposure to low-density lipoprotein cholesterol (LDL-C) on cardiovascular disease (CVD) risk. METHODS A new cost-effectiveness model was developed from the perspective of the UK National Health Service (NHS), informed by routine data from individuals with FH. The primary outcome was net health gain (i.e., health benefits net of the losses due to costs), expressed in quality-adjusted life years (QALYs) at the £15,000/QALY threshold. Prognostic factors included pre-treatment LDL-C, age, gender, and CVD history. RESULTS If cholesterol burden is considered, diagnosis resulted in positive net health gain (i.e., it is cost-effective) in all individuals with pre-treatment LDL-C ≥ 4 mmol/L, and in those with pre-treatment LDL-C ≥ 2 mmol/L aged ≥50 years or who have CVD history. If cholesterol burden is not considered, diagnosis resulted in lower net health gain, but still positive in children aged 10 years with pre-treatment LDL-C ≥ 6 mmol/L and adults aged 30 years with pre-treatment LDL-C ≥ 4 mmol/L. CONCLUSIONS Diagnosis and treatment of most people with FH results in large net health gains, particularly in those with higher pre-treatment LDL-C. Economic evaluations of FH interventions should consider the sensitivity of the study conclusions to cholesterol burden, particularly where interventions target younger patients, and explicitly consider prognostic factors such as pre-treatment LDL-C, age, and CVD history.
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Affiliation(s)
- Rita Faria
- Centre for Health Economics, University of York, UK.
| | | | - Edward Cox
- Centre for Health Economics, University of York, UK
| | - Stephen Weng
- Centre of Academic Primary Care, University of Nottingham, UK
| | - Barbara Iyen
- Centre of Academic Primary Care, University of Nottingham, UK
| | - Ralph K Akyea
- Centre of Academic Primary Care, University of Nottingham, UK
| | | | - Nadeem Qureshi
- Centre of Academic Primary Care, University of Nottingham, UK
| | - Beth Woods
- Centre for Health Economics, University of York, UK
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16
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Verbeke E, Luyten J. Future Offspring Costs in Economic Evaluation. PHARMACOECONOMICS 2022; 40:141-147. [PMID: 34713421 DOI: 10.1007/s40273-021-01102-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/06/2021] [Indexed: 06/13/2023]
Abstract
Economic evaluation guidelines increasingly prescribe inclusion of all future costs. We point at an important dimension of future costs that is systematically neglected. Healthcare can affect future offspring, either through affecting the patient's fertility or through determining future offspring's health. As we show, the future costs associated with these changes can be substantial and will vary across interventions and demographic groups. However, systematic inclusion of these future offspring costs would raise many problems on its own. Based on the population ethics concept of necessitarianism, we suggest that only those future costs that spring from 'necessary' future lives should be included in future cost calculations, while all costs associated with 'potential' future lives can be ignored. This approach allows excluding most future offspring costs and avoids skewed cost-effectiveness outcomes of interventions with fertility effects, while taking into account the economic implications of preventing disease in future generations that will exist by necessity. Overall, future generations expose a substantial gap in today's Health Technology Assessment (HTA) methodology and further discussion of the issues they raise is needed.
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Affiliation(s)
- Evelyn Verbeke
- Leuven Institute for Healthcare Policy, KU Leuven, Leuven, Belgium.
| | - Jeroen Luyten
- Leuven Institute for Healthcare Policy, KU Leuven, Leuven, Belgium
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Abstract
IMPORTANCE Nearly 10 million US adults experience stable angina, which occurs when myocardial oxygen supply does not meet demand, resulting in myocardial ischemia. Stable angina is associated with an average annual risk of 3% to 4% for myocardial infarction or death. Diagnostic tests and medical therapies for stable angina have evolved over the last decade with a better understanding of the optimal use of coronary revascularization. OBSERVATIONS Coronary computed tomographic angiography is a first-line diagnostic test in the evaluation of patients with stable angina due to higher sensitivity and comparable specificity compared with imaging-based stress testing. Moreover, coronary computed tomographic angiography allows detection of nonobstructive atherosclerosis that would not be identified with other noninvasive imaging modalities, improving risk assessment and potentially triggering more appropriate allocation of preventive therapies. Novel therapies treating lipids (proprotein convertase subtilisin/kexin type 9 inhibitors, ezetimibe, and icosapent ethyl) and type 2 diabetes (sodium-glucose cotransporter 2 inhibitors, glucagon-like peptide 1 receptor agonists) have improved cardiovascular outcomes in patients with stable ischemic heart disease when added to usual care. Randomized clinical trials showed no improvement in the rates of mortality or myocardial infarction with revascularization (largely by percutaneous coronary intervention) compared with optimal medical therapy alone, even in the setting of moderate to severe ischemia. In contrast, revascularization provides a meaningful benefit on angina and quality of life compared with antianginal therapies. Measures of the effect of angina on a patient's quality of life should be integrated into the clinic encounter to assist with the decision to proceed with revascularization. CONCLUSIONS AND RELEVANCE For patients with stable angina, emphasis should be placed on optimizing lifestyle factors and preventive medications such as lipid-lowering and antiplatelet agents to reduce the risk for cardiovascular events and death. Antianginal medications, such as β-blockers, nitrates, or calcium channel blockers, should be initiated to improve angina symptoms. Revascularization with percutaneous coronary intervention should be reserved for patients in whom angina symptoms negatively influence quality of life, generally after a trial of antianginal medical therapy. Shared decision-making with an informed patient is important for effective treatment of stable angina.
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Affiliation(s)
- Parag H Joshi
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - James A de Lemos
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
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18
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Westwood M, Ramaekers B, Grimm S, Worthy G, Fayter D, Armstrong N, Buksnys T, Ross J, Joore M, Kleijnen J. High-sensitivity troponin assays for early rule-out of acute myocardial infarction in people with acute chest pain: a systematic review and economic evaluation. Health Technol Assess 2021; 25:1-276. [PMID: 34061019 PMCID: PMC8200931 DOI: 10.3310/hta25330] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Early diagnosis of acute myocardial infarction is important, but only 20% of emergency admissions for chest pain will actually have an acute myocardial infarction. High-sensitivity cardiac troponin assays may allow rapid rule out of myocardial infarction and avoid unnecessary hospital admissions. OBJECTIVES To assess the clinical effectiveness and cost-effectiveness of high-sensitivity cardiac troponin assays for the management of adults presenting with acute chest pain, in particular for the early rule-out of acute myocardial infarction. METHODS Sixteen databases were searched up to September 2019. Review methods followed published guidelines. Studies were assessed for quality using appropriate risk-of-bias tools. The bivariate model was used to estimate summary sensitivity and specificity for meta-analyses involving four or more studies; otherwise, random-effects logistic regression was used. The health economic analysis considered the long-term costs and quality-adjusted life-years associated with different troponin testing methods. The de novo model consisted of a decision tree and a state-transition cohort model. A lifetime time horizon (of 60 years) was used. RESULTS Thirty-seven studies (123 publications) were included in the review. The high-sensitivity cardiac troponin test strategies evaluated are defined by the combination of four factors (i.e. assay, number and timing of tests, and threshold concentration), resulting in a large number of possible combinations. Clinical opinion indicated a minimum clinically acceptable sensitivity of 97%. When considering single test strategies, only those using a threshold at or near to the limit of detection for the assay, in a sample taken at presentation, met the minimum clinically acceptable sensitivity criterion. The majority of the multiple test strategies that met this criterion comprised an initial rule-out step, based on high-sensitivity cardiac troponin levels in a sample taken on presentation and a minimum symptom duration, and a second stage for patients not meeting the initial rule-out criteria, based on presentation levels of high-sensitivity cardiac troponin and absolute change after 1, 2 or 3 hours. Two large cluster randomised controlled trials found that implementation of an early rule-out pathway for myocardial infarction reduced length of stay and rate of hospital admission without increasing cardiac events. In the base-case analysis, standard troponin testing was both the most effective and the most costly. Other testing strategies with a sensitivity of 100% (subject to uncertainty) were almost equally effective, resulting in the same life-year and quality-adjusted life-year gain at up to four decimal places. Comparisons based on the next best alternative showed that for willingness-to-pay values below £8455 per quality-adjusted life-year, the Access High Sensitivity Troponin I (Beckman Coulter, Brea, CA, USA) [(symptoms > 3 hours AND < 4 ng/l at 0 hours) OR (< 5 ng/l AND Δ < 5 ng/l at 0 to 2 hours)] would be cost-effective. For thresholds between £8455 and £20,190 per quality-adjusted life-year, the Elecsys® Troponin-T high sensitive (Roche, Basel, Switzerland) (< 12 ng/l at 0 hours AND Δ < 3 ng/l at 0 to 1 hours) would be cost-effective. For a threshold > £20,190 per quality-adjusted life-year, the Dimension Vista® High-Sensitivity Troponin I (Siemens Healthcare, Erlangen, Germany) (< 5 ng/l at 0 hours AND Δ < 2 ng/l at 0 to 1 hours) would be cost-effective. CONCLUSIONS High-sensitivity cardiac troponin testing may be cost-effective compared with standard troponin testing. STUDY REGISTRATION This study is registered as PROSPERO CRD42019154716. FUNDING This project was funded by the National Institute for Health Research (NIHR) Evidence Synthesis programme and will be published in full in Health Technology Assessment; Vol. 25, No. 33. See the NIHR Journals Library website for further project information.
