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Krittayaphong R, Permsuwan U. Employing Real-World Evidence for the Economic Evaluation of Non-Vitamin K Antagonist Oral Anticoagulants in Patients with Atrial Fibrillation in Thailand. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2024; 22:725-734. [PMID: 38858344 DOI: 10.1007/s40258-024-00891-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/14/2024] [Indexed: 06/12/2024]
Abstract
BACKGROUND This study aimed to assess the cost-effectiveness of non-vitamin K antagonist oral anticoagulants (NOACs) in comparison with warfarin using data from real practice based on the perspective of the health care system in Thailand. METHODS A four-state Markov model encompassing well-controlled atrial fibrillation (AF), stroke and systemic embolism, major bleeding and death was utilised to forecast clinical and economic outcomes. Transitional probabilities, direct medical costs and utilities were derived from the real-world data of the 'COOL-AF Thailand' registry, Thailand's largest nationwide registry spanning 27 hospitals. The cohort comprised AF patients. The primary outcomes assessed were total costs, life years, quality-adjusted life years (QALYs) and the incremental cost-effectiveness ratio. All costs and outcomes were subject to an annual discount rate of 3.0%. A spectrum of sensitivity analyses was conducted. RESULTS The mean age of the cohort was 68.8 ± 10.7 years. The NOACs group incurred a marginally lower total lifetime cost than the warfarin group (247,857 Thai baht [THB] vs 253,654 THB or 7137 USD vs 7304 USD) and experienced gains of 0.045 life years and 0.043 QALYs over the warfarin group. Given the lower cost and higher benefits associated with NOACs, this implies that NOAC treatment is a dominant strategy compared to warfarin for AF patients. At a ceiling ratio of 160,000 THB (4607 USD) per QALY, NOACs presented a 61.2% probability of being cost effective. CONCLUSIONS Non-vitamin K antagonist oral anticoagulants represent a cost-saving alternative to warfarin in the real clinical practice. However, with a probability of being cost effective below 65%, it suggests some parameter uncertainty regarding their overall cost effectiveness compared to warfarin.
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Affiliation(s)
- Rungroj Krittayaphong
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Unchalee Permsuwan
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, 50200, Thailand.
- Center for Medical and Health Technology Assessment (CM-HTA), Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, 50200, Thailand.
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Ospel JM, Kunz WG, Rinkel LA, Sanelli PC, Hirsch JA. What should neurointerventionalists know about cost-effectiveness research, and why should they care? J Neurointerv Surg 2024; 16:221-224. [PMID: 37468268 DOI: 10.1136/jnis-2023-020753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2023] [Indexed: 07/21/2023]
Affiliation(s)
- Johanna M Ospel
- Department of Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Wolfgang G Kunz
- Department of Radiology, Ludwig Maximilians University Munich, Munich, Germany
| | - Leon A Rinkel
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Department of Neurology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Pina C Sanelli
- Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
- Institute for Health System Science, Northwell Health Feinstein Institutes for Medical Research, Manhasset, New York, USA
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Frausing MHJP, Nielsen JC, Westergaard CL, Gerdes C, Kjellberg J, Boriani G, Kronborg MB. Economic analyses in cardiac electrophysiology: from clinical efficacy to cost utility. Europace 2024; 26:euae031. [PMID: 38289720 PMCID: PMC10858642 DOI: 10.1093/europace/euae031] [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] [Received: 11/21/2023] [Accepted: 01/24/2024] [Indexed: 02/01/2024] Open
Abstract
Cardiac electrophysiology is an evolving field that relies heavily on costly device- and catheter-based technologies. An increasing number of patients with heart rhythm disorders are becoming eligible for cardiac interventions, not least due to the rising prevalence of atrial fibrillation and increased longevity in the population. Meanwhile, the expansive costs of healthcare face finite societal resources, and a cost-conscious approach to new technologies is critical. Cost-effectiveness analyses support rational decision-making in healthcare by evaluating the ratio of healthcare costs to health benefits for competing therapies. They may, however, be subject to significant uncertainty and bias. This paper aims to introduce the basic concepts, framework, and limitations of cost-effectiveness analyses to clinicians including recent examples from clinical electrophysiology and device therapy.
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Affiliation(s)
- Maria Hee Jung Park Frausing
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Bvld 99, DK-8200 Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Bvld. 99, DK-8200 Aarhus, Denmark
| | - Jens Cosedis Nielsen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Bvld 99, DK-8200 Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Bvld. 99, DK-8200 Aarhus, Denmark
| | - Caroline Louise Westergaard
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Christian Gerdes
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Bvld 99, DK-8200 Aarhus, Denmark
| | - Jakob Kjellberg
- The Danish Center for Social Science Research, VIVE, Copenhagen, Denmark
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Mads Brix Kronborg
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Bvld 99, DK-8200 Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Bvld. 99, DK-8200 Aarhus, Denmark
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Samson R, Le Jemtel TH. Sacubitril-Valsartan in Heart Failure: The Hard Sell of Spending More to Save Later. Am J Cardiol 2023; 202:237-238. [PMID: 37495439 DOI: 10.1016/j.amjcard.2023.06.110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 06/29/2023] [Indexed: 07/28/2023]
Affiliation(s)
- Rohan Samson
- Advanced Heart Failure Therapies Program, University of Louisville Health-Jewish Hospital, Louisville, Kentucky.
