Estimating the economic impacts of percutaneous coronary intervention in Australia: a registry-based cost burden study

In-hospital outcomes by insurance type among patients undergoing percutaneous coronary interventions for acute myocardial infarction in New South Wales public hospitals

BACKGROUND

International evidence suggests patients receiving cardiac interventions experience differential outcomes by their insurance status. We investigated outcomes of in-hospital care according to insurance status among patients admitted in public hospitals with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI).

METHODS

We conducted a cohort study within the Australian universal health care system with supplemental private insurance. Using linked hospital and mortality data, we included patients aged 18 + years admitted to New South Wales public hospitals with AMI and undergoing their first PCI from 2017-2020. We measured hospital-acquired complications (HACs), length of stay (LOS) and in-hospital mortality among propensity score-matched private and publicly funded patients. Matching was based on socio-demographic, clinical, admission and hospital-related factors.

RESULTS

Of 18,237 inpatients, 30.0% were privately funded. In the propensity-matched cohort (n = 10,630), private patients had lower rates of in-hospital mortality than public patients (odds ratio: 0.59, 95% CI: 0.45-0.77; approximately 11 deaths avoided per 1,000 people undergoing PCI procedures). Mortality differences were mostly driven by STEMI patients and those from major cities. There were no significant differences in rates of HACs or average LOS in private, compared to public, patients.

CONCLUSION

Our findings suggest patients undergoing PCI in Australian public hospitals with private health insurance experience lower in-hospital mortality compared with their publicly insured counterparts, but in-hospital complications are not related to patient health insurance status. Our findings are likely due to unmeasured confounding of broader patient selection, socioeconomic differences and pathways of care (e.g. access to emergency and ambulatory care; delays in treatment) that should be investigated to improve equity in health outcomes.

Temporal trends in percutaneous coronary intervention in Australia: A retrospective analysis from 2000-2021

OBJECTIVE

The aim of this study was to describe the trend in percutaneous coronary intervention (PCI) with insertion of a stent in Australia from 2000/01 to 2020/21 and investigate trends in same-day versus non-same-day discharge following PCI. A secondary aim was to compare the rate of coronary artery bypass grafting (CABG) with PCI procedures, while a third aim was to compare marked PCI trend changes with the PCI guidelines during the study period.

BACKGROUND

PCI with stent deployment is the most common form of interventional treatment for coronary artery disease, and its use has been expanding since 2000. However, there is a lack of descriptive studies of the national trend in Australia.

METHODS

All procedures for PCI and CABG were extracted across 21 years (2000/01 to 2020/21) from the Australian Institute of Health and Welfare data. Age-standardized rates were calculated using the Australian standard population as of June 2001. The ratio of PCI to CABG procedures was also calculated. Trends for PCI were stratified by age, gender, and same-day or overnight discharge episodes. Linear regression analysis was done to compare the age-standardized rates across different age categories. Segmented regression analysis was performed to ascertain the change in the age-standardized rates of PCI during the study period. Whether the changepoints in the trend were matched with guideline updates was also assessed.

RESULTS

There were 751 728 PCI procedures in persons aged 30 years and above between 2000/01 and 2020/21. The age-standardized rate for the study period showed that persons aged 60-74 years had a higher rate of procedures (102.7) compared to persons aged 30-59 years (81.3) and 75 years and older (61.8) (P < 0.001). There were two statistically significant changepoints in the overall trend; 2005/06 and 2013/14, matched with the change in PCI guidelines. Despite the lower number of procedures for same-day discharge episodes, there has been an increasing trend since 2014/15. More than two-thirds of all stenting procedures were the insertion of a single stent. PCI to CABG procedure ratio increased from 0.6 in 2000/01 to 1.8 in 2020/21.

CONCLUSIONS

There was a varying trend in the age-standardized rate of PCI with a peak in 2005/06. The trend appears to be stabilizing in the later part of the study period, but the rate for same-day discharge episodes showed an increasing trend after 2014/15. There is consistency with changepoints in the trend and updated PCI guideline recommendations. The ratio of PCI with insertion of a stent to CABG procedure increased substantially across the study period.

Cost-utility analysis of a supervised exercise intervention for women with early-stage endometrial cancer

PURPOSE

Cardiovascular disease (CVD) is the leading cause of death after treatment for endometrial cancer (EC). There is clinical evidence that exercise significantly reduces the risks of CVD and cancer recurrence in this population; however, it is unclear whether there is value for money in integrating exercise into cancer recovery care for women treated for EC. This paper assesses the long-term cost-effectiveness of a 12-week supervised exercise intervention, as compared with standard care, for women diagnosed with early-stage EC.

METHOD

A cost-utility analysis was conducted from the Australian health system perspective for a time horizon of 5 years. A Markov cohort model was designed with six mutually exclusive health states: (i) no CVD, (ii) post-stroke, (iii) post-coronary heart disease (CHD), (iv) post-heart failure, (v) post-cancer recurrence, and (vi) death. The model was populated using the best available evidence. Costs and quality-adjusted life years (QALYs) were discounted at 5% annual rate. Uncertainty in the results was explored using one-way and probabilistic sensitivity analyses (PSA).

RESULT

The incremental cost of supervised exercise versus standard care was AUD $358, and the incremental QALY was 0.0789, resulting in an incremental cost-effectiveness ratio (ICER) of AUD $5184 per QALY gained. The likelihood that the supervised exercise intervention was cost-effective at a willingness-to-pay threshold of AUD $50,000 per QALY was 99.5%.

CONCLUSION

This is the first economic evaluation of exercise after treatment for EC. The results suggest that exercise is cost-effective for Australian EC survivors. Given the compelling evidence, efforts could now focus on the implementation of exercise as part of cancer recovery care in Australia.