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Affiliation(s)
| | - Bram Ramaekers
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University, Maastricht, the Netherlands
| | - Sabine Grimm
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University, Maastricht, the Netherlands
| | | | | | | | | | | | - Manuela Joore
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University, Maastricht, the Netherlands
| | - Jos Kleijnen
- Kleijnen Systematic Reviews Ltd, York, UK
- School for Public Health and Primary Care, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
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McDaid D, Park AL. Modelling the Economic Impact of Reducing Loneliness in Community Dwelling Older People in England. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18041426. [PMID: 33546496 PMCID: PMC7913744 DOI: 10.3390/ijerph18041426] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 01/28/2021] [Accepted: 01/30/2021] [Indexed: 01/01/2023]
Abstract
Loneliness has been associated with poor mental health and wellbeing. In England, a 2018 national strategy on loneliness was published, and public health guidelines recommend participation in social activities. In the absence of existing economic evidence, we modelled the potential cost effectiveness of a service that connects lonely older people to social activities against no-intervention. A 5-year Markov model was constructed from a health and social care perspective. Parameters were drawn from the literature, with the intervention structure based on an existing loneliness alleviation programme implemented in several settings across England. Univariate and probabilistic sensitivity analyses were undertaken. The total expected cost per participant in the intervention group is £ 7131 compared to £ 6783 in the usual care group with 0.45 loneliness free years (LFY) gained. The incremental cost per LFY gained is £ 768; in the probabilistic sensitivity analysis the intervention is cost saving in 3.5% of iterations. Potentially such interventions may be cost-effective but are unlikely to be cost-saving even allowing for sustained effects and cumulative adverse health and social care events averted. Empirical studies are needed to determine the cost-effectiveness of these interventions, ideally mapping changes in loneliness to the quality of life, in order to allow the key metric in health economic studies, cost per quality adjusted life year to be estimated.
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Roze S, Isitt J, Smith-Palmer J, Javanbakht M, Lynch P. Long-term Cost-Effectiveness of Dexcom G6 Real-time Continuous Glucose Monitoring Versus Self-Monitoring of Blood Glucose in Patients With Type 1 Diabetes in the U.K. Diabetes Care 2020; 43:2411-2417. [PMID: 32647050 DOI: 10.2337/dc19-2213] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 06/18/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE A long-term health economic analysis was performed to establish the cost-effectiveness of real-time continuous glucose monitoring (RT-CGM) (Dexcom G6) versus self-monitoring of blood glucose (SMBG) alone in U.K.-based patients with type 1 diabetes (T1D). RESEARCH DESIGN AND METHODS The analysis used the IQVIA CORE Diabetes Model. Clinical input data were sourced from the DIAMOND trial in adults with T1D. Simulations were performed separately in the overall population of patients with baseline HbA1c ≥7.5% (58 mmol/mol), and a secondary analysis was performed in patients with baseline HbA1c ≥8.5% (69 mmol/mol). The analysis was performed from the National Health Service health care payer perspective over a lifetime time horizon. RESULTS In the overall population, G6 RT-CGM was associated with a mean incremental gain in quality-adjusted life expectancy of 1.49 quality-adjusted life years (QALYs) versus SMBG (mean [SD] 11.47 [2.04] QALYs versus 9.99 [1.84] QALYs). Total mean (SD) lifetime costs were also pounds sterling (GBP) 14,234 higher with RT-CGM (GBP 102,468 [35,681] versus GBP 88,234 [39,027]) resulting in an incremental cost-effectiveness ratio of GBP 9,558 per QALY gained. Sensitivity analyses revealed that the findings were sensitive to changes in the quality-of-life benefit associated with reduced fear of hypoglycemia and avoidance of fingerstick testing as well as the HbA1c benefit associated with RT-CGM use. CONCLUSIONS For U.K.-based T1D patients, the G6 RT-CGM device is associated with significant improvements in clinical outcomes and, over patient lifetimes, is a cost-effective disease management option relative to SMBG on the basis of a willingness-to-pay threshold of GBP 20,000 per QALY gained.
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Knapik A, Dąbek J, Gallert-Kopyto W, Plinta R, Brzęk A. Psychometric Features of the Polish Version of TSK Heart in Elderly Patients with Coronary Artery Disease. MEDICINA (KAUNAS, LITHUANIA) 2020; 56:E467. [PMID: 32933100 PMCID: PMC7559263 DOI: 10.3390/medicina56090467] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 08/29/2020] [Accepted: 09/07/2020] [Indexed: 11/16/2022]
Abstract
Background and objectives: Recommendations for the control of stable patients with coronary artery disease (CAD) related to an adequate level of physical activity (PA). Practical experience shows that the PA level in most people with CAD is definitely too low in relation to the guidelines. The cause may be psychological factors and among them the fear of movement-kinesiophobia. The aim of this project was to examine the evaluation of psychometric features of the Polish version of the Tampa Scale for Kinesiophobia Heart (TSK Heart), used in people with CAD. Materials and methods: The study involved 287 patients with stable CAD: 112 women and 175 men. Age: 63.50 (SD = 11.49) years. Kinesiophobia was assessed using TSK Heart, physical activity (PA)-using the International Physical Activity Questionnaire (IPAQ), and anxiety and depression was examined using the Hospital Anxiety and Depression Scale (HADS). The structure of TSK was examined using principal component analysis (PCA), internal cohesion (Cronbach's alpha, AC), and content validity was calculated by linear regression. Results: PCA showed a three-factor TSK structure. One-dimensionality and satisfactory reliability were found: TSK Heart: AC = 0.878. Kinesiophobia as a predictor of PA: R2 = 0.162 (p = 0.000000). Anxiety and depression-TSK: R2 = 0.093 (p = 0.00000). Conclusions: The Polish version of TSK Heart for cardiac patients is characterized by good psychometric features. The use of it can improve the cooperation of rehabilitation teams for patients with CAD.
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Affiliation(s)
- Andrzej Knapik
- Department of Adapted Physical Activity and Sport, Chair of Physiotherapy, School of Health Sciences in Katowice, Medical University of Silesia, 40–055 Katowice, Poland; (A.K.); (R.P.)
| | - Józefa Dąbek
- Department of Cardiology, School of Health Sciences in Katowice, Medical University of Silesia in Katowice, 40–055 Katowice, Poland;
| | - Weronika Gallert-Kopyto
- Department of Kinesiology, Chair of Physiotherapy, School of Health Sciences in Katowice, Medical University of Silesia, 40–055 Katowice, Poland;
| | - Ryszard Plinta
- Department of Adapted Physical Activity and Sport, Chair of Physiotherapy, School of Health Sciences in Katowice, Medical University of Silesia, 40–055 Katowice, Poland; (A.K.); (R.P.)
| | - Anna Brzęk
- Department of Physiotherapy, Chair of Physiotherapy, School of Health Sciences in Katowice, Medical University of Silesia, 40–055 Katowice, Poland
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22
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Sawicki OA, Mueller A, Glushan A, Breitkreuz T, Wicke FS, Karimova K, Gerlach FM, Wensing M, Smetak N, Bosch RF, Beyer M. Intensified ambulatory cardiology care: effects on mortality and hospitalisation-a comparative observational study. Sci Rep 2020; 10:14695. [PMID: 32895445 PMCID: PMC7477232 DOI: 10.1038/s41598-020-71770-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 08/03/2020] [Indexed: 11/24/2022] Open
Abstract
Since 2010, an intensified ambulatory cardiology care programme has been implemented in southern Germany. To improve patient management, the structure of cardiac disease management was improved, guideline-recommended care was supported, new ambulatory medical services and a morbidity-adapted reimbursement system were set up. Our aim was to determine the effects of this programme on the mortality and hospitalisation of enrolled patients with cardiac disorders. We conducted a comparative observational study in 2015 and 2016, based on insurance claims data. Overall, 13,404 enrolled patients with chronic heart failure (CHF) and 19,537 with coronary artery disease (CAD) were compared, respectively, to 8,776 and 16,696 patients that were receiving usual ambulatory cardiology care. Compared to the control group, patients enrolled in the programme had lower mortality (Hazard Ratio: 0.84; 95% CI: 0.77-0.91) and fewer all-cause hospitalisations (Rate Ratio: 0.94; 95% CI: 0.90-0.97). CHF-related hospitalisations in patients with CHF were also reduced (Rate Ratio: 0.76; 95% CI: 0.69-0.84). CAD patients showed a similar reduction in mortality rates (Hazard Ratio: 0.81; 95% CI: 0.76-0.88) and all-cause hospitalisation (Rate Ratio: 0.94; 95% CI: 0.91-0.97), but there was no effect on CAD-related hospitalisation. We conclude that intensified ambulatory care reduced mortality and hospitalisation in cardiology patients.
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Affiliation(s)
- Olga A Sawicki
- Institute of General Practice, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany.