| | - Thierry H Le Jemtel
- Section of Cardiology, John W. Deming Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana
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Kaehne A, Keating P. Measuring the impact of an acute visiting scheme on emergency department attendances - a pre-post cohort design. BMC Health Serv Res 2021; 21:521. [PMID: 34049540 PMCID: PMC8164303 DOI: 10.1186/s12913-021-06557-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 05/17/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Emergency department (ED) attendances are contributing to rising costs of the National Health Service (NHS) in England. Critically assessing the impact of new services to reduce emergency department use can be difficult as new services may create additional access points, unlocking latent demand. The study evaluated an Acute Visiting Scheme (AVS) in a primary care context. We asked if AVS reduces overall ED demand and whether or not it changed utilisation patterns for frequent attenders. METHOD The study used a pre post single cohort design. The impact of AVS on all-cause ED attendances was hypothesised as a substitution effect, where AVS duty doctor visits would replace emergency department visits. Primary outcome was frequency of ED attendances. End points were reduction of frequency of service use and increase of intervals between attendances by frequent attenders. RESULTS ED attendances for AVS users rose by 47.6%. If AVS use was included, there was a more than fourfold increase of total service utilisation, amounting to 438.3%. It shows that AVS unlocked significant latent demand. However, there was some reduction in the frequency of ED attendances for some patients and an increase in time intervals between ED attendances for others. CONCLUSION The study demonstrates that careful analysis of patient utilisation can detect a differential impact of AVS on the use of ED. As the new service created additional access points for patients and hence introduces an element of choice, the new service is likely to unlock latent demand. This study illustrates that AVS may be most useful if targeted at specific patient groups who are most likely to benefit from the new service.
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Affiliation(s)
- Axel Kaehne
- Reader Health Services Research, Medical School, Edge Hill University, Ormskirk, L39 4QP, UK.
| | - Paula Keating
- Head of Women's and Children's Health Care, Faculty of Health, Social Care and Medicine, Edge Hill University, Ormskirk, UK
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Cardiac-CT and cardiac-MR cost-effectiveness: a literature review. Radiol Med 2020; 125:1200-1207. [PMID: 32970273 DOI: 10.1007/s11547-020-01290-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 09/08/2020] [Indexed: 01/18/2023]
Abstract
Cardiovascular diseases are still among the first causes of death worldwide with a huge impact on healthcare systems. Within these conditions, the correct diagnosis of coronary artery disease with the most appropriate imaging-based evaluations is of utmost importance. The sustainability of the healthcare systems, considering the high economic burden of modern cardiac imaging equipments, makes cost-effective analysis an important tool, currently used for weighing different costs and health outcomes, when policy makers have to allocate funds and to prioritize interventions, getting the most out of their financial resources. This review aims at evaluating cost-effective analysis in the more recent literature, focused on the role of Calcium Score, coronary computed tomography angiography and cardiac magnetic resonance.
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Castañeda-Orjuela C, García-Molina M, De la Hoz-Restrepo F. Is There Something Else Beyond Cost-Effectiveness Analysis for Public Health Decision Making? Value Health Reg Issues 2019; 23:1-5. [PMID: 31881441 DOI: 10.1016/j.vhri.2019.09.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 08/13/2019] [Accepted: 09/09/2019] [Indexed: 10/25/2022]
Abstract
Healthcare costs are a concern for the sustainability of health systems in both rich and poor countries. Achieving a balance between the aspirations of payers and the manufacturers of new technologies is a challenge for democratic societies. Evidence about the efficacy and effectiveness of a new intervention is a fundamental aspect for its inclusion, but additional information about organization, implementation, and feasibility is required. Economic evaluations, especially cost-effectiveness analyses (CEA), help inform the choice of a particular health intervention, but they are not the only input for decision making (DM). Use of CEA is relatively recent but has quickly become widespread. CEA techniques have evolved into increasingly complex and sophisticated methods intended to reflect reality closely but, at the same time, their results have become more difficult to verify and validate. In developed countries, CEA results have generated intense debates, but in developing countries, these reflections are still weak due to lack of technical capacity. Competing perspectives on CEAs exist and can heavily influence the DM process. The use of CEAs and the interpretation of their results requires critical analysis, especially when public funds are to be invested. Here, we present a perspective on the use of CEAs for DM that arises from our experience of its use in developing countries and requires the consideration of other rationalities, in addition to the economic one, for DM.
