Effects of stroke on medical resource use and costs in acute myocardial infarction. GUSTO I Investigators. Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries Study

A Systematic Review of Cardiovascular Outcomes-Based Cost-Effectiveness Analyses of Lipid-Lowering Therapies

BACKGROUND

Previous reviews have evaluated economic analyses of lipid-lowering therapies using lipid levels as surrogate markers for cardiovascular disease. However, drug approval and health technology assessment agencies have stressed that surrogates should only be used in the absence of clinical endpoints.

OBJECTIVE

The aim of this systematic review was to identify and summarise the methodologies, weaknesses and strengths of economic models based on atherosclerotic cardiovascular disease event rates.

METHODS

Cost-effectiveness evaluations of lipid-lowering therapies using cardiovascular event rates in adults with hyperlipidaemia were sought in Medline, Embase, Medline In-Process, PubMed and NHS EED and conference proceedings. Search results were independently screened, extracted and quality checked by two reviewers.

RESULTS

Searches until February 2016 retrieved 3443 records, from which 26 studies (29 publications) were selected. Twenty-two studies evaluated secondary prevention (four also assessed primary prevention), two considered only primary prevention and two included mixed primary and secondary prevention populations. Most studies (18) based treatment-effect estimates on single trials, although more recent evaluations deployed meta-analyses (5/10 over the last 10 years). Markov models (14 studies) were most commonly used and only one study employed discrete event simulation. Models varied particularly in terms of health states and treatment-effect duration. No studies used a systematic review to obtain utilities. Most studies took a healthcare perspective (21/26) and sourced resource use from key trials instead of local data. Overall, reporting quality was suboptimal.

CONCLUSIONS

This review reveals methodological changes over time, but reporting weaknesses remain, particularly with respect to transparency of model reporting.

Early Empowerment Strategies Boost Self-Efficacy to Improve Cardiovascular Health Behaviors

Background:

Self-efficacy, defined as confidence in the ability to carry out behavior to achieve a desired goal, is considered to be a prerequisite for behavior change. Self-efficacy correlates with cardiovascular health although optimal timing to incorporate self-efficacy strategies is not well established. We sought to study the effect of an empowerment approach implemented in the introductory phase of a multicomponent lifestyle intervention on cardiovascular health outcomes.

Design:

Prospective intervention cohort study.

Methods:

Patients in the Integrative Cardiac Health Project Registry, a prospective lifestyle change program for the prevention of cardiovascular disease were analyzed for behavioral changes by survey, at baseline and one year, in the domains of nutrition, exercise, stress management and sleep. Self-efficacy questionnaires were administered at baseline and after the empowerment intervention, at 8 weeks.

Results:

Of 119 consecutive registry completers, 60 comprised a high self-efficacy group (scoring at or above the median of 36 points) and 59 the low self-efficacy group (scoring below median). Self-efficacy scores increased irrespective of baseline self-efficacy but the largest gains in self-efficacy occurred in patients who ranked in the lower half for self-efficacy at baseline. This lower self-efficacy group demonstrated behavioral gains that erased differences between the high and low self-efficacy groups.

Conclusions:

A boost to self-efficacy early in a lifestyle intervention program produces significant improvements in behavioral outcomes. Employing empowerment in an early phase may be a critical strategy to improve self-efficacy and lower risk in individuals vulnerable to cardiovascular disease.

A Retrospective Study to Examine Healthcare Costs Related to Cardiovascular Events in Individuals with Hyperlipidemia

Introduction

Few studies have demonstrated the cost burden of cardiovascular events (CVEs) among patients with hyperlipidemia. The primary objective of this study was to determine the mean costs associated with CVEs among patients with hyperlipidemia by follow-up time period. Secondary objectives of this study included characterizing costs by CVE type and coronary heart disease (CHD) risk.

Methods

This retrospective cohort study used longitudinal claims to calculate payer costs according to CHD risk level and type of CVE, during several follow-up periods (acute and short-term, comprising year 1; plus years 2 and 3).