| | - Angelina Mueller
- Institute of General Practice, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Anastasiya Glushan
- Institute of General Practice, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Thorben Breitkreuz
- aQua, Institute for Applied Quality Improvement and Research in Health Care, 37073, Goettingen, Germany
| | - Felix S Wicke
- Institute of General Practice, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Kateryna Karimova
- Institute of General Practice, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Ferdinand M Gerlach
- Institute of General Practice, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Michel Wensing
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Ralph F Bosch
- Cardio Centre Ludwigsburg-Bietigheim, 71634, Ludwigsburg, Germany
| | - Martin Beyer
- Institute of General Practice, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
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Javanbakht M, Hemami MR, Mashayekhi A, Branagan-Harris M, Zaman A, Al-Najjar Y, O'Donoghue D, Fath-Ordoubadi F, Wheatcroft S. DyeVert™ PLUS EZ System for Preventing Contrast-Induced Acute Kidney Injury in Patients Undergoing Diagnostic Coronary Angiography and/or Percutaneous Coronary Intervention: A UK-Based Cost-Utility Analysis. PHARMACOECONOMICS - OPEN 2020; 4:459-472. [PMID: 31989464 PMCID: PMC7426357 DOI: 10.1007/s41669-020-00195-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
BACKGROUND Contrast-induced acute kidney injury (CI-AKI) is a complication commonly associated with invasive angiographic procedures and is considered the leading cause of hospital-acquired acute kidney injury. CI-AKI can lead to a prolonged hospital stay, with a substantial economic impact, and increased mortality. The DyeVert™ PLUS EZ system (FDA approved and CE marked) is a device that has been developed to divert a portion of the theoretical injected contrast media volume (CMV), reducing the overall volume of contrast media injected and aortic reflux, and potentially improving long-term health outcomes. OBJECTIVES To assess the long-term costs and health outcomes associated with the introduction of the DyeVert™ PLUS EZ system into the UK health care service for the prevention of CI-AKI in a cohort of patients with chronic kidney disease (CKD) stage 3-4 undergoing diagnostic coronary angiography (DAG) and/or percutaneous coronary intervention (PCI), and to compare these costs and outcomes with those of the current practice. METHODS A de novo economic model was developed based on the current pathway of managing patients undergoing DAG and/or PCI and on evidence related to the clinical effectiveness of DyeVert™ in terms of its impact on relevant clinical outcomes and health service resource use. Clinical data used to populate the model were derived from the literature or were based on assumptions informed by expert clinical input. Costs included in the model were from the NHS and personal social services perspective and obtained from the literature and UK-based routine sources. Probabilistic distributions were assigned to the majority of model parameters so that a probabilistic analysis could be undertaken, while deterministic sensitivity analyses were also carried out to explore the impact of key parameter variation on the model results. RESULTS Base-case results indicate that the intervention leads to cost savings (- £435) and improved effectiveness (+ 0.028 QALYs) over the patient's lifetime compared with current practice. Output from the probabilistic analysis points to a high likelihood of the intervention being cost-effective across presented willingness-to-pay (WTP) thresholds. The overall long-term cost saving for the NHS associated with the introduction of the DyeVert™ PLUS EZ system is over £19.7 million for each annual cohort of patients. The cost savings are mainly driven by a lower risk of subsequent diseases and their associated costs. CONCLUSIONS The introduction of the DyeVert™ PLUS EZ system has the potential to reduce costs for the health care service and yield improved clinical outcomes for patients with CKD stage 3-4 undergoing angiographic procedures.
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Affiliation(s)
- Mehdi Javanbakht
- Optimax Access UK Ltd, Market Access Consultancy, Southampton, UK.
- Device Access UK Ltd, Market Access Consultancy, University of Southampton Science Park, Kenneth Dibben House, Enterprise Rd, Southampton Science Park, Southampton, Hampshire, SO16 7NS, UK.
| | | | - Atefeh Mashayekhi
- Optimax Access UK Ltd, Market Access Consultancy, Southampton, UK
- Device Access UK Ltd, Market Access Consultancy, University of Southampton Science Park, Kenneth Dibben House, Enterprise Rd, Southampton Science Park, Southampton, Hampshire, SO16 7NS, UK
| | - Michael Branagan-Harris
- Device Access UK Ltd, Market Access Consultancy, University of Southampton Science Park, Kenneth Dibben House, Enterprise Rd, Southampton Science Park, Southampton, Hampshire, SO16 7NS, UK
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Yadegarfar ME, Gale CP, Dondo TB, Wilkinson CG, Cowie MR, Hall M. Association of treatments for acute myocardial infarction and survival for seven common comorbidity states: a nationwide cohort study. BMC Med 2020; 18:231. [PMID: 32829713 PMCID: PMC7444071 DOI: 10.1186/s12916-020-01689-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 06/29/2020] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Comorbidity is common and has a substantial negative impact on the prognosis of patients with acute myocardial infarction (AMI). Whilst receipt of guideline-indicated treatment for AMI is associated with improved prognosis, the extent to which comorbidities influence treatment provision its efficacy is unknown. Therefore, we investigated the association between treatment provision for AMI and survival for seven common comorbidities. METHODS We used data of 693,388 AMI patients recorded in the Myocardial Ischaemia National Audit Project (MINAP), 2003-2013. We investigated the association between comorbidities and receipt of optimal care for AMI (receipt of all eligible guideline-indicated treatments), and the effect of receipt of optimal care for comorbid AMI patients on long-term survival using flexible parametric survival models. RESULTS A total of 412,809 [59.5%] patients with AMI had at least one comorbidity, including hypertension (302,388 [48.7%]), diabetes (122,228 [19.4%]), chronic obstructive pulmonary disease (COPD, 89,221 [14.9%]), cerebrovascular disease (51,883 [8.6%]), chronic heart failure (33,813 [5.6%]), chronic renal failure (31,029 [5.0%]) and peripheral vascular disease (27,627 [4.6%]). Receipt of optimal care was associated with greatest survival benefit for patients without comorbidities (HR 0.53, 95% CI 0.51-0.56) followed by patients with hypertension (HR 0.60, 95% CI 0.58-0.62), diabetes (HR 0.83, 95% CI 0.80-0.87), peripheral vascular disease (HR 0.85, 95% CI 0.79-0.91), renal failure (HR 0.89, 95% CI 0.84-0.94) and COPD (HR 0.90, 95% CI 0.87-0.94). For patients with heart failure and cerebrovascular disease, optimal care for AMI was not associated with improved survival. CONCLUSIONS Overall, guideline-indicated care was associated with improved long-term survival. However, this was not the case in AMI patients with concomitant heart failure or cerebrovascular disease. There is therefore a need for novel treatments to improve outcomes for AMI patients with pre-existing heart failure or cerebrovascular disease.
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Affiliation(s)
- Mohammad E Yadegarfar
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.,Leeds Institute for Data Analytics, University of Leeds, Worsley Building, Level 11, Clarendon Way, Leeds, LS2 9NL, UK
| | - Chris P Gale
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.,Leeds Institute for Data Analytics, University of Leeds, Worsley Building, Level 11, Clarendon Way, Leeds, LS2 9NL, UK.,Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Tatendashe B Dondo
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.,Leeds Institute for Data Analytics, University of Leeds, Worsley Building, Level 11, Clarendon Way, Leeds, LS2 9NL, UK
| | - Chris G Wilkinson
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.,Leeds Institute for Data Analytics, University of Leeds, Worsley Building, Level 11, Clarendon Way, Leeds, LS2 9NL, UK.,Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Martin R Cowie
- Faculty of Medicine, National Heart & Lung Institute, Imperial College London, London, UK.,Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Marlous Hall
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK. .,Leeds Institute for Data Analytics, University of Leeds, Worsley Building, Level 11, Clarendon Way, Leeds, LS2 9NL, UK.
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25
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Cardiovascular Healthcare in 2020 – Alarming Realities in Romania. JOURNAL OF INTERDISCIPLINARY MEDICINE 2020. [DOI: 10.2478/jim-2020-0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Greenwood JP, Walker S. Stress CMR Imaging for Stable Chest Pain Syndromes. JACC Cardiovasc Imaging 2020; 13:1518-1520. [DOI: 10.1016/j.jcmg.2020.04.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 04/08/2020] [Accepted: 04/09/2020] [Indexed: 02/04/2023]
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Javanbakht M, Trevor M, Rezaei Hemami M, Rahimi K, Branagan-Harris M, Degener F, Adam D, Preissing F, Scheier J, Cook SF, Mortensen E. Ticagrelor Removal by CytoSorb ® in Patients Requiring Emergent or Urgent Cardiac Surgery: A UK-Based Cost-Utility Analysis. PHARMACOECONOMICS - OPEN 2020; 4:307-319. [PMID: 31620999 PMCID: PMC7248150 DOI: 10.1007/s41669-019-00183-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
BACKGROUND Acute coronary syndrome patients receiving dual antiplatelet therapy who need emergent or urgent cardiac surgery are at high risk of major bleeding, which can impair postoperative outcomes. CytoSorb®, a blood purification technology based on adsorbent polymer, has been demonstrated to remove ticagrelor from blood during on-pump cardiac surgery. OBJECTIVE The aim of this study was to evaluate the cost utility of intraoperative removal of ticagrelor using CytoSorb versus usual care among patients requiring emergent or urgent cardiac surgery in the UK. METHODS A de novo decision analytic model, based on current treatment pathways, was developed to estimate the short- and long-term costs and outcomes. Results from randomised clinical trials and national standard sources such as National Health Service (NHS) reference costs were used to inform the model. Costs were estimated from the NHS and Personal Social Services perspective. Deterministic and probabilistic sensitivity analyses (PSAs) explored the uncertainty surrounding the input parameters. RESULTS In emergent cardiac surgery, intraoperative removal of ticagrelor using CytoSorb was less costly (£12,933 vs. £16,874) and more effective (0.06201vs. 0.06091 quality-adjusted life-years) than cardiac surgery without physiologic clearance of ticagrelor over a 30-day time horizon. For urgent cardiac surgery, the use of CytoSorb was less costly than any of the three comparators-delaying surgery for natural washout without adjunctive therapy, adjunctive therapy with short-acting antiplatelet agents, or adjunctive therapy with low-molecular-weight heparin. Results from the PSAs showed that CytoSorb has a high probability of being cost saving (99% in emergent cardiac surgery and 53-77% in urgent cardiac surgery, depending on the comparators). Cost savings derive from fewer transfusions of blood products and re-thoracotomies, and shorter stay in the hospital/intensive care unit. CONCLUSIONS The implementation of CytoSorb as an intraoperative intervention for patients receiving ticagrelor undergoing emergent or urgent cardiac surgery is a cost-saving strategy, yielding improvement in perioperative and postoperative outcomes and decreased health resource use.
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Affiliation(s)
- Mehdi Javanbakht
- Optimax Access UK Ltd, Market Access Consultancy, 20 Forth Banks Tower, Newcastle upon Tyne, NE1 3PN, UK.