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Affiliation(s)
- Carlos Castañeda-Orjuela
- Epidemiology and Public Health Evaluation Group, Public Health Department, Universidad Nacional de Colombia, Bogotá, Colombia; Colombian National Health Observatory, Instituto Nacional de Salud, Bogotá, Colombia.
| | | | - Fernando De la Hoz-Restrepo
- Epidemiology and Public Health Evaluation Group, Public Health Department, Universidad Nacional de Colombia, Bogotá, Colombia
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Antonides CFJ, Cohen DJ, Osnabrugge RLJ. Statistical primer: a cost-effectiveness analysis. Eur J Cardiothorac Surg 2019; 54:209-213. [PMID: 29726940 DOI: 10.1093/ejcts/ezy187] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 04/02/2018] [Indexed: 01/03/2023] Open
Abstract
Cost-effectiveness analyses (CEAs) of new treatment strategies are increasingly reported. This can be a part of a clinical trial or as a separate study. Governments and healthcare payers frequently require a CEA to decide whether a new treatment strategy will be reimbursed. CEA is a framework to assess the effectiveness and costs of a new treatment strategy (e.g. a drug or intervention) when compared with a reference strategy. Effectiveness is often measured in life-years or quality-adjusted life-years, whereas costs consist of direct costs (the costs of the treatment), induced costs (downstream costs and cost offsets) and indirect costs. In this statistical primer, the rationale for assessing the economic consequences of new therapies is explained, followed by the fundamental concepts of CEAs, the different types of CEAs and an introduction to interpretation of CEAs. Finally, a real-world example of a CEA is discussed, comparing cost-effectiveness of transcatheter versus surgical aortic valve replacement in patients with severe aortic stenosis at intermediate surgical risk.
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Affiliation(s)
| | - David J Cohen
- Cardiovascular Division, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Ruben L J Osnabrugge
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, Netherlands
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Ferraris VA. What are the "costs" of cost-effectiveness? J Thorac Cardiovasc Surg 2017; 155:1682-1683. [PMID: 29254639 DOI: 10.1016/j.jtcvs.2017.11.069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 11/28/2017] [Indexed: 10/18/2022]
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Abstract
Transcatheter aortic valve implantation (TAVI), an established treatment for inoperable and high-risk operable symptomatic patients with severe aortic stenosis with growing numbers of procedures and expanding indications, is an expensive therapy. Cost-effectiveness analyses rely on the value of the incremental cost-effectiveness ratio (ICER), which is the difference in cost between two possible interventions, divided by the difference in their effect. Several analyses have demonstrated that TAVI is cost-effective with an acceptable ICER for the inoperable patient alone and only via the iliofemoral route, while TAVI is more costly and is either less or equally effective as surgery in high-risk operable patients. When use of TAVI is extended to include a larger number of patients suitable for surgery, the overall results become less favorable. Acceptable ICERs should practically equate to the value of the gross domestic product (GDP) per capita in each country; however, the cost of the TAVI kit alone already exceeds the GDP per capita of all moderate- and low-income countries. An overview of the current cost-efficacy issues of TAVI is presented and this grisly reality is discussed, which may hopefully be improved in the future.
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Affiliation(s)
- Antonis S Manolis
- Third Department of Cardiology, Athens University School of Medicine, Athens, Greece
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de Boer PT, Crépey P, Pitman RJ, Macabeo B, Chit A, Postma MJ. Cost-Effectiveness of Quadrivalent versus Trivalent Influenza Vaccine in the United States. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2016; 19:964-975. [PMID: 27987647 DOI: 10.1016/j.jval.2016.05.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 05/17/2016] [Accepted: 05/18/2016] [Indexed: 06/06/2023]
Abstract
BACKGROUND Designed to overcome influenza B mismatch, new quadrivalent influenza vaccines (QIVs) contain one additional B strain compared with trivalent influenza vaccines (TIVs). OBJECTIVE To examine the expected public health impact, budget impact, and incremental cost-effectiveness of QIV versus TIV in the United States. METHODS A dynamic transmission model was used to predict the annual incidence of influenza over the 20-year-period of 2014 to 2034 under either a TIV program or a QIV program. A decision tree model was interfaced with the transmission model to estimate the public health impact and the cost-effectiveness of replacing TIV with QIV from a societal perspective. Our models were informed by published data from the United States on influenza complication probabilities and relevant costs. The incremental vaccine price of QIV as compared with that of TIV was set at US $5.40 per dose. RESULTS Over the next 20 years, replacing TIV with QIV may reduce the number of influenza B cases by 27.2% (16.0 million cases), resulting in the prevention of 137,600 hospitalizations and 16,100 deaths and a gain of 212,000 quality-adjusted life-years (QALYs). The net societal budget impact would be US $5.8 billion and the incremental cost-effectiveness ratio US $27,411/QALY gained. In the probabilistic sensitivity analysis, 100% and 96.5% of the simulations fell below US $100,000/QALY and US $50,000/QALY, respectively. CONCLUSIONS Introducing QIV into the US immunization program may prevent a substantial number of hospitalizations and deaths. QIV is also expected to be a cost-effective alternative option to TIV.
