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Guduguntla V, Redberg RF. Popular procedures without evidence of benefit: A case study of percutaneous coronary intervention for stable coronary artery disease. Eur J Intern Med 2021; 94:15-21. [PMID: 34535375 DOI: 10.1016/j.ejim.2021.08.027] [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: 06/13/2021] [Revised: 08/24/2021] [Accepted: 08/31/2021] [Indexed: 01/09/2023]
Abstract
Despite limited benefit, percutaneous coronary intervention (PCI) remains a common procedure that is often performed for uncertain or inappropriate indications in patients with stable coronary artery disease (CAD). PCI cases per capita have increased year-over-year in most European countries, and many have higher rates than the U.S. Meanwhile, first-line therapy such as optimal medical therapy (OMT) and lifestyle changes, continue to be under-utilized. This article reviews the evidence on use of PCI in stable CAD. Specifically, we analyzed randomized control trials, systematic reviews, appropriate use criteria, and professional society guidelines that examine the risks and benefits of PCI compared to OMT. We then highlight utilization patterns as well as interventions that better align current practice with evidence-based care.
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Affiliation(s)
- Vinay Guduguntla
- Department of Medicine, University of California San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94131, United States.
| | - Rita F Redberg
- Department of Cardiology, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94131, United States
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Ahmad M, Asghar M, Joshi U, Neilson NA, Tye M, Divecha C, Kim M, Mungee S. Study of Association Between Different Coronary Artery Disease Presentations and Its Effect on Short-Term Mortality, Readmission, and Cost in Patients Undergoing Percutaneous Coronary Interventions. Cureus 2021; 13:e16862. [PMID: 34513438 PMCID: PMC8411994 DOI: 10.7759/cureus.16862] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction Atherosclerotic coronary artery disease (CAD) is the major cause of mortality in the USA. CAD requiring percutaneous coronary intervention (PCI) can have a wide spectrum of presentations. We reviewed the cost of admission and PCI at the tertiary care center stratified for different CAD presentation types. Methods We performed a retrospective study of 7,389 patients undergoing coronary angiogram at our facility from 2015 to 2017. Patients were selected from CathPCI registry. Chart review was done for readmission and death data. Cost data were provided by the finance department. Patients going for coronary artery bypass surgery (CABG) were excluded. We split the patients based on their need for PCI. Cost analysis was based on CAD presentation types (No symptoms, atypical symptoms, stable angina, unstable angina, NSTEMI [non-ST segment elevation myocardial infarction], STEMI [ST-segment elevation myocardial infarction]). Adjusted linear regression was run for the outcomes. Primary outcomes were 30-day readmission and death. The secondary outcome was cost of admission. Results The final sample size was 6,403. The mean age was 65.6 years (SD: 12.5; male: 63.8%). 2444 required PCI (38%; p < 0.001). PCI group had lower mean age (62.5 years; SD: 12.3, p<0.001) with lower BMI (30.6 vs 31.1, p=0.015). PCI group had significantly lower odds for 30-day readmission (OR: 0.63; CI: 0.45-0.89; p=0.009) and 30-day mortality (OR:0.60; CI: 0.41-0.89; p = 0.011). A severe presentation increased the odds of getting PCI. Cost of admission was higher in all groups receiving PCI. Conclusions PCI group had better 30-day readmission and mortality rates. PCI increases the cost of admission in all CAD types.
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Affiliation(s)
- Mansoor Ahmad
- Cardiology, University of Illinois College of Medicine at Peoria, Peoria, USA
| | - Muhammad Asghar
- Internal Medicine, University of Illinois Chicago, College of Medicine at Peoria, Peoria, USA
| | - Udit Joshi
- Cardiology, University of Illinois College of Medicine at Peoria, Peoria, USA
| | - Nathan A Neilson
- Cardiology, University of Illinois Chicago, College of Medicine at Peoria, Peoria, USA
| | - Michael Tye
- Cardiology, University of Illinois Chicago, College of Medicine at Peoria, Peoria, USA
| | - Chirag Divecha
- Cardiology, University of Illinois College of Medicine at Peoria, Peoria, USA
| | - Minchul Kim
- Internal Medicine, University of Illinois College of Medicine at Peoria, Peoria, USA
| | - Sudhir Mungee
- Cardiology, University of Illinois College of Medicine, Order of St. Francis Medical Centre, Peoria, USA
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Lu Y, Zhang H, Wang Y, Zhou T, Welsh J, Liu J, Guan W, Li J, Li X, Zheng X, Spertus JA, Masoudi FA, Krumholz HM, Jiang L. Percutaneous Coronary Intervention in Patients Without Acute Myocardial Infarction in China: Results From the China PEACE Prospective Study of Percutaneous Coronary Intervention. JAMA Netw Open 2018; 1:e185446. [PMID: 30646292 PMCID: PMC6324328 DOI: 10.1001/jamanetworkopen.2018.5446] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
IMPORTANCE Despite a rapid increase in percutaneous coronary intervention (PCI) procedures in China, little is known about patient-reported health status before and after PCI in patients without acute myocardial infarction (AMI). OBJECTIVE To describe self-perceived angina-specific health status prior to PCI and 1 year after the procedure in patients without AMI in China. DESIGN, SETTING, AND PARTICIPANTS The China Patient-Centered Evaluative Assessment of Cardiac Events (PEACE) Prospective Study of PCI was a population-based, multicenter cohort study of a consecutive sample of 1611 patients without AMI undergoing elective PCI. Participants were enrolled from 40 hospitals in 18 provinces in China from December 2012 to August 2014. Participants were eligible if they underwent PCI for stable and unstable angina and did not have AMI. Participants were excluded if they died in hospital, withdrew from follow-up, or had missing data on self-reported health status at baseline or at 1 year after PCI. The date of the analysis was