Estimating the cost-effectiveness and return on investment of the Victorian Cardiac Outcomes Registry in Australia: a minimum threshold analysis

OBJECTIVES

We sought to establish the minimum level of clinical benefit attributable to the Victorian Cardiac Outcomes Registry (VCOR) for the registry to be cost-effective.

DESIGN

A modelled cost-effectiveness study of VCOR was conducted from the Australian healthcare system and societal perspectives.

SETTING

Observed deaths and costs attributed to coronary heart disease (CHD) over a 5-year period (2014-2018) were compared with deaths and costs arising from a hypothetical situation which assumed that VCOR did not exist. Data from the Australian Bureau of Statistics and published sources were used to construct a decision analytic life table model to simulate the follow-up of Victorians aged ≥25 years for 5 years, or until death. The assumed contribution of VCOR to the proportional change in CHD mortality trend observed over the study period was varied to quantify the minimum level of clinical benefits required for the registry to be cost-effective. The marginal costs of VCOR operation and years of life saved (YoLS) were estimated.

PRIMARY OUTCOME MEASURES

The return on investment (ROI) ratio and the incremental cost-effectiveness ratio (ICER).

RESULTS

The minimum proportional change in CHD mortality attributed to VCOR required for the registry to be considered cost-effective was 0.125%. Assuming this clinical benefit, a net return of $A4.30 for every dollar invested in VCOR was estimated (ROI ratio over 5 years: 4.3 (95% CI 3.6 to 5.0)). The ICER estimated for VCOR was $A49 616 (95% CI $A42 228 to $A59 608) per YoLS. Sensitivity analyses found that the model was sensitive to the time horizon assumed and the extent of registry contribution to CHD mortality trends.

CONCLUSIONS

VCOR is likely cost-effective and represents a sound investment for the Victorian healthcare system. Our evaluation highlights the value of clinical quality registries in Australia.

Cost-effectiveness of follow-up invasive coronary angiography after percutaneous coronary stenting: a real-world observational cohort study in Japan

OBJECTIVES

Follow-up invasive coronary angiography (FUICA) after percutaneous coronary intervention (PCI) has been shown to increase the rate of early coronary revascularisation without reducing the incidence of subsequent myocardial infarction or death. However, no studies have evaluated the cost-effectiveness of FUICA in patients after coronary stenting. Therefore, this study aimed to evaluate the cost-effectiveness of FUICA after PCI.

DESIGN

Retrospective observational cohort study.

SETTING

497 hospitals.

PARTICIPANTS AND INTERVENTIONS

Overall, 558 patients who underwent coronary artery stenting between April 2014 and March 2015 were matched and included in the invasive angiographic follow-up (AF) group (n=279), in which patients underwent FUICA 6-12 months after PCI, or in the clinical follow-up alone group (CF; n=279) using propensity scores.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary endpoint was the composite outcome of death, myocardial infarction, urgent coronary revascularisation, stroke or hospitalisation for the heart failure. The secondary endpoints included all-cause death, non-fatal myocardial infarction, urgent revascularisation, coronary artery bypass grafting, stroke, hospitalisation for the heart failure and any coronary revascularisation after a minimum of 6 months of follow-up.

RESULTS

Costs were calculated as direct medical expenses based on medical fee billing information. The cumulative 3-year incidence of the primary endpoint was 5.3% in the AF group and 4.7% in the CF group (HR 1.02; 95% CI 0.47 to 2.20; p=0.98). The total incremental cost at the 3-year endpoint in the AF group was US$1874 higher than that in the CF group (US$8947±US$5684 vs US$7073±US$6360; p≤0.001).

CONCLUSIONS

FUICA increased the costs but did not improve clinical benefits. Thus, FUICA is not economically more attractive than CF alone.

TRIAL REGISTRATION NUMBER

UMIN000039768.

Estimating the economic impact of acute coronary syndrome in New Zealand over time (ANZACS-QI 64): a national registry-based cost burden study

OBJECTIVES

To estimate the changes in costs associated with acute coronary syndrome (ACS) admissions in New Zealand (NZ) public hospitals over a 12-year period.

DESIGN

A cost-burden study of ACS in NZ was conducted from the NZ healthcare system perspective.

SETTING

Hospital admission costs were estimated using relevant diagnosis-related groups and their costs for publicly funded casemix hospitalisations, and applied to 190 364 patients with ACS admitted to NZ public hospitals between 2007 and 2018 identified from routine national hospital datasets. Trends in the costs of index ACS hospitalisation, hospital admissions costs, coronary revascularisation and all-cause mortality up to 1 year were evaluated. All costs were presented as 2019 NZ dollars.

PRIMARY OUTCOME MEASURES

Healthcare costs attributed to ACS admissions in NZ over time.

RESULTS

Between 2007 and 2018, there was a 42% decrease in costs attributed to ACS (NZ$7.7 million (M) to NZ$4.4 M per 100 000 per year), representing a decrease of NZ$298 827 per 100 000 population per year. Mean admission costs associated with each admission declined from NZ$18 411 in 2007 to NZ$16 898 over this period (p<0.001) after adjustment for key clinical and procedural characteristics. These reductions were against a background of increased use of coronary revascularisation (23.1% (2007) to 38.1% (2018)), declining ACS admissions (366-252 per 100 000 population) and an improvement in 1-year survival post-ACS. Nevertheless, the total ACS cost burden remained considerable at NZ$237 M in 2018.

CONCLUSIONS

The economic cost of hospitalisations for ACS in NZ decreased considerably over time. Further studies are warranted to explore the association between reductions in ACS cost burden and changes in the management of ACS.