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Affiliation(s)
- Pieter T de Boer
- Unit of PharmacoTherapy, -Epidemiology & -Economics (PTE2), Department of Pharmacy, University of Groningen, Groningen, The Netherlands.
| | - Pascal Crépey
- EHESP Rennes, Sorbonne Paris-Cité, Paris, France; Aix-Marseille Univ, UMR EPV 190, Marseille, France
| | | | | | - Ayman Chit
- Sanofi Pasteur, Swiftwater, PA, USA; Lesli Dan Faculty of Pharmacy, Toronto, Ontario, Canada
| | - Maarten J Postma
- Unit of PharmacoTherapy, -Epidemiology & -Economics (PTE2), Department of Pharmacy, University of Groningen, Groningen, The Netherlands; Institute of Science in Healthy Aging & healthcaRE (SHARE), University Medical Center Groningen (UMCG), Groningen, The Netherlands; Department of Epidemiology, University Medical Center Groningen (UMCG), University of Groningen, Groningen, The Netherlands
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Savitz LA, Savitz ST. Can delivery systems use cost-effectiveness analysis to reduce healthcare costs and improve value? F1000Res 2016; 5. [PMID: 27830055 PMCID: PMC5081157 DOI: 10.12688/f1000research.7531.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/19/2016] [Indexed: 11/24/2022] Open
Abstract
Understanding costs and ensuring that we demonstrate value in healthcare is a foundational presumption as we transform the way we deliver and pay for healthcare in the U.S. With a focus on population health and payment reforms underway, there is increased pressure to examine cost-effectiveness in healthcare delivery. Cost-effectiveness analysis (CEA) is a type of economic analysis comparing the costs and effects (i.e. health outcomes) of two or more treatment options. The result is expressed as a ratio where the denominator is the gain in health from a measure (e.g. years of life or quality-adjusted years of life) and the numerator is the incremental cost associated with that health gain. For higher cost interventions, the lower the ratio of costs to effects, the higher the value. While CEA is not new, the approach continues to be refined with enhanced statistical techniques and standardized methods. This article describes the CEA approach and also contrasts it to optional approaches, in order for readers to fully appreciate caveats and concerns. CEA as an economic evaluation tool can be easily misused owing to inappropriate assumptions, over reliance, and misapplication. Twelve issues to be considered in using CEA results to drive healthcare delivery decision-making are summarized. Appropriately recognizing both the strengths and the limitations of CEA is necessary for informed resource allocation in achieving the maximum value for healthcare services provided.
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Affiliation(s)
- Lucy A Savitz
- Institute for Healthcare Delivery Research, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Samuel T Savitz
- Department of Health Policy and Management, School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Lindvall C, Chatterjee NA, Chang Y, Chernack B, Jackson VA, Singh JP, Metlay JP. National Trends in the Use of Cardiac Resynchronization Therapy With or Without Implantable Cardioverter-Defibrillator. Circulation 2016; 133:273-81. [PMID: 26635400 PMCID: PMC5259807 DOI: 10.1161/circulationaha.115.018830] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 11/30/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Candidates for cardiac resynchronization therapy (CRT) receive either a biventricular pacemaker or a biventricular pacemaker with an implantable cardioverter-defibrillator (CRT-D). Optimal device selection remains challenging because the benefit of implantable cardioverter-defibrillator therapy may not be uniform, particularly in patients at competing risk of nonsudden death. METHODS AND RESULTS In this serial cross-sectional study using the National Inpatient Sample database, we identified 311,086 admissions associated with CRT implant between 2006 to 2012. CRT-D was the most common device type (86.1%), including in patients ≥ 75 years of age with ≥ 5 Elixhauser comorbidities (75.5%). Multivariate predictors of CRT-D implant included demographic, clinical, and geographic factors: prior ventricular arrhythmia (rate ratio [RR], 1.14; 95% CI, 1.13-1.14), ischemic heart disease (RR, 1.11; 95% CI, 1.10-1.11), male sex (RR, 1.10; 95% CI, 1.09-1.10), black race (RR, 1.06; 95% CI: 1.04-1.07), and Northeast geographic region (RR, 1.06; 95% CI, 1.04-1.09). There was significant interhospital variation in the use of CRT-D (10-90 percentile range, 72.9%-98.0% CRT-D). CONCLUSIONS The majority of patients in this contemporary US cohort underwent implantation of CRT-D. Predictors of CRT-D implant included demographic, clinical, and geographic factors. In patient subgroups predicted to have an attenuated benefit from implantable cardioverter-defibrillator therapy (older adults with multiple comorbidities), CRT-D remained the dominant device type. An improved understanding of the determinants of device selection may aid in decision making and ultimately better align patient risk with device benefit at the time of CRT implantation.
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Affiliation(s)
- Charlotta Lindvall
- From Divisions of Palliative Care (C.L., V.A.J.), General Internal Medicine (C.L., Y.C., J.P.M.), and Cardiology (N.A.C., J.P.S.), Department of Medicine, Massachusetts General Hospital, Boston, MA and Harvard Medical School (C.L., Y.C., B.C., V.A.J., J.P.S., J.P.M.), Boston, MA.