Results

There were 193,385 patients with hyperlipidemia with a CVE. Costs in the acute (30-day) period were highest ($22,404) driven by inpatient care (77%). Costs remained high ($15,133 in year 3) with ambulatory care (from 14% in acute to 37% in year 3) and pharmaceutical costs (from 2% in acute to 24% in year 3) representing a greater proportion. After second and third CVEs, acute costs were lower than for the first CVE. But in the post-acute periods, costs were higher after second and third CVEs than after first CVEs. Acute costs varied considerably by type of CVE ($9149 for transient ischemic attack to $54,251 for coronary artery bypass graft; P < 0.001), but post-acute costs were more similar across types. Costs differed by baseline CHD risk for all follow-up periods (P < 0.001), but less than by CVE type. As expected, patients without CVEs had significantly lower costs.

Conclusion

Among patients with hyperlipidemia, the economic burden of CVEs is substantial up to 3 years after a CVE. Costs remain high after subsequent CVEs and actually increase for non-inpatient utilization.

Funding

Amgen Inc.

Electronic supplementary material

The online version of this article (doi:10.1007/s12325-015-0264-7) contains supplementary material, which is available to authorized users.

Neurologic complications of myocardial infarction

Cardiac disease, in particular coronary artery disease, is the leading cause of mortality in developed nations. Strokes can complicate cardiac disease - either as result of left ventricular dysfunction and associated thrombus formation or of therapy for the cardiac disease. Antiplatelet drugs and anticoagulants routinely used to treat cardiac disease increase the risk for hemorrhagic stroke.

Multimorbidity and health-related quality of life in the older population: results from the German KORA-age study

BACKGROUND

Multimorbidity in the older population is well acknowledged to negatively affect health-related quality of life (HRQL). Several studies have examined the independent effects of single diseases; however, little research has focused on interaction between diseases. The purpose of this study was to assess the impact of six self-reported major conditions and their combinations on HRQL measured by the EQ-5D.

METHODS

The EQ-5D was administered in the population-based KORA-Age study of 4,565 Germans aged 65 years or older. A generalised additive regression model was used to assess the effects of chronic conditions on HRQL and to account for the nonlinear associations with age and body mass index (BMI). Disease interactions were identified by a forward variable selection method.

RESULTS

The conditions with the greatest negative impact on the EQ-5D index were the history of a stroke (regression coefficient -11.3, p < 0.0001) and chronic bronchitis (regression coefficient -8.1, p < 0.0001). Patients with both diabetes and coronary disorders showed more impaired HRQL than could be expected from their separate effects (coefficient of interaction term -8.1, p < 0.0001). A synergistic effect on HRQL was also found for the combination of coronary disorders and stroke. The effect of BMI on the mean EQ-5D index was inverse U-shaped with a maximum at around 24.8 kg/m².

CONCLUSIONS

There are important interactions between coronary problems, diabetes mellitus, and the history of a stroke that negatively affect HRQL in the older German population. Not only high but also low BMI is associated with impairments in health status.

Cost-effectiveness of warfarin: trial versus "real-world" stroke prevention in atrial fibrillation

BACKGROUND AND PURPOSE

Previous cost-effectiveness analyses analyzed warfarin for stroke prevention in randomized trial settings. Given the complexities of warfarin treatment, cost-effectiveness should be examined within a real-world setting.

METHODS

Our model followed patients with atrial fibrillation at moderate to high risk of stroke through primary and recurrent ischemic stroke, hemorrhages--intracranial and extracranial, and the resulting disability. Four scenarios were examined: (1) all patients start on warfarin with perfect control, that is, international normalized ratio (INR) values always within range; (2) all patients start on warfarin with trial-like control, where INR can fall outside the recommended range; (3) all patients start on warfarin with real-world INR control; and (4) real-world prescription (and control) of warfarin, aspirin, or neither for warfarin-eligible patients. Reported warfarin discontinuation rates were used. Main outcomes were total number of events, quality adjusted life years, and costs in a US setting.

RESULTS

The total number of primary and recurrent ischemic strokes in a 1,000-patient cohort (age 70 years, lifetime analysis) was 626, 832, 984, and 1,171 in scenarios 1 to 4, respectively. The corresponding mean quality adjusted life years per patient were 7.21, 6.92, 6.75, and 6.67 for scenarios 1 to 4, respectively. Costs per patient were $68,039, $77,764, $84,518, and $87,248 in scenarios 1 to 4, respectively. If "perfect" adherence to warfarin was assumed, except for discontinuations for clinical reasons, strokes would decrease to 503, 737, 909, and 1,120 in scenarios 1 to 4, respectively.