- Device Access UK Ltd, Market Access Consultancy, University of Southampton Science Park, Chilworth Hampshire, UK.
| | | | | | - Kazem Rahimi
- The George Institute for Global Health, University of Oxford, Oxford, UK
| | - Michael Branagan-Harris
- Device Access UK Ltd, Market Access Consultancy, University of Southampton Science Park, Chilworth Hampshire, UK
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Kirsch F, Becker C, Schramm A, Maier W, Leidl R. Patients with coronary artery disease after acute myocardial infarction: effects of continuous enrollment in a structured Disease Management Program on adherence to guideline-recommended medication, health care expenditures, and survival. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2020; 21:607-619. [PMID: 32006188 PMCID: PMC7214389 DOI: 10.1007/s10198-020-01158-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 01/06/2020] [Indexed: 05/15/2023]
Abstract
OBJECTIVE Acute myocardial infarction (AMI) carries increased risk of mortality and excess costs. Disease Management Programs (DMPs) providing guideline-recommended care for chronic diseases seem an intuitively appealing way to enhance health outcomes for patients with chronic conditions such as AMI. The aim of the study is to compare adherence to guideline-recommended medication, health care expenditures and survival of patients enrolled and not enrolled in the German DMP for coronary artery disease (CAD) after an AMI from the perspective of a third-party payer over a follow-up period of 3 years. METHODS The study is based on routinely collected data from a regional statutory health insurance fund (n = 15,360). A propensity score matching with caliper method was conducted. Afterwards guideline-recommended medication, health care expenditures, and survival between patients enrolled and not enrolled in the DMP were compared with generalized linear and Cox proportional hazard models. RESULTS The propensity score matching resulted in 3870 pairs of AMI patients previously and continuously enrolled and not enrolled in the DMP. In the 3-year follow-up period the proportion of days covered rates for ACE-inhibitors (60.95% vs. 58.92%), anti-platelet agents (74.20% vs. 70.66%), statins (54.18% vs. 52.13%), and β-blockers (61.95% vs. 52.64%) were higher in the DMP group. Besides that, DMP participants induced lower health care expenditures per day (€58.24 vs. €72.72) and had a significantly lower risk of death (HR: 0.757). CONCLUSION Previous and continuous enrollment in the DMP CAD for patients after AMI is a promising strategy as it enhances guideline-recommended medication, reduces health care expenditures and the risk of death.
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Affiliation(s)
- Florian Kirsch
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München, Neuherberg, Germany.
- Munich School of Management and Munich Center of Health Sciences, Ludwig-Maximilians-Universität, Munich, Germany.
| | - Christian Becker
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München, Neuherberg, Germany
| | - Anja Schramm
- AOK Bayern, Service Center of Health Care Management, Regensburg, Germany
| | - Werner Maier
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München, Neuherberg, Germany
| | - Reiner Leidl
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München, Neuherberg, Germany
- Munich School of Management and Munich Center of Health Sciences, Ludwig-Maximilians-Universität, Munich, Germany
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Ride J, Kasteridis P, Gutacker N, Aragon Aragon MJ, Jacobs R. Healthcare Costs for People with Serious Mental Illness in England: An Analysis of Costs Across Primary Care, Hospital Care, and Specialist Mental Healthcare. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2020; 18:177-188. [PMID: 31701484 PMCID: PMC7085478 DOI: 10.1007/s40258-019-00530-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
BACKGROUND Serious mental illness (SMI) is a set of disabling conditions associated with poor outcomes and high healthcare utilisation. However, little is known about patterns of utilisation and costs across sectors for people with SMI. OBJECTIVE The aim was to develop a costing methodology and estimate annual healthcare costs for people with SMI in England across primary and secondary care settings. METHODS A retrospective observational cohort study was conducted using linked administrative records from primary care, emergency departments, inpatient admissions, and community mental health services, covering financial years 2011/12-2013/14. Costs were calculated using bottom-up costing and are expressed in 2013/14 British pounds (GBP). Determinants of annual costs by sector were estimated using generalised linear models. RESULTS Mean annual total healthcare costs for 13,846 adults with SMI were £4989 (median £1208), comprising 19% from primary care (£938, median £531), 34% from general hospital care (£1717, median £0), and 47% from inpatient and community-based specialist mental health services (£2334, median £0). Mean annual costs related specifically to mental health, as distinct from physical health, were £2576 (median £290). Key predictors of total cost included physical comorbidities, ethnicity, neighbourhood deprivation, SMI diagnostic subgroup, and age. Some associations varied across care context; for example, older age was associated with higher primary care and hospital costs, but lower mental healthcare costs. CONCLUSIONS Annual healthcare costs for people with SMI vary significantly across clinical and socioeconomic characteristics and healthcare sectors. This analysis informs policy and research, including estimation of health budgets for particular patient profiles, and economic evaluation of health services and policies.
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Affiliation(s)
- Jemimah Ride
- Health Economics Unit, Melbourne School of Population and Global Health, University of Melbourne, Level 4, 207 Bouverie Street, Parkville, VIC 3010 Australia
| | | | - Nils Gutacker
- Centre for Health Economics, University of York, York, UK
| | | | - Rowena Jacobs
- Centre for Health Economics, University of York, York, UK
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Asher A, Ghelani R, Thornton G, Rathod K, Jones D, Wragg A, Timmis A. UK perspective on the changing landscape of non-invasive cardiac testing. Open Heart 2019; 6:e001186. [PMID: 31908814 PMCID: PMC6927513 DOI: 10.1136/openhrt-2019-001186] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 11/07/2019] [Accepted: 11/18/2019] [Indexed: 11/28/2022] Open
Abstract
Objective To document UK rates of exercise treadmill testing, functional stress testing and CT coronary angiography (CTCA). Specific aims were to determine how rates have changed in the context of changing guideline recommendations within the UK and to identify regional inequalities in the utilisation of testing modalities. Secondary objectives were to compare these trends with national data on revascularisation. Methods 159 acute National Health Service trusts were served Freedom of Information (FOI) requests to provide total numbers of CTCA and functional imaging tests for each financial year from 2011–2012 to 2016–2017. Results The FOI requests yielded data from 88% of Trusts, increasing from 81.9% in 2011–2012% to 92.1% in 2016–2017. Exercise treadmill tests (ETTs) were performed by over 97% of Trusts. ETT was the most commonly performed diagnostic test in the UK across the study period despite declining by 8.4%. Utilisation of non-invasive stress imaging tests increased by 80.9% during the same period. Myocardial perfusion scintigraphy and stress echocardiography increased by 25.8% and 73.9%, respectively. The 268% increase in CTCA scans was yet greater. Trends in test utilisation during the study period showed important regional differences between devolved nations. Comparably, only small changes in rates of invasive coronary angiography and revascularisation have been reported during the study period. Conclusion Non-invasive imaging in UK Trusts has increased substantially since 2010 with only a small decline in use of the ETT and minimal changes in rates of invasive coronary angiography and revascularisation in the same time period.
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Affiliation(s)
- Alex Asher
- Cardiology, Barts Health NHS Trust, London, UK
| | | | | | | | - Daniel Jones
- Cardiology, Barts Health NHS Trust, London, UK.,Faculty of Medicine and Dentistry, Barts and The London School of Medicine and Dentistry Postgraduate Studies, London, UK
| | - Andrew Wragg
- Faculty of Medicine and Dentistry, Barts and The London School of Medicine and Dentistry Postgraduate Studies, London, UK.,Cardiology, Barts Health NHS Trust, London, UK
| | - Adam Timmis
- Faculty of Medicine and Dentistry, Barts and The London School of Medicine and Dentistry Postgraduate Studies, London, UK.,Cardiology, Barts Health NHS Trust, London, UK
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Wang Q, Zhang S, Wang Y, Zhang X, Zhang Y. Factors Associated With Hospitalization Costs of Coronary Heart Disease in Township Hospitals in Rural China. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2019; 56:46958019886958. [PMID: 31701787 PMCID: PMC6843734 DOI: 10.1177/0046958019886958] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
In large proportions of rural areas in many developing countries, health care delivery system is less developed and is less likely to be equipped to conduct sophisticated treatment for coronary heart disease (CHD) patients locally. This study aims at describing the status quo of and exploring factors associated with hospitalization costs of CHD in township hospitals where only drug therapy was available for CHD conditions. We collected data of inpatients with CHD from discharge records from 10 township hospitals in rural Liaoning from December 2013 to December 2014. We used multilevel linear regression to analyze the factors associated with CHD hospitalization costs. A total of 4635 inpatients were included in the analysis. We found that the average hospitalization costs were 6249.97 RMB (US$1012.47) with the average of 8.89 days of hospitalization in township hospitals in Liaoning. Age, gender, length of stay, the number of times of admissions, by which route was hospitalized, and type of CHD were all the factors significantly associated with hospitalization costs of CHD in township hospitals. The factors associated with hospitalization costs of CHD in township hospitals in rural China showed some different features from the existing studies. When the government designs the related policy, the policy makers need to consider the specific feature of hospitalization costs of CHD in township hospitals in rural areas.