| | - Neal A Chatterjee
- From Divisions of Palliative Care (C.L., V.A.J.), General Internal Medicine (C.L., Y.C., J.P.M.), and Cardiology (N.A.C., J.P.S.), Department of Medicine, Massachusetts General Hospital, Boston, MA and Harvard Medical School (C.L., Y.C., B.C., V.A.J., J.P.S., J.P.M.), Boston, MA
| | - Yuchiao Chang
- From Divisions of Palliative Care (C.L., V.A.J.), General Internal Medicine (C.L., Y.C., J.P.M.), and Cardiology (N.A.C., J.P.S.), Department of Medicine, Massachusetts General Hospital, Boston, MA and Harvard Medical School (C.L., Y.C., B.C., V.A.J., J.P.S., J.P.M.), Boston, MA
| | - Betty Chernack
- From Divisions of Palliative Care (C.L., V.A.J.), General Internal Medicine (C.L., Y.C., J.P.M.), and Cardiology (N.A.C., J.P.S.), Department of Medicine, Massachusetts General Hospital, Boston, MA and Harvard Medical School (C.L., Y.C., B.C., V.A.J., J.P.S., J.P.M.), Boston, MA
| | - Vicki A Jackson
- From Divisions of Palliative Care (C.L., V.A.J.), General Internal Medicine (C.L., Y.C., J.P.M.), and Cardiology (N.A.C., J.P.S.), Department of Medicine, Massachusetts General Hospital, Boston, MA and Harvard Medical School (C.L., Y.C., B.C., V.A.J., J.P.S., J.P.M.), Boston, MA
| | - Jagmeet P Singh
- From Divisions of Palliative Care (C.L., V.A.J.), General Internal Medicine (C.L., Y.C., J.P.M.), and Cardiology (N.A.C., J.P.S.), Department of Medicine, Massachusetts General Hospital, Boston, MA and Harvard Medical School (C.L., Y.C., B.C., V.A.J., J.P.S., J.P.M.), Boston, MA
| | - Joshua P Metlay
- From Divisions of Palliative Care (C.L., V.A.J.), General Internal Medicine (C.L., Y.C., J.P.M.), and Cardiology (N.A.C., J.P.S.), Department of Medicine, Massachusetts General Hospital, Boston, MA and Harvard Medical School (C.L., Y.C., B.C., V.A.J., J.P.S., J.P.M.), Boston, MA
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Reimbursement for Prostate Cancer Treatment. Prostate Cancer 2016. [DOI: 10.1016/b978-0-12-800077-9.00041-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Anderson JL, Heidenreich PA, Barnett PG, Creager MA, Fonarow GC, Gibbons RJ, Halperin JL, Hlatky MA, Jacobs AK, Mark DB, Masoudi FA, Peterson ED, Shaw LJ. ACC/AHA statement on cost/value methodology in clinical practice guidelines and performance measures: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and Task Force on Practice Guidelines. Circulation 2014; 129:2329-45. [PMID: 24677315 DOI: 10.1161/cir.0000000000000042] [Citation(s) in RCA: 207] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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16
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Anderson JL, Heidenreich PA, Barnett PG, Creager MA, Fonarow GC, Gibbons RJ, Halperin JL, Hlatky MA, Jacobs AK, Mark DB, Masoudi FA, Peterson ED, Shaw LJ. ACC/AHA statement on cost/value methodology in clinical practice guidelines and performance measures: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 63:2304-22. [PMID: 24681044 DOI: 10.1016/j.jacc.2014.03.016] [Citation(s) in RCA: 330] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Eze-Nliam CM, Zhang Z, Weiss SA, Weintraub WS. Cost-effectiveness Assessment of Cardiac Interventions: Determining a Socially Acceptable Cost Threshold. Interv Cardiol 2014; 6:45-55. [PMID: 26136831 DOI: 10.2217/ica.13.81] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Health care is a vital good for which there is an infinite demand. However, societal resources are finite and need to be distributed efficiently to avoid waste. Thus, the relative value of an intervention - cost compared to its effectiveness- needs to be taken into consideration when deciding which interventions to adopt. Cost-effectiveness analysis provides the crucial information which guides these decisions. As the field of medicine and indeed cardiology move forward with innovations which are effective but often expensive, it becomes imperative to employ these cost-effectiveness analytic tools, not with the intention of denying vital health services but to ascertain what the society willing to pay for.
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Affiliation(s)
- Chete M Eze-Nliam
- Cardiology Section, Christiana Care Health System/Thomas Jefferson University,4755 Ogletown-Stanton Road, Newark, DE 19718, USA
| | - Zugui Zhang
- Cardiology Section, Christiana Care Health System/Thomas Jefferson University,4755 Ogletown-Stanton Road, Newark, DE 19718, USA
| | - Sandra A Weiss
- Cardiology Section, Christiana Care Health System/Thomas Jefferson University,4755 Ogletown-Stanton Road, Newark, DE 19718, USA
| | - William S Weintraub
- Cardiology Section, Christiana Care Health System/Thomas Jefferson University,4755 Ogletown-Stanton Road, Newark, DE 19718, USA
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Carter MJ. Health Economics Information in Wound Care: The Elephant in the Room. Adv Wound Care (New Rochelle) 2013; 2:563-570. [PMID: 24527322 PMCID: PMC3865616 DOI: 10.1089/wound.2013.0479] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Accepted: 06/21/2013] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To describe the role of health economics (HE) in wound care in relation to coverage and reimbursement. APPROACH Narrative description of key concepts with supporting references. RESULTS The process of approval or clearance of wound care products within the U.S. regulatory framework often causes lack of high level of evidence regarding clinical outcomes. There is also a paucity of HE information and great reluctance to use such information (when it is available) by insurers and Centers for Medicare and Medicaid, as well as other health-care agencies. Cost-effectiveness (CE) studies are the most common type of HE study in wound care, and the most common outcomes are incremental CE ratios (ICERs). Interpretation of ICERs requires considerable judgment when results are not obvious and is hampered by lack of contemporary and useful benchmarks. While many lessons have been learned in applying CE to coverage and reimbursement decisions in other western countries-including transparency of decision-making and involvement of patients-there is still a major aversion to using CE in the United States Applying CE to basic wound care and advanced therapeutics has the potential to decrease the costs of wound healing considerably. INNOVATION AND CONCLUSIONS Many CE approaches, including modeling, provide sufficiently detailed information that decision-makers can make informed decisions about wound care products in regard to coverage and reimbursement. The reluctance to use CE information in the United States, however, is likely to contribute heavily to the ever-increasing costs in wound care.