CONCLUSIONS

Clinical and cost outcomes are strongly dependent on the quality of anticoagulation and rates of warfarin discontinuation. Clinicians should work to improve both. Policy makers should use real-world INR control and warfarin discontinuation rates when assessing cost-effectiveness.

Comparing and predicting the costs and outcomes of patients with major and minor stroke using the Boston Acute Stroke Imaging Scale neuroimaging classification system

BACKGROUND AND PURPOSE

A neuroimaging-based ischemic stroke classification system that predicts costs and outcomes would be useful for clinical prognostication and hospital resource planning. The Boston Acute Stroke Imaging Scale (BASIS), a neuroimaging-based ischemic stroke classification system, was tested to determine whether it was able to predict the costs and clinical outcomes of patients with stroke at an urban academic medical center.

MATERIALS AND METHODS

Patients with ischemic stroke who presented in the emergency department in 2000 (230 patients) and 2005 (250 patients) were classified by using BASIS as having either a major or minor stroke. Compared outcomes included death, length of hospitalization, discharge disposition, use of imaging and intensive care unit (ICU) resources, and total in-hospital cost. Continuous variables were compared by univariate analysis by using the Student t test or the Satterthwaite test adjusted for unequal variances. Categoric variables were tested with the chi(2) test. Multiple regression analyses related total hospital cost (dependent variable) to stroke severity (major versus minor), sex, age, presence of comorbidities, and death during hospitalization. Logistic regression analysis was applied to identify the significant predictive variables indicating a greater likelihood of discharge home.

RESULTS

In both years, individuals with strokes classified as major had a significantly longer length of stay, spent more days in the ICU, and had a higher cost of hospitalization than patients with minor strokes (all outcomes, P < .0001). All deaths (8 in 2000, 26 in 2005) occurred in patients with major stroke. Whereas 73% of patients with minor stroke were discharged home, only 12.2% of patients with major stroke were discharged home (P < .0001); 61% of patients with major stroke were discharged to a rehabilitation or skilled nursing facility. Patients with major stroke cost 4.4 times and 3.0 times that of patients with minor stroke in 2000 and 2005, respectively. Making up less than one third of all patients, patients with major stroke accounted for 60% of the total in-hospital cost of acute stroke care.

CONCLUSIONS

BASIS, a neuroimaging-based stroke classification system, is highly effective at predicting in-hospital resource use, acute-hospitalization cost, and outcome. Predictive ability was maintained across the years studied.

Tissue plasminogen activator was cost-effective compared to streptokinase in only selected patients with acute myocardial infarction

OBJECTIVE

We sought to explore the patient-specific cost-effectiveness in a community-based sample for a therapy for which the average cost-effectiveness in a clinical trial has been well-described.

STUDY DESIGN AND SETTING

Based on a validated multivariate model, we generated predictions of the effectiveness and cost-effectiveness of t-PA compared to streptokinase on 921 consecutive patients who received thrombolytic therapy for acute myocardial infarction.

RESULTS

The average cost-effectiveness of t-PA was US dollar 40,140 per life-year saved. For the quartile of patients most likely to benefit, the incremental cost-effectiveness of t-PA was US dollar 15,396. However, only 44% of patients who received thrombolytic therapy had an estimated cost-effectiveness ratio below US dollar 50,000 per year of life saved; the ratio was greater than US dollar 100,000 in 37% of treated patients. Patients in the lowest quartile of expected benefit are, overall, more likely to be harmed than to benefit from t-PA.

CONCLUSION

Compared to the pattern of thrombolytic agent choice observed, targeting t-PA to the half of patients most likely to benefit could save 247 lives and US dollar 174 million nationally per year.

Clopidogrel versus aspirin for secondary prophylaxis of vascular events: a cost-effectiveness analysis

PURPOSE

Clopidogrel is more effective than aspirin in preventing recurrent vascular events, but concerns about its cost-effectiveness have limited its use. We evaluated the cost-effectiveness of clopidogrel and aspirin as secondary prevention in patients with a prior myocardial infarction, a prior stroke, or peripheral arterial disease.