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Affiliation(s)
- Qun Wang
- Dalian University of Technology, China
| | | | - Yaling Wang
- Affiliated Fuyang Hospital of Anhui Medical University, China
| | - Xichun Zhang
- Administration Office of New Rural Cooperative Medical System in Liaoning, Shenyang, China
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Virk HUH, Tripathi B, Kumar V, Lakhter V, Khan MS, Ijaz SH, Dean S, Gupta S, Sharma P, Mishra R, George JC, Gopalan R, Zidar D, Janzer S. Causes, Trends, and Predictors of 90-Day Readmissions After Spontaneous Coronary Artery Dissection (from A Nationwide Readmission Database). Am J Cardiol 2019; 124:1333-1339. [PMID: 31551116 DOI: 10.1016/j.amjcard.2019.07.058] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 07/21/2019] [Accepted: 07/23/2019] [Indexed: 11/25/2022]
Abstract
Spontaneous coronary artery dissection (SCAD) is a frequently missed diagnosis in patients presenting with acute coronary syndrome (ACS). Our aim was to evaluate the causes, trends, and predictors of 90-day hospital readmission in patients presenting with SCAD. The Nationwide Readmissions Database (2013 to 2014) was utilized to identify patients with primary discharge diagnosis of SCAD using the International Classification of Diseases, Ninth Revision, Clinical Modification, diagnostic code 414.12. The primary outcome was 90-day readmission. Among 11,228 patients admitted with the primary diagnosis of SCAD, 2,424 patients (21.6%) were readmitted within 90 days (68% women, 82% <65 years of age). Common causes for 90-day readmission were ACS (25%), acute heart failure (11%), acute respiratory failure (7%), and arrhythmias (5%). Multivariate predictors of 90-day readmissions were hypertension, chronic obstructive pulmonary disease, peripheral arterial disease, discharge to facility and increased length of stay (LOS) during index admission. Multivariate predictors of increased healthcare-related costs were older age, female gender, discharge to facility, and increased LOS. Over half of the readmissions (52%) occurred in first 30 days after discharge. In conclusion, we found a high rate of rehospitalization among SCAD patients, particularly within the first 30 days of index hospitalization. ACS, heart failure, and acute respiratory failure were the most common reasons for readmission. Hypertension, chronic obstructive pulmonary disease, peripheral arterial disease, and increased LOS were independent predictors of readmission. Further studies are warranted to confirm these predictors of readmission in this high-risk population.
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Ryder S, Fox K, Rane P, Armstrong N, Wei CY, Deshpande S, Stirk L, Qian Y, Kleijnen J. A Systematic Review of Direct Cardiovascular Event Costs: An International Perspective. PHARMACOECONOMICS 2019; 37:895-919. [PMID: 30949988 DOI: 10.1007/s40273-019-00795-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
INTRODUCTION There is a lack of comprehensive cost information for cardiovascular events since 2013. OBJECTIVE A systematic review on the contemporary cost of cardiovascular events was therefore undertaken. METHODS Methods complied with those recommended by the Cochrane Collaboration and the Centre for Reviews and Dissemination. Studies were unrestricted by language, were from 2013 to 23 December 2017, and included cost-of-illness data in adults with the following cardiovascular conditions: myocardial infarction (MI), stroke, transient ischaemic attack (TIA), heart failure (HF), unstable angina (UA), coronary artery bypass graft (CABG), percutaneous coronary intervention (PCI), or peripheral artery disease (PAD). Seven electronic databases were searched, namely Embase (Ovid), MEDLINE (Ovid), MEDLINE In-Process Citations and Daily Update (Ovid), NHS Economic Evaluation Database (NHS EED), Health Technology Assessment (HTA) database, Cochrane Central Register of Controlled Trials (CENTRAL), and PubMed. The included studies reported data from a variety of years (sometimes prior to 2013), so costs were inflated and converted to $US, year 2018 values, for standardization. RESULTS After de-duplication, 29,945 titles and abstracts and then 403 full papers were screened; 82 studies (88 papers) were extracted. Year 1 average cost ranges were as follows: MI ($11,970 in Sweden to $61,864 in the USA), stroke ($10,162 in Spain to $46,162 in the USA), TIA ($6049 in Sweden to $25,306 in the USA), HF ($4456 in China to $49,427 in the USA), UA ($11,237 in Sweden to $31,860 in the USA), PCI ($17,923 in Italy to $45,533 in the USA), CABG ($17,972 in the UK to $76,279 in the USA). One Swedish study reported PAD costs in a format convertible to $US, 2018 values, with a mean annual cost of $15,565. CONCLUSIONS There was considerable unexplained variation in contemporary costs for all major cardiovascular events. One emerging theme was that average costs in the USA were considerably higher than anywhere else.
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Affiliation(s)
- Steve Ryder
- Kleijnen Systematic Reviews Ltd, Unit 6, Escrick Business Park, Riccall Road, Escrick, York, YO19 6FD, UK.
| | - Kathleen Fox
- Strategic Healthcare Solutions LLC, 133 Cottonwood Creek Lane, Aiken, SC, 29803, USA
| | - Pratik Rane
- Amgen Inc, One Amgen Center Drive, Thousand Oaks, CA, 91320-1799, USA
| | - Nigel Armstrong
- Kleijnen Systematic Reviews Ltd, Unit 6, Escrick Business Park, Riccall Road, Escrick, York, YO19 6FD, UK
| | - Ching-Yun Wei
- Kleijnen Systematic Reviews Ltd, Unit 6, Escrick Business Park, Riccall Road, Escrick, York, YO19 6FD, UK
| | - Sohan Deshpande
- Kleijnen Systematic Reviews Ltd, Unit 6, Escrick Business Park, Riccall Road, Escrick, York, YO19 6FD, UK
| | - Lisa Stirk
- Kleijnen Systematic Reviews Ltd, Unit 6, Escrick Business Park, Riccall Road, Escrick, York, YO19 6FD, UK
| | - Yi Qian
- Amgen Inc, One Amgen Center Drive, Thousand Oaks, CA, 91320-1799, USA
| | - Jos Kleijnen
- School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
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Franklin M, Lomas J, Walker S, Young T. An Educational Review About Using Cost Data for the Purpose of Cost-Effectiveness Analysis. PHARMACOECONOMICS 2019; 37:631-643. [PMID: 30746613 DOI: 10.1007/s40273-019-00771-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
This paper provides an educational review covering the consideration of costs for cost-effectiveness analysis (CEA), summarising relevant methods and research from the published literature. Cost data are typically generated by applying appropriate unit costs to healthcare resource-use data for patients. Trial-based evaluations and decision analytic modelling represent the two main vehicles for CEA. The costs to consider will depend on the perspective taken, with conflicting recommendations ranging from focusing solely on healthcare to the broader 'societal' perspective. Alternative sources of resource-use are available, including medical records and forms completed by researchers or patients. Different methods are available for the statistical analysis of cost data, although consideration needs to be given to the appropriate methods, given cost data are typically non-normal with a mass point at zero and a long right-hand tail. The choice of covariates for inclusion in econometric models also needs careful consideration, focusing on those that are influential and that will improve balance and precision. Where data are missing, it is important to consider the type of missingness and then apply appropriate analytical methods, such as imputation. Uncertainty around costs should also be reflected to allow for consideration on the impacts of the CEA results on decision uncertainty. Costs should be discounted to account for differential timing, and are typically inflated to a common cost year. The choice of methods and sources of information used when accounting for cost information within CEA will have an effect on the subsequent cost-effectiveness results and how information is presented to decision makers. It is important that the most appropriate methods are used as overlooking the complicated nature of cost data could lead to inaccurate information being given to decision makers.
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Affiliation(s)
- Matthew Franklin
- Health Economics and Decision Science (HEDS), School of Health and Related Research (ScHARR), University of Sheffield, West Court, 1 Mappin Street, Sheffield, S1 4DT, UK.
| | - James Lomas
- Centre for Health Economics, University of York, Heslington, York, YO10 5DD, UK
| | - Simon Walker
- Centre for Health Economics, University of York, Heslington, York, YO10 5DD, UK
| | - Tracey Young
- Health Economics and Decision Science (HEDS), School of Health and Related Research (ScHARR), University of Sheffield, West Court, 1 Mappin Street, Sheffield, S1 4DT, UK
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Lomas J, Asaria M, Bojke L, Gale CP, Richardson G, Walker S. Which Costs Matter? Costs Included in Economic Evaluation and their Impact on Decision Uncertainty for Stable Coronary Artery Disease. PHARMACOECONOMICS - OPEN 2018; 2:403-413. [PMID: 29446055 PMCID: PMC6249199 DOI: 10.1007/s41669-018-0068-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND Variation exists in the resource categories included in economic evaluations, and National Institute for Health and Care Excellence (NICE) guidance suggests the inclusion only of costs related to the index condition or intervention. However, there is a growing consensus that all healthcare costs should be included in economic evaluations for Health Technology Assessments (HTAs), particularly those related to extended years of life. OBJECTIVE AND METHODS We aimed to quantify the impact of a range of cost categories on the adoption decision about a hypothetical intervention, and uncertainty around that decision, for stable coronary artery disease (SCAD) based on a dataset comprising 94,966 patients. Three costing scenarios were considered: coronary heart disease (CHD) costs only, cardiovascular disease (CVD) costs and all costs. The first two illustrate different interpretations of what might be regarded as related costs. RESULTS Employing a 20-year time horizon, the highest mean expected incremental cost was when all costs were included (£2468) and the lowest when CVD costs only were included (£2377). The probability of the treatment being cost effective, estimating health opportunity costs using a ratio of £30,000 per quality-adjusted life-year (QALY), was different for each of the CHD (70%) costs, CVD costs (73%) and all costs (56%) scenarios. The results concern a hypothetical intervention and are illustrative only, as such they cannot necessarily be generalised to all interventions and diseases. CONCLUSIONS Cost categories included in an economic evaluation of SCAD impact on estimates of both cost effectiveness and decision uncertainty. With an aging and co-morbid population, the inclusion of all healthcare costs may have important ramifications for the selection of healthcare provision on economic grounds.