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Goyal SS, Shah R, Roberson DW, Schwartz ML. Variation in post-adenotonsillectomy admission practices in 24 pediatric hospitals. Laryngoscope 2013; 123:2560-6. [PMID: 23907959 DOI: 10.1002/lary.24172] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Revised: 03/08/2013] [Accepted: 04/01/2013] [Indexed: 11/07/2022]
Abstract
OBJECTIVES/HYPOTHESIS There is controversy about which children should be admitted after adenotonsillectomy (T&A) and limited clinical evidence to help with this decision. Current practice has evolved based on empirical or anecdotal evidence. We sought to identify practice variations in postoperative admission after T&A in tertiary care pediatric hospitals. STUDY DESIGN Retrospective database study using administrative information stored in the Pediatric Health Information System (PHIS) database. METHODS There were 29,920 T&As performed in 24 pediatric hospitals included in the PHIS database between July 1, 2009 and June 30, 2010. Patients were identified as outpatient (discharged the same day) or inpatient (not discharged on the day of surgery). We examined admission rates across different hospitals stratified by age, obstructive sleep apnea (OSA), and other complex chronic conditions. RESULTS Younger age, the existence of a complex chronic condition, and OSA were all associated with higher post-T&A admission rates. Admission rates ranged from >94% for children under 2 years of age, with OSA and at least one medical comorbidity, to 14% for children older than 5 years, without OSA and without any medical comorbidities. Between-hospital variability was extreme; for example, for 3 to 5 year olds, the admission rate varied from 5% to 90% between hospitals. Very significant variation remained even after controlling for age, comorbidities, and OSA. CONCLUSIONS Post T&A admission rates vary tremendously across comparable tertiary-care pediatric hospitals. There is a crucial need for a better understanding of the risk of complications on the first postoperative night, and the appropriate indications for monitored admission on that night. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- Samita S Goyal
- Department of Plastic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
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What is the role of cost-effectiveness analysis in clinical practice? J Urol 2013; 190:1163-4. [PMID: 23871931 DOI: 10.1016/j.juro.2013.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2013] [Indexed: 11/21/2022]
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Francis SA, Daly C, Heydari B, Abbasi S, Shah RV, Kwong RY. Cost-effectiveness analysis for imaging techniques with a focus on cardiovascular magnetic resonance. J Cardiovasc Magn Reson 2013; 15:52. [PMID: 23767423 PMCID: PMC3707775 DOI: 10.1186/1532-429x-15-52] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Accepted: 06/03/2013] [Indexed: 12/19/2022] Open
Abstract
With the need for healthcare cost-containment, increased scrutiny will be placed on new medical therapeutic or diagnostic technologies. Several challenges exist for a new diagnostic test to demonstrate cost-effectiveness. New diagnostic tests differ from therapeutic procedures due to the fact that diagnostic tests do not generally directly affect long-term patient outcomes. Instead, the results of diagnostic tests can influence management decisions for patients and by this route, diagnostic tests indirectly affect long-term outcomes. The benefits from a specific diagnostic technology depend therefore not only on its performance characteristics, but also on other factors such as prevalence of disease, and effectiveness of existing treatments for the disease of interest. We review the concepts and theories of cost-effectiveness analyses (CEA) as they apply to diagnostic tests in general. The limitations of CEA across different study designs and geographic regions are discussed, and we also examine the strengths and weakness of the existing publications where CMR was the focus of CEA compared to other diagnostic options.