September 15, 2018. EXPOSURES Percutaneous coronary intervention for ischemic heart disease. MAIN OUTCOMES AND MEASURES Angina frequency and angina-related quality of life were assessed with the Seattle Angina Questionnaire (SAQ) immediately prior to PCI and 1 year after the procedure. Either (1) an increase in the SAQ Angina Frequency score of 10 or more points or (2) an increase in the SAQ Quality-of-Life score of 10 or more points was considered to represent clinically significant improvement. RESULTS Of 1611 patients, 520 (32.3%) were women; mean (SD) age was 61.3 (9.8) years. Among these patients, 443 (27.5%) had stable coronary artery disease and 1168 (72.5%) had unstable angina. One hundred fourteen of 443 patients undergoing PCI for stable coronary artery disease (25.7%) and 175 of 1168 undergoing PCI for unstable angina (15.0%) had no reported angina symptoms at the time of the procedure (SAQ Angina Frequency score = 100). Moreover, 18% of all patients (290) had minimal angina symptoms (SAQ Angina Frequency score >90) and, thus, no potential for substantial clinical improvement. Patients with smaller clinical improvements in angina symptom burden at 1 year following PCI had significantly higher baseline SAQ scores for all scales than patients with greater clinical improvement, but generally similar sociodemographic and procedural characteristics. CONCLUSIONS AND RELEVANCE In this study, 25.7% of patients undergoing PCI for stable coronary artery disease had no reported angina symptoms at the time of the procedure. Patients with smaller clinical improvements in angina symptom burden had higher baseline SAQ scores, which highlights the importance of ascertaining impairment from angina among patients without AMI prior to performing PCI.
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Affiliation(s)
- Yuan Lu
- Center for Outcomes Research and Evaluation, Yale University/Yale-New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Haibo Zhang
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- NHC Key Laboratory of Clinical Research for Cardiovascular Medications, Beijing, People’s Republic of China
| | - Yongfei Wang
- Center for Outcomes Research and Evaluation, Yale University/Yale-New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Tianna Zhou
- Center for Outcomes Research and Evaluation, Yale University/Yale-New Haven Hospital, New Haven, Connecticut
| | - John Welsh
- Center for Outcomes Research and Evaluation, Yale University/Yale-New Haven Hospital, New Haven, Connecticut
| | - Jiamin Liu
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- NHC Key Laboratory of Clinical Research for Cardiovascular Medications, Beijing, People’s Republic of China
| | - Wenchi Guan
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- NHC Key Laboratory of Clinical Research for Cardiovascular Medications, Beijing, People’s Republic of China
| | - Jing Li
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- NHC Key Laboratory of Clinical Research for Cardiovascular Medications, Beijing, People’s Republic of China
| | - Xi Li
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- NHC Key Laboratory of Clinical Research for Cardiovascular Medications, Beijing, People’s Republic of China
| | - Xin Zheng
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- NHC Key Laboratory of Clinical Research for Cardiovascular Medications, Beijing, People’s Republic of China
| | - John A. Spertus
- Health Outcomes Research, Saint Luke’s Mid America Heart Institute/University of Missouri-Kansas City, Kansas City
| | | | - Harlan M. Krumholz
- Center for Outcomes Research and Evaluation, Yale University/Yale-New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
| | - Lixin Jiang
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- NHC Key Laboratory of Clinical Research for Cardiovascular Medications, Beijing, People’s Republic of China
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Stevens ER, Farrell D, Jumkhawala SA, Ladapo JA. Quality of health economic evaluations for the ACC/AHA stable ischemic heart disease practice guideline: A systematic review. Am Heart J 2018; 204:17-33. [PMID: 30077048 DOI: 10.1016/j.ahj.2018.06.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 06/30/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND The American College of Cardiology/American Heart Association (ACC/AHA) recently published a rigorous framework to guide integration of economic data into clinical guidelines. We assessed the quality of economic evaluations in a major ACC/AHA clinical guidance report. METHODS We systematically identified cost-effectiveness analyses (CEAs) of RCTs cited in the ACC/AHA 2012 Guideline for the Diagnosis and Management of Patients with Stable Ischemic Heart Disease. We extracted: (1) study identifiers; (2) parent RCT information; (3) economic analysis characteristics; and (4) study quality using the Quality of Health Economic Studies instrument (QHES). RESULTS Quality scores were categorized as high (≥75 points) or low (<75 points). Of 1,266 citations in the guideline, 219 were RCTs associated with 77 CEAs. Mean quality score was 81 (out of 100) and improved over time, though 29.9% of studies were low-quality. Cost-per-QALY was the most commonly reported primary outcome (39.0%). Low-quality studies were less likely to report study perspective, use appropriate time horizons, or address statistical and clinical uncertainty. Funding was overwhelmingly private (83%). A detailed methodological assessment of high-quality studies revealed domains of additional methodological issues not identified by the QHES. CONCLUSIONS Economic evaluations of RCTs in the 2012 ACC/AHA ischemic heart disease guideline largely had high QHES scores but methodological issues existed among "high-quality" studies. Because the ACC/AHA has generally been more systematic in its integration of scientific evidence compared to other professional societies, it is likely that most societies will need to proceed more cautiously in their integration of economic evidence.
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Nguyen E, Coleman CI, Kohn CG, Weeda ER. Ranolazine in patients with type 2 diabetes and chronic angina: A cost-effectiveness analysis and assessment