METHODS

We constructed Markov models assuming a societal perspective, and based analyses on the lifetime treatment of a 63-year-old patient facing event probabilities derived from the Clopidogrel versus Aspirin in Patients at Risk of Ischemic Events (CAPRIE) trial as the base case. Outcome measures included costs, life expectancy in quality-adjusted life-years (QALYs), incremental cost-effectiveness ratios, and events averted.

RESULTS

In patients with peripheral arterial disease, clopidogrel increased life expectancy by 0.55 QALYs at an incremental cost-effectiveness ratio of $25,100 per QALY, as compared with aspirin. In poststroke patients, clopidogrel increased life expectancy by 0.17 QALYs at a cost of $31,200 per QALY. Aspirin was both less expensive and more effective than clopidogrel in post-myocardial infarction patients. In probabilistic sensitivity analyses, our evaluation for patients with peripheral vascular disease was robust. Evaluations of stroke and myocardial infarction patients were sensitive predominantly to the cost and efficacy of clopidogrel, with aspirin therapy more effective and less expensive in 153 of 1000 simulations (15.3%) in poststroke patients and clopidogrel more effective in 119 of 1000 simulations (11.9%) in the myocardial infarction sample.

CONCLUSION

Clopidogrel provides a substantial increase in quality-adjusted life expectancy at a cost that is within traditional societal limits for patients with either peripheral arterial disease or a recent stroke. Current evidence does not support increased efficacy with clopidogrel relative to aspirin in patients following myocardial infarction.

Cost effectiveness of aggressive care for patients with nontraumatic coma

OBJECTIVE

To estimate the cost effectiveness of aggressive care for patients with nontraumatic coma.

DESIGN

Cost-effectiveness analysis.

SETTING

Five academic medical centers.

PATIENTS

Patients with nontraumatic coma enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). Patients with reversible metabolic causes of coma such as diabetic ketoacidosis or uremia were excluded.

MEASUREMENTS

We calculated the incremental cost effectiveness of continuing aggressive care vs. withholding cardiopulmonary resuscitation and ventilatory support after day 3 of coma. We estimated life expectancy based on up to 4.6 yrs of follow-up. Utilities (quality-of-life weights) were estimated using time-tradeoff questions. Costs were based on hospital fiscal data and Medicare data. Separate analyses were conducted for two prognostic groups based on five risk factors assessed on day 3 of coma: age > or = 70 yrs, abnormal brainstem response, absent verbal response, absent withdrawal to pain, and serum creatinine > or = 132.6 micromol/L (1.5 mg/dL).

RESULTS

For the 596 patients studied, the median (25th, 75th percentile) age was 67 yrs (range, 55-77), and 52% were female. By 2 months after enrollment, 69% had died, 19% were severely disabled, 7% had survived without severe disability, and 4% had survived with unknown functional status. The incremental cost effectiveness of the more aggressive care strategy was $140,000 (1998 dollars) per quality-adjusted life year (QALY) for high-risk patients (3-5 risk factors, 93% 2-month mortality) and $87,000/QALY for low-risk patients (0-2 risk factors, 49% mortality). In sensitivity analyses, the incremental cost per QALY did not fall below $50,000/QALY, even with wide variation in our baseline estimates.

CONCLUSIONS

Continuing aggressive care after day 3 of nontraumatic coma is associated with a high cost per QALY gained, especially for patients at high risk for poor outcomes. Earlier decisions to withhold life-sustaining treatments for patients with very poor prognoses may yield considerable cost savings.

NONARRHYTHMIC COMPLICATIONS OF ACUTE MYOCARDIAL INFARCTION

Complications of acute myocardial infarction can be categorized as nonarrhythmic or arrhythmic; the latter is discussed elsewhere. Patients are at risk for a number of potentially serious or fatal complications during or after the acute infarction phase. These include shock, left ventricular free wall rupture, rupture of the interventricular septum, papillary muscle rupture, ventricular pseudoaneurysm, and stroke. Right ventricular infarction, which is typically associated with inferior myocardial infarction, will also be discussed.