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Affiliation(s)
- Sanjeev A Francis
- Cardiology Division, Department of Medicine, Massuchusetts General Hospital, Boston, MA, USA
| | - Caroline Daly
- Cardiology Division, St. James’ Hospital, Dublin, Ireland
| | - Bobak Heydari
- Department of Medicine, Brigham and Women's Hospital, Cardiovascular Division, Boston, MA, USA
| | - Siddique Abbasi
- Department of Medicine, Brigham and Women's Hospital, Cardiovascular Division, Boston, MA, USA
| | - Ravi V Shah
- Department of Medicine, Brigham and Women's Hospital, Cardiovascular Division, Boston, MA, USA
| | - Raymond Y Kwong
- Department of Medicine, Brigham and Women's Hospital, Cardiovascular Division, Boston, MA, USA
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Zanaboni P, Landolina M, Marzegalli M, Lunati M, Perego GB, Guenzati G, Curnis A, Valsecchi S, Borghetti F, Borghi G, Masella C. Cost-utility analysis of the EVOLVO study on remote monitoring for heart failure patients with implantable defibrillators: randomized controlled trial. J Med Internet Res 2013; 15:e106. [PMID: 23722666 PMCID: PMC3670725 DOI: 10.2196/jmir.2587] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Revised: 04/25/2013] [Accepted: 05/09/2013] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Heart failure patients with implantable defibrillators place a significant burden on health care systems. Remote monitoring allows assessment of device function and heart failure parameters, and may represent a safe, effective, and cost-saving method compared to conventional in-office follow-up. OBJECTIVE We hypothesized that remote device monitoring represents a cost-effective approach. This paper summarizes the economic evaluation of the Evolution of Management Strategies of Heart Failure Patients With Implantable Defibrillators (EVOLVO) study, a multicenter clinical trial aimed at measuring the benefits of remote monitoring for heart failure patients with implantable defibrillators. METHODS Two hundred patients implanted with a wireless transmission-enabled implantable defibrillator were randomized to receive either remote monitoring or the conventional method of in-person evaluations. Patients were followed for 16 months with a protocol of scheduled in-office and remote follow-ups. The economic evaluation of the intervention was conducted from the perspectives of the health care system and the patient. A cost-utility analysis was performed to measure whether the intervention was cost-effective in terms of cost per quality-adjusted life year (QALY) gained. RESULTS Overall, remote monitoring did not show significant annual cost savings for the health care system (€1962.78 versus €2130.01; P=.80). There was a significant reduction of the annual cost for the patients in the remote arm in comparison to the standard arm (€291.36 versus €381.34; P=.01). Cost-utility analysis was performed for 180 patients for whom QALYs were available. The patients in the remote arm gained 0.065 QALYs more than those in the standard arm over 16 months, with a cost savings of €888.10 per patient. Results from the cost-utility analysis of the EVOLVO study show that remote monitoring is a cost-effective and dominant solution. CONCLUSIONS Remote management of heart failure patients with implantable defibrillators appears to be cost-effective compared to the conventional method of in-person evaluations. TRIAL REGISTRATION ClinicalTrials.gov NCT00873899; http://clinicaltrials.gov/show/NCT00873899 (Archived by WebCite at http://www.webcitation.org/6H0BOA29f).
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Affiliation(s)
- Paolo Zanaboni
- Norwegian Centre for Integrated Care and Telemedicine, University Hospital of North Norway, Tromsø, Norway.
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Katsanos K, Karnabatidis D, Diamantopoulos A, Spiliopoulos S, Siablis D. Cost-effectiveness analysis of infrapopliteal drug-eluting stents. Cardiovasc Intervent Radiol 2013; 36:90-7. [PMID: 22414987 DOI: 10.1007/s00270-012-0370-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2011] [Accepted: 02/13/2012] [Indexed: 02/05/2023]
Abstract
INTRODUCTION There are no cost-utility data about below-the-knee placement of drug-eluting stents. The authors determined the cost-effectiveness of infrapopliteal drug-eluting stents for critical limb ischemia (CLI) treatment. METHODS The event-free individual survival outcomes defined by the absence of any major events, including death, major amputation, and target limb repeat procedures, were reconstructed on the basis of two published infrapopliteal series. The first included spot Bail-out use of Sirolimus-eluting stents versus bare metal stents after suboptimal balloon angioplasty (Bail-out SES).The second was full-lesion Primary Everolimus-eluting stenting versus plain balloon angioplasty and bail-out bare metal stenting as necessary (primary EES). The number-needed-to-treat (NNT) to avoid one major event and incremental cost-effectiveness ratios (ICERs) were calculated for a 3-year postprocedural period for both strategies. RESULTS Overall event-free survival was significantly improved in both strategies (hazard ratio (HR) [confidence interval (CI)]: 0.68 [0.41-1.12] in Bail-out SES and HR [CI]: 0.53 [0.29-0.99] in Primary EES). Event-free survival gain per patient was 0.89 (range, 0.11-3.0) years in Bail-out SES with an NNT of 4.6 (CI: 2.5-25.6) and a corresponding ICER of 6,518<euro> (range 1,685-10,112<euro>). Survival gain was 0.91 (range 0.25-3.0) years in Primary EES with an NNT of 2.7 (CI: 1.7-5.8) and an ICER of 11,581<euro> (range, 4,945-21,428<euro>) per event-free life-year gained. Two-way sensitivity analysis showed that stented lesion length >10 cm and/or DES list price >1000<euro> were associated with the least economically favorable scenario in both strategies. CONCLUSIONS Both strategies of bail-out SES and primary EES placement in the infrapopliteal arteries for CLI treatment exhibit single-digit NNT and relatively low corresponding ICERs.
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Affiliation(s)
- Konstantinos Katsanos
- Department of Interventional Radiology, School of Medicine, Patras University Hospital, 26504, Rion, Greece.