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Affiliation(s)
- James Lomas
- Centre for Health Economics, University of York, York, YO10 5DD, UK.
| | - Miqdad Asaria
- Centre for Health Economics, University of York, York, YO10 5DD, UK
| | - Laura Bojke
- Centre for Health Economics, University of York, York, YO10 5DD, UK
| | - Chris P Gale
- MRC Bioinformatics Centre, LICAMM, University of Leeds, Leeds, UK
| | - Gerry Richardson
- Centre for Health Economics, University of York, York, YO10 5DD, UK
| | - Simon Walker
- Centre for Health Economics, University of York, York, YO10 5DD, UK
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Pandya A, Doran T, Zhu J, Walker S, Arntson E, Ryan AM. Modelling the cost-effectiveness of pay-for-performance in primary care in the UK. BMC Med 2018; 16:135. [PMID: 30153827 PMCID: PMC6114231 DOI: 10.1186/s12916-018-1126-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 07/12/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Introduced in 2004, the United Kingdom's (UK) Quality and Outcomes Framework (QOF) is the world's largest primary-care pay-for-performance programme. Given some evidence of the benefits and the substantial costs associated with the QOF, it remains unclear whether the programme is cost-effective. Therefore, we assessed the cost-effectiveness of continuing versus stopping the QOF. METHODS We developed a lifetime simulation model to estimate quality-adjusted life years (QALYs) and costs for a UK population cohort aged 40-74 years (n = 27,070,862) exposed to the QOF and for a counterfactual scenario without exposure. Based on a previous retrospective cross-country analysis using data from 1994 to 2010, we assumed the benefits of the QOF to be a change in age-adjusted mortality of -3.68 per 100,000 population (95% confidence interval -8.16 to 0.80). We used cost-effectiveness thresholds of £30,000/QALY, £20,000/QALY and £13,000/QALY to determine the optimal strategy in base-case and sensitivity analyses. RESULTS In the base-case analysis, continuing the QOF increased population-level QALYs and health-care costs yielding an incremental cost-effectiveness ratio (ICER) of £49,362/QALY. The ICER remained >£30,000/QALY in scenarios with and without non-fatal outcomes or increased drug costs, and under differing assumptions about the duration of QOF benefit following its hypothetical discontinuation. The ICER for continuing the programme fell below £30,000/QALY when QOF incentive payments were 36% lower (while preserving QOF mortality benefits), and in scenarios where the QOF resulted in substantial reductions in health-care spending or non-fatal cardiovascular disease events. Continuing the QOF was cost-effective in 18%, 3% and 0% of probabilistic sensitivity analysis iterations using thresholds of £30,000/QALY, £20,000/QALY and £13,000/QALY, respectively. CONCLUSIONS Compared to stopping the QOF and returning all associated incentive payments to the National Health Service, continuing the QOF is not cost-effective. To improve population health efficiently, the UK should redesign the QOF or pursue alternative interventions.
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Affiliation(s)
- Ankur Pandya
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, 718 Huntington Ave, 2nd Floor, Boston, MA, 02115, USA. .,Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Tim Doran
- Department of Health Sciences, University of York, Heslington, York, UK
| | - Jinyi Zhu
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Simon Walker
- Centre for Health Economics, University of York, Heslington, York, UK
| | - Emily Arntson
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Andrew M Ryan
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA
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Timmis A, Raharja A, Archbold RA, Mathur A. Validity of inducible ischaemia as a surrogate for adverse outcomes in stable coronary artery disease. Heart 2018; 104:1733-1738. [PMID: 29875140 PMCID: PMC6241629 DOI: 10.1136/heartjnl-2018-313230] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 04/25/2018] [Accepted: 05/17/2018] [Indexed: 01/09/2023] Open
Abstract
Regional myocardial ischaemia is commonly expressed as exertional angina in patients with stable coronary artery disease (CAD). It also associates with prognosis, risk tending to increase with the severity of ischaemia. The validity of myocardial ischaemia as a surrogate for adverse clinical outcomes, however, has not been well established. Thus, in cohort studies, ischaemia testing has failed to influence rates of myocardial infarction and coronary death. Moreover, in clinical studies, pharmacological and interventional treatments that are effective in correcting ischaemia have rarely been shown to reduce cardiovascular (CV) risk. This contrasts with statins and other anti-inflammatory drugs that have no direct effect on ischaemia but improve CV outcomes by modifying the atherothrombotic disease process. Despite this, and with little evidence of patient benefit, stress testing is commonly used during the follow-up of patients with stable CAD when the demonstration of ischaemic change may be seen as a target for treatment, independently of symptomatic status. Substitution of a symptom-driven management strategy has the potential to reduce rates of non-invasive stress testing, unnecessary downstream revascularisation procedures and use of valuable resources in patients with stable CAD without adverse consequences for CV risk.
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Affiliation(s)
- Adam Timmis
- Barts and The London School of Medicine and Dentistry, Queen Mary University London, London, UK.,Department of Interventional Cardiology, Barts Heart Centre, London, UK
| | - Antony Raharja
- Barts and The London School of Medicine and Dentistry, Queen Mary University London, London, UK
| | - R Andrew Archbold
- Department of Interventional Cardiology, Barts Heart Centre, London, UK
| | - Anthony Mathur
- Barts and The London School of Medicine and Dentistry, Queen Mary University London, London, UK.,Department of Interventional Cardiology, Barts Heart Centre, London, UK
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Asthana S, Moon G, Gibson A, Bailey T, Hewson P, Dibben C. Inequity in cardiovascular care in the English National Health Service (NHS): a scoping review of the literature. HEALTH & SOCIAL CARE IN THE COMMUNITY 2018; 26:259-272. [PMID: 27747961 DOI: 10.1111/hsc.12384] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/11/2016] [Indexed: 06/06/2023]
Abstract
There is a general understanding that socioeconomically disadvantaged people are also disadvantaged with respect to their access to NHS care. Insofar as considerable NHS funding has been targeted at deprived areas, it is important to better understand whether and why socioeconomic variations in access and utilisation exist. Exploring this question with reference to cardiovascular care, our aims were to synthesise and evaluate evidence relating to access to and/or use of English NHS services around (i) different points on the care pathway (i.e. presentation, primary management and specialist management) and (ii) different dimensions of inequality (socioeconomic, age- and gender-related, ethnic or geographical). Restricting our search period from 2004 to 2016, we were concerned to examine whether, compared to earlier research, there has been a change in the focus of research examining inequalities in cardiac care and whether the pro-rich bias reported in the late 1990s and early 2000s still applies today. We conducted a scoping study drawing on Arksey & O'Malley's framework. A total of 174 studies were included in the review and appraised for methodological quality. Although, in the past decade, there has been a shift in research focus away from gender and age inequalities in access/use and towards socioeconomic status and ethnicity, evidence that deprived people are less likely to access and use cardiovascular care is very contradictory. Patterns of use appear to vary by ethnicity; South Asian populations enjoying higher access, black populations lower. By contrast, female gender and older age are consistently associated with inequity in cardiovascular care. The degree of geographical variation in access/use is also striking. Finally, evidence of inequality increases with stage on the care pathway, which may indicate that barriers to access arise from the way in which health professionals are adjudicating health needs rather than a failure to seek help in the first place.
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Affiliation(s)
- Sheena Asthana
- School of Government, University of Plymouth, Plymouth, UK
| | - Graham Moon
- School of Geography and the Environment, University of Southampton, Southampton, UK
| | - Alex Gibson
- School of Government, University of Plymouth, Plymouth, UK
| | - Trevor Bailey
- Mathematics and Physical Sciences, University of Exeter, Exeter, UK
| | - Paul Hewson
- School of Computing and Mathematics, University of Plymouth, Plymouth, UK
| | - Chris Dibben
- School of Geosciences, University of Edinburgh, Edinburgh, UK
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Hall M, Dondo TB, Yan AT, Mamas MA, Timmis AD, Deanfield JE, Jernberg T, Hemingway H, Fox KAA, Gale CP. Multimorbidity and survival for patients with acute myocardial infarction in England and Wales: Latent class analysis of a nationwide population-based cohort. PLoS Med 2018; 15:e1002501. [PMID: 29509764 PMCID: PMC5839532 DOI: 10.1371/journal.pmed.1002501] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 01/08/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND There is limited knowledge of the scale and impact of multimorbidity for patients who have had an acute myocardial infarction (AMI). Therefore, this study aimed to determine the extent to which multimorbidity is associated with long-term survival following AMI. METHODS AND FINDINGS This national observational study included 693,388 patients (median age 70.7 years, 452,896 [65.5%] male) from the Myocardial Ischaemia National Audit Project (England and Wales) who were admitted with AMI between 1 January 2003 and 30 June 2013. There were 412,809 (59.5%) patients with multimorbidity at the time of admission with AMI, i.e., having at least 1 of the following long-term health conditions: diabetes, chronic obstructive pulmonary disease or asthma, heart failure, renal failure, cerebrovascular disease, peripheral vascular disease, or hypertension. Those with heart failure, renal failure, or cerebrovascular disease had the worst outcomes (39.5 [95% CI 39.0-40.0], 38.2 [27.7-26.8], and 26.6 [25.2-26.4] deaths per 100 person-years, respectively). Latent class analysis revealed 3 multimorbidity phenotype clusters: (1) a high multimorbidity class, with concomitant heart failure, peripheral vascular disease, and hypertension, (2) a medium multimorbidity class, with peripheral vascular disease and hypertension, and (3) a low multimorbidity class. Patients in class 1 were less likely to receive pharmacological therapies compared with class 2 and 3 patients (including aspirin, 83.8% versus 87.3% and 87.2%, respectively; β-blockers, 74.0% versus 80.9% and 81.4%; and statins, 80.6% versus 85.9% and 85.2%). Flexible parametric survival modelling indicated that patients in class 1 and class 2 had a 2.4-fold (95% CI 2.3-2.5) and 1.5-fold (95% CI 1.4-1.5) increased risk of death and a loss in life expectancy of 2.89 and 1.52 years, respectively, compared with those in class 3 over the 8.4-year follow-up period. The study was limited to all-cause mortality due to the lack of available cause-specific mortality data. However, we isolated the disease-specific association with mortality by providing the loss in life expectancy following AMI according to multimorbidity phenotype cluster compared with the general age-, sex-, and year-matched population. CONCLUSIONS Multimorbidity among patients with AMI was common, and conferred an accumulative increased risk of death. Three multimorbidity phenotype clusters that were significantly associated with loss in life expectancy were identified and should be a concomitant treatment target to improve cardiovascular outcomes. TRIAL REGISTRATION ClinicalTrials.gov NCT03037255.