Outcomes of noncardiac surgery after coronary bypass surgery or coronary angioplasty in the Bypass Angioplasty Revascularization Investigation (BARI)

PURPOSE

Previous studies have shown that coronary artery bypass surgery reduces the risk of cardiac complications after noncardiac surgery. Whether coronary angioplasty provides equivalent protection is not known.

SUBJECTS AND METHODS

Patients were randomly assigned to undergo cardiac artery bypass surgery or angioplasty as part of the Bypass Angioplasty Revascularization Investigation trial. All subsequent noncardiac surgeries during a mean (+/- SD) follow-up of 7.7 years were recorded among participants in the ancillary Study of Economics and Quality of Life. Rates of mortality and nonfatal myocardial infarction, length of stay, and hospital costs were compared by the original randomized assignment.

RESULTS

A total of 501 patients had noncardiac surgery at a median of 29 months after their most recent coronary revascularization procedure. Mortality and nonfatal myocardial infarction within 30 days of the first noncardiac surgery occurred in 4 of the 250 of the surgery-assigned patients and in 4 of the 251 of the angioplasty-assigned patients (P = 1.0). There were no significant differences in the mean length of hospital stay (6.3 +/- 6.7 versus 6.2 +/- 6.8 days; P = 0.47) or hospital cost ($8,920 +/- $11,511 versus $7,785 +/- $7,643; P = 0.33) between the surgery and angioplasty groups. Similar results were obtained when subsequent noncardiac procedures were included in the analysis.

CONCLUSION

Rates of myocardial infarction and death after noncardiac surgery are similarly low after contemporary bypass surgery or angioplasty in patients with multivessel coronary artery disease.

Cost-effectiveness of 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor therapy in older patients with myocardial infarction

BACKGROUND

3-Hydroxy-3-methylglutaryl coenzyme A reductase inhibitor (statin) therapy has proven efficacy in reducing the rate of coronary and cerebrovascular events in patients 75 years of age or younger with a history of myocardial infarction. However, in patients older than 75 years of age, the efficacy and potential cost-effectiveness of statins are unknown.

OBJECTIVE

To estimate the incremental cost-effectiveness of statin therapy compared with usual care in patients 75 to 84 years of age with previous myocardial infarction.

DESIGN

Cost-effectiveness analysis.

DATA SOURCES

Published data from cohort studies.

TARGET POPULATION

Patients 75 to 84 years of age with a history of myocardial infarction.

TIME HORIZON

Lifetime.

PERSPECTIVE

Societal.

INTERVENTION

Statin therapy.

OUTCOME MEASURES

Life expectancy, quality-adjusted life expectancy, and incremental cost-effectiveness.

RESULTS OF BASE-CASE ANALYSIS

The incremental cost-effectiveness of statin therapy compared with usual care in patients 75 to 84 years of age with previous myocardial infarction was $18800 per quality-adjusted life-year (QALY).

RESULTS OF SENSITIVITY ANALYSIS

On the basis of a probabilistic sensitivity analysis, there is a 75% chance that statin therapy costs less than $39800 per QALY compared with usual care. If the cost of statin therapy and efficacy of statin therapy at reducing myocardial infarction were set to their most favorable values, statin therapy cost $5400 per QALY; if cost and efficacy were set to their least favorable values, statin therapy cost $97800 per QALY.

CONCLUSIONS

The cost-effectiveness ratios of statin therapy in older patients with previous myocardial infarction are reasonable under a wide variety of assumptions about drug efficacy, drug cost, and rates of cardiac and cerebrovascular events. Pending results of randomized, controlled trials of secondary prevention in patients in this age group, statin therapy seems to be as cost-effective as many routinely accepted medical interventions in this setting.

Effects of statins on carotid disease and stroke

The results of recent trials indicate that statin treatment reduces not only the risk of coronary heart disease, but also the risk of stroke, in patients with existing heart disease. The need for the treatment of such patients is now generally recognized. Mechanisms for risk reduction include the retardation of plaque progression, plaque stabilization, and reducing the risk of coronary events. Questions remain regarding the discrepancy between epidemiological data and statin trials data, the precise mechanism of action of statins, and their role in the prevention of recurrent stroke in individuals who have experienced a previous stroke or transient ischemic attack but are free of coronary disease.