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Chia WK, Toh HC. Is Cost-Effective Healthcare Compatible with Publicly Financed Academic Medical Centres? ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2013. [DOI: 10.47102/annals-acadmedsg.v42n1p42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Probably more than any country, Singapore has made significant investment into the biomedical enterprise as a proportion of its economy and size. This focus recently witnessed a shift towards a greater emphasis on translational and clinical development. Key to the realisation of this strategy will be Academic Medical Centres (AMCs), as a principal tool to developing and applying useful products for the market and further improving health outcomes. Here, we explore the principal value proposition of the AMC to Singapore society and its healthcare system. We question if the values inherent within academic medicine —that of inquiry, innovation, pedagogy and clinical exceptionalism—can be compatible with the seemingly paradoxical mandate of providing cost-effective or rationed healthcare.
Key words: Academic Medical Centre, Cost-effective healthcare
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Holubar SD, Chatterjee A, Finlayson SR. Cost-Based Comparative-Effectiveness Research in Colon and Rectal Surgery. SEMINARS IN COLON AND RECTAL SURGERY 2011. [DOI: 10.1053/j.scrs.2011.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Affiliation(s)
- Harlan M. Krumholz
- From the Section of Cardiovascular Medicine and the Robert Wood Johnson Clinical Scholars Program, Department of Medicine; the Section of Health Policy and Administration, School of Public Health, Yale University School of Medicine; and the Center for Outcomes Research and Evaluation, Yale–New Haven Hospital, New Haven, CT
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Spertus JA, Bonow RO, Chan P, Diamond GA, Drozda JP, Kaul S, Krumholz HM, Masoudi FA, Normand SLT, Peterson ED, Radford MJ, Rumsfeld JS. ACCF/AHA new insights into the methodology of performance measurement: a report of the American College of Cardiology Foundation/American Heart Association Task Force on performance measures. Circulation 2010; 122:2091-106. [PMID: 21060078 DOI: 10.1161/cir.0b013e3181f7d78c] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Affiliation(s)
- Harlan M. Krumholz
- From the Section of Cardiovascular Medicine and the Robert Wood Johnson Clinical Scholars Program, Department of Medicine; Section of Health Policy and Administration, School of Public Health, Yale University School of Medicine; and the Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Conn
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Henriksson M, Palmer S, Chen R, Damant J, Fitzpatrick NK, Abrams K, Hingorani AD, Stenestrand U, Janzon M, Feder G, Keogh B, Shipley MJ, Kaski JC, Timmis A, Sculpher M, Hemingway H. Assessing the cost effectiveness of using prognostic biomarkers with decision models: case study in prioritising patients waiting for coronary artery surgery. BMJ 2010; 340:b5606. [PMID: 20085988 PMCID: PMC2808469 DOI: 10.1136/bmj.b5606] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To determine the effectiveness and cost effectiveness of using information from circulating biomarkers to inform the prioritisation process of patients with stable angina awaiting coronary artery bypass graft surgery. DESIGN Decision analytical model comparing four prioritisation strategies without biomarkers (no formal prioritisation, two urgency scores, and a risk score) and three strategies based on a risk score using biomarkers: a routinely assessed biomarker (estimated glomerular filtration rate), a novel biomarker (C reactive protein), or both. The order in which to perform coronary artery bypass grafting in a cohort of patients was determined by each prioritisation strategy, and mean lifetime costs and quality adjusted life years (QALYs) were compared. DATA SOURCES Swedish Coronary Angiography and Angioplasty Registry (9935 patients with stable angina awaiting coronary artery bypass grafting and then followed up for cardiovascular events after the procedure for 3.8 years), and meta-analyses of prognostic effects (relative risks) of biomarkers. RESULTS The observed risk of cardiovascular events while on the waiting list for coronary artery bypass grafting was 3 per 10,000 patients per day within the first 90 days (184 events in 9935 patients). Using a cost effectiveness threshold of pound20,000- pound30,000 (euro22,000-euro33,000; $32,000-$48,000) per additional QALY, a prioritisation strategy using a risk score with estimated glomerular filtration rate was the most cost effective strategy (cost per additional QALY was < pound410 compared with the Ontario urgency score). The impact on population health of implementing this strategy was 800 QALYs per 100,000 patients at an additional cost of pound 245,000 to the National Health Service. The prioritisation strategy using a risk score with C reactive protein was associated with lower QALYs and higher costs compared with a risk score using estimated glomerular filtration rate. CONCLUSION Evaluating the cost effectiveness of prognostic biomarkers is important even when effects at an individual level are small. Formal prioritisation of patients awaiting coronary artery bypass grafting using a routinely assessed biomarker (estimated glomerular filtration rate) along with simple, routinely collected clinical information was cost effective. Prioritisation strategies based on the prognostic information conferred by C reactive protein, which is not currently measured in this context, or a combination of C reactive protein and estimated glomerular filtration rate, is unlikely to be cost effective. The widespread practice of using only implicit or informal means of clinically ordering the waiting list may be harmful and should be replaced with formal prioritisation approaches.
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Affiliation(s)
- Martin Henriksson
- Centre for Medical Technology Assessment, Linkoping University, Sweden
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