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Affiliation(s)
- Marlous Hall
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
- * E-mail:
| | - Tatendashe B. Dondo
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Andrew T. Yan
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mamas A. Mamas
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom
| | - Adam D. Timmis
- NIHR Cardiovascular Biomedical Research Unit, Barts Heart Centre, London, United Kingdom
| | - John E. Deanfield
- National Institute for Cardiovascular Outcomes Research, University College London, London, United Kingdom
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Harry Hemingway
- Farr Institute of Health Informatics Research, University College London, London, United Kingdom
- NIHR Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, University College London, London, United Kingdom
| | - Keith A. A. Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Chris P. Gale
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
- York Teaching Hospital NHS Foundation Trust, York, United Kingdom
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Timmis A, Townsend N, Gale C, Grobbee R, Maniadakis N, Flather M, Wilkins E, Wright L, Vos R, Bax J, Blum M, Pinto F, Vardas P. European Society of Cardiology: Cardiovascular Disease Statistics 2017. Eur Heart J 2017; 39:508-579. [PMID: 29190377 DOI: 10.1093/eurheartj/ehx628] [Citation(s) in RCA: 511] [Impact Index Per Article: 73.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 10/26/2017] [Indexed: 12/26/2022] Open
Abstract
Aims The European Society of Cardiology (ESC) Atlas has been compiled by the European Heart Agency to document cardiovascular disease (CVD) statistics of the 56 ESC member countries. A major aim of this 2017 data presentation has been to compare high-income and middle-income ESC member countries to identify inequalities in disease burden, outcomes, and service provision. Methods and results The Atlas utilizes a variety of data sources, including the World Health Organization, the Institute for Health Metrics and Evaluation, and the World Bank to document risk factors, prevalence, and mortality of cardiovascular disease and national economic indicators. It also includes novel ESC-sponsored survey data of health infrastructure and cardiovascular service provision provided by the national societies of the ESC member countries. Data presentation is descriptive with no attempt to attach statistical significance to differences observed in stratified analyses. Important differences were identified between the high-income and middle-income member countries of the ESC with regard to CVD risk factors, disease incidence, and mortality. For both women and men, the age-standardized prevalence of hypertension was lower in high-income countries (18% and 27%) compared with middle-income countries (24% and 30%). Smoking prevalence in men (not women) was also lower (26% vs. 41%) and together these inequalities are likely to have contributed to the higher CVD mortality in middle-income countries. Declines in CVD mortality have seen cancer becoming a more common cause of death in a number of high-income member countries, but in middle-income countries declines in CVD mortality have been less consistent where CVD remains the leading cause of death. Inequalities in CVD mortality are emphasized by the smaller contribution they make to potential years of life lost in high-income countries compared with middle-income countries both for women (13% vs. 23%) and men (20% vs. 27%). The downward mortality trends for CVD may, however, be threatened by the emerging obesity epidemic that is seeing rates of diabetes increasing across all the ESC member countries. Survey data from the National Cardiac Societies showed that rates of cardiac catheterization and coronary artery bypass surgery, as well as the number of specialist centres required to deliver them, were greatest in the high-income member countries of the ESC. The Atlas confirmed that these ESC member countries, where the facilities for the contemporary treatment of coronary disease were best developed, were often those in which declines in coronary mortality have been most pronounced. Economic resources were not the only driver for delivery of equitable cardiovascular health care, as some middle-income ESC member countries reported rates for interventional procedures and device implantations that matched or exceeded the rates in wealthier member countries. Conclusion In documenting national CVD statistics, the Atlas provides valuable insights into the inequalities in risk factors, health care delivery, and outcomes of CVD across the ESC member countries. The availability of these data will underpin the ESC's ambitious mission 'to reduce the burden of cardiovascular disease' not only in its member countries but also in nation states around the world.
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Affiliation(s)
- Adam Timmis
- Department of Cardiology, Barts Heart Centre, Queen Mary University, West Smithfield, London, UK
| | - Nick Townsend
- Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, UK
| | - Chris Gale
- Division of Epidemiology, Medical Research Council Bioinformatics Centre, Leeds Institute of Cardiovascular and Metabolic Medicine, Worsley Building, Level 11, Clarendon Way, University of Leeds, Leeds, UK
| | - Rick Grobbee
- Department of Clinical Epidemiology, University Medical Center, Heidelberglaan 100, CX Utrecht, Netherlands
| | - Nikos Maniadakis
- European Society of Cardiology Health Policy Unit, European Heart Health Institute, 29 Square de Meeus, 4th Floor, Brussels, Belgium
| | - Marcus Flather
- Department of Medicine and Health Sciences, Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, UK
| | - Elizabeth Wilkins
- Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, UK
| | - Lucy Wright
- Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, UK
| | - Rimke Vos
- Department of Clinical Epidemiology, University Medical Center, Heidelberglaan 100, CX Utrecht, Netherlands
| | - Jeroen Bax
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, ZA Leiden, Netherlands
| | - Maxim Blum
- European Society of Cardiology Health Policy Unit, European Heart Health Institute, 29 Square de Meeus, 4th Floor, Brussels, Belgium
| | - Fausto Pinto
- Department of Cardiology, University Hospital Santa Maria, University of Lisbon, Avenida Professor Egas Moniz, Lisbon, Portugal
| | - Panos Vardas
- European Society of Cardiology Health Policy Unit, European Heart Health Institute, 29 Square de Meeus, 4th Floor, Brussels, Belgium
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Timmis A, Gale CP, Flather M, Maniadakis N, Vardas P. Cardiovascular disease statistics from the European atlas: inequalities between high- and middle-income member countries of the ESC. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2017; 4:1-3. [DOI: 10.1093/ehjqcco/qcx045] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Salmoirago-Blotcher E, Wayne PM, Dunsiger S, Krol J, Breault C, Bock BC, Wu WC, Yeh GY. Tai Chi Is a Promising Exercise Option for Patients With Coronary Heart Disease Declining Cardiac Rehabilitation. J Am Heart Assoc 2017; 6:e006603. [PMID: 29021268 PMCID: PMC5721863 DOI: 10.1161/jaha.117.006603] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 08/15/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND More than 60% of patients decline participation in cardiac rehabilitation after a myocardial infarction. Options to improve physical activity (PA) and other risk factors in these high-risk individuals are limited. We conducted a phase 2 randomized controlled trial to determine feasibility, safety, acceptability, and estimates of effect of tai chi on PA, fitness, weight, and quality of life. METHODS AND RESULTS Patients with coronary heart disease declining cardiac rehabilitation enrollment were randomized to a "LITE" (2 sessions/week for 12 weeks) or to a "PLUS" (3 sessions/week for 12 weeks, then maintenance classes for 12 additional weeks) condition. PA (accelerometry), weight, and quality of life (Health Survey Short Form) were measured at baseline and 3, 6, and 9 months after baseline; aerobic fitness (stress test) was measured at 3 months. Twenty-nine participants (13 PLUS and 16 LITE) were enrolled. Retention at 9 months was 90% (LITE) and 88% (PLUS). No serious tai chi-related adverse events occurred. Significant mean between group differences in favor of the PLUS group were observed at 3 and 6 months for moderate-to-vigorous PA (100.33 min/week [95% confidence interval, 15.70-184.95 min/week] and 111.62 min/week; [95% confidence interval, 26.17-197.07 min/week], respectively, with a trend toward significance at 9 months), percentage change in weight, and quality of life. No changes in aerobic fitness were observed within and between groups. CONCLUSIONS In this community sample of patients with coronary heart disease declining enrollment in cardiac rehabilitation, a 6-month tai chi program was safe and improved PA, weight, and quality of life compared with a 3-month intervention. Tai chi could be an effective option to improve PA in this high-risk population. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT02165254.
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Affiliation(s)
| | - Peter M Wayne
- Osher Center for Integrative Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Shira Dunsiger
- The Miriam Hospital and The Warren Alpert Medical School of Brown University, Providence, RI
| | | | | | - Beth C Bock
- The Miriam Hospital and The Warren Alpert Medical School of Brown University, Providence, RI
| | - Wen-Chih Wu
- The Miriam Hospital and The Warren Alpert Medical School of Brown University, Providence, RI
| | - Gloria Y Yeh
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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Timmis A, Roobottom CA. National Institute for Health and Care Excellence updates the stable chest pain guideline with radical changes to the diagnostic paradigm. Heart 2017; 103:982-986. [PMID: 28446550 DOI: 10.1136/heartjnl-2015-308341] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 02/19/2017] [Accepted: 03/07/2017] [Indexed: 01/09/2023] Open
Abstract
In the 2016 update of the stable chest pain guideline, the National Institute for Health and Care Excellence (NICE) has made radical changes to the diagnostic paradigm that it-like other international guidelines-had previously placed at the centre of its recommendations. No longer are quantitative assessments of the disease probability considered necessary to determine the need for diagnostic testing and the choice of test. Instead, the recommendation is for no diagnostic testing if chest pain is judged to be 'non-anginal' and CT coronary angiography (CTCA) in patients with 'typical' or 'atypical' chest pain with additional perfusion imaging only if there is uncertainty about the functional significance of coronary lesions. The new emphasis on anatomical-as opposed to functional-testing is driven in large part by cost-effectiveness analysis and despite inevitable resource implications NICE calculates that annual savings for the population of England will be significant. In making CTCA the default diagnostic testing strategy in its updated chest pain guideline, NICE has responded emphatically to calls from trialists for CTCA to have a greater role in the diagnostic pathway of patients with suspected angina.
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Affiliation(s)
- Adam Timmis
- NIHR Cardiovascular Biomedical Research Unit, Bart's Heart Centre, London, UK
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Pasea L, Chung SC, Pujades-Rodriguez M, Moayyeri A, Denaxas S, Fox KAA, Wallentin L, Pocock SJ, Timmis A, Banerjee A, Patel R, Hemingway H. Personalising the decision for prolonged dual antiplatelet therapy: development, validation and potential impact of prognostic models for cardiovascular events and bleeding in myocardial infarction survivors. Eur Heart J 2017; 38:1048-1055. [PMID: 28329300 PMCID: PMC5400049 DOI: 10.1093/eurheartj/ehw683] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 09/23/2016] [Accepted: 12/30/2016] [Indexed: 12/15/2022] Open
Abstract
Aims The aim of this study is to develop models to aid the decision to prolong dual antiplatelet therapy (DAPT) that requires balancing an individual patient's potential benefits and harms. Methods and results Using population-based electronic health records (EHRs) (CALIBER, England, 2000-10), of patients evaluated 1 year after acute myocardial infarction (MI), we developed (n = 12 694 patients) and validated (n = 5613) prognostic models for cardiovascular (cardiovascular death, MI or stroke) events and three different bleeding endpoints. We applied trial effect estimates to determine potential benefits and harms of DAPT and the net clinical benefit of individuals. Prognostic models for cardiovascular events (c-index: 0.75 (95% CI: 0.74, 0.77)) and bleeding (c index 0.72 (95% CI: 0.67, 0.77)) were well calibrated: 3-year risk of cardiovascular events was 16.5% overall (5.2% in the lowest- and 46.7% in the highest-risk individuals), while for major bleeding, it was 1.7% (0.3% in the lowest- and 5.4% in the highest-risk patients). For every 10 000 patients treated per year, we estimated 249 (95% CI: 228, 269) cardiovascular events prevented and 134 (95% CI: 87, 181) major bleeding events caused in the highest-risk patients, and 28 (95% CI: 19, 37) cardiovascular events prevented and 9 (95% CI: 0, 20) major bleeding events caused in the lowest-risk patients. There was a net clinical benefit of prolonged DAPT in 63-99% patients depending on how benefits and harms were weighted. Conclusion Prognostic models for cardiovascular events and bleeding using population-based EHRs may help to personalise decisions for prolonged DAPT 1-year following acute MI.
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Affiliation(s)
- Laura Pasea
- The Farr Institute of Health Informatics Research, University College London, London, UK
| | - Sheng-Chia Chung
- The Farr Institute of Health Informatics Research, University College London, London, UK
| | - Mar Pujades-Rodriguez
- The Farr Institute of Health Informatics Research, University College London, London, UK
- MRC Medical Bioinformatics Centre, Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, UK
| | - Alireza Moayyeri
- The Farr Institute of Health Informatics Research, University College London, London, UK
| | - Spiros Denaxas
- The Farr Institute of Health Informatics Research, University College London, London, UK
| | - Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Lars Wallentin
- Department of Medical Sciences Cardiology, Uppsala Clinical Research Centre, Uppsala University, Uppsala, Sweden
| | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Adam Timmis
- Bart's Heart Centre, Barts and the London National Institute for Health Research Cardiovascular Biomedical Research Unit, London, UK
| | - Amitava Banerjee
- The Farr Institute of Health Informatics Research, University College London, London, UK
| | - Riyaz Patel
- The Farr Institute of Health Informatics Research, University College London, London, UK
| | - Harry Hemingway
- The Farr Institute of Health Informatics Research, University College London, London, UK
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Hemingway H, Feder GS, Fitzpatrick NK, Denaxas S, Shah AD, Timmis AD. Using nationwide ‘big data’ from linked electronic health records to help improve outcomes in cardiovascular diseases: 33 studies using methods from epidemiology, informatics, economics and social science in the ClinicAl disease research using LInked Bespoke studies and Electronic health Records (CALIBER) programme. PROGRAMME GRANTS FOR APPLIED RESEARCH 2017. [DOI: 10.3310/pgfar05040] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BackgroundElectronic health records (EHRs), when linked across primary and secondary care and curated for research use, have the potential to improve our understanding of care quality and outcomes.ObjectiveTo evaluate new opportunities arising from linked EHRs for improving quality of care and outcomes for patients at risk of or with coronary disease across the patient journey.DesignEpidemiological cohort, health informatics, health economics and ethnographic approaches were used.Setting230 NHS hospitals and 226 general practices in England and Wales.ParticipantsUp to 2 million initially healthy adults, 100,000 people with stable coronary artery disease (SCAD) and up to 300,000 patients with acute coronary syndrome.Main outcome measuresQuality of care, fatal and non-fatal cardiovascular disease (CVD) events.Data platform and methodsWe created a novel research platform [ClinicAl disease research using LInked Bespoke studies and Electronic health Records (CALIBER)] based on linkage of four major sources of EHR data in primary care and national registries. We carried out 33 complementary studies within the CALIBER framework. We developed a web-based clinical decision support system (CDSS) in hospital chest pain clinics. We established a novel consented prognostic clinical cohort of SCAD patients.ResultsCALIBER was successfully established as a valid research platform based on linked EHR data in nearly 2 million adults with > 600 EHR phenotypes implemented on the web portal (seehttps://caliberresearch.org/portal). Despite national guidance, key opportunities for investigation and treatment were missed across the patient journey, resulting in a worse prognosis for patients in the UK compared with patients in health systems in other countries. Our novel, contemporary, high-resolution studies showed heterogeneous associations for CVD risk factors across CVDs. The CDSS did not alter the decision-making behaviour of clinicians in chest pain clinics. Prognostic models using real-world data validly discriminated risk of death and events, and were used in cost-effectiveness decision models.ConclusionsEmerging ‘big data’ opportunities arising from the linkage of records at different stages of a patient’s journey are vital to the generation of actionable insights into the diagnosis, risk stratification and cost-effective treatment of people at risk of, or with, CVD.Future workThe vast majority of NHS data remain inaccessible to research and this hampers efforts to improve efficiency and quality of care and to drive innovation. We propose three priority directions for further research. First, there is an urgent need to ‘unlock’ more detailed data within hospitals for the scale of the UK’s 65 million population. Second, there is a need for scaled approaches to using EHRs to design and carry out trials, and interpret the implementation of trial results. Third, large-scale, disease agnostic genetic and biological collections linked to such EHRs are required in order to deliver precision medicine and to innovate discovery.Study registrationCALIBER studies are registered as follows: study 2 – NCT01569139, study 4 – NCT02176174 and NCT01164371, study 5 – NCT01163513, studies 6 and 7 – NCT01804439, study 8 – NCT02285322, and studies 26–29 – NCT01162187. Optimising the Management of Angina is registered as Current Controlled Trials ISRCTN54381840.FundingThe National Institute for Health Research (NIHR) Programme Grants for Applied Research programme (RP-PG-0407-10314) (all 33 studies) and additional funding from the Wellcome Trust (study 1), Medical Research Council Partnership grant (study 3), Servier (study 16), NIHR Research Methods Fellowship funding (study 19) and NIHR Research for Patient Benefit (study 33).
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Affiliation(s)
- Harry Hemingway
- Institute of Health Informatics, University College London, London, UK
- Farr Institute of Health Informatics Research, University College London, London, UK
| | - Gene S Feder
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Natalie K Fitzpatrick
- Institute of Health Informatics, University College London, London, UK
- Farr Institute of Health Informatics Research, University College London, London, UK
| | - Spiros Denaxas
- Institute of Health Informatics, University College London, London, UK
- Farr Institute of Health Informatics Research, University College London, London, UK
| | - Anoop D Shah
- Institute of Health Informatics, University College London, London, UK
- Farr Institute of Health Informatics Research, University College London, London, UK
| | - Adam D Timmis
- Farr Institute of Health Informatics Research, University College London, London, UK
- Barts Health NHS Trust, London, UK
- Farr Institute of Health Informatics Research, Queen Mary University of London, London, UK
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Henderson RA. Cost and efficacy of myocardial revascularization in the drug-eluting stent era: how much for how much? EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2016; 2:225-228. [PMID: 29474721 DOI: 10.1093/ehjqcco/qcw047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Indexed: 11/12/2022]
Affiliation(s)
- Robert A Henderson
- Consultant Cardiologist, Trent Cardiac Centre, Nottingham University Hospitals, City Hospital Campus, Nottingham NG51PB, UK
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Banerjee A. Stable coronary disease: Cinderella must go to the ball. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2016; 2:151-152. [PMID: 29474614 DOI: 10.1093/ehjqcco/qcw022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Amitava Banerjee
- Farr Institute of Health Informatics Research, University College London, 222 Euston Road, London NW1 2DA, UK
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Asaria M, Grasic K, Walker S. Using Linked Electronic Health Records to Estimate Healthcare Costs: Key Challenges and Opportunities. PHARMACOECONOMICS 2016; 34:155-60. [PMID: 26645571 DOI: 10.1007/s40273-015-0358-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
This paper discusses key challenges and opportunities that arise when using linked electronic health records (EHR) in health economics and outcomes research (HEOR), with a particular focus on estimating healthcare costs. These challenges and opportunities are framed in the context of a case study modelling the costs of stable coronary artery disease in England. The challenges and opportunities discussed fall broadly into the categories of (1) handling and organising data of this size and sensitivity; (2) extracting clinical endpoints from datasets that have not been designed and collected with such endpoints in mind; and (3) the principles and practice of costing resource use from routinely collected data. We find that there are a number of new challenges and opportunities that arise when working with EHR compared with more traditional sources of data for HEOR. These call for greater clinician involvement and intelligent use of sensitivity analysis.
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Affiliation(s)
- Miqdad Asaria
- Centre for Health Economics, University of York, Heslington, York, YO10 5DD, UK.
| | - Katja Grasic
- Centre for Health Economics, University of York, Heslington, York, YO10 5DD, UK
| | - Simon Walker
- Centre for Health Economics, University of York, Heslington, York, YO10 5DD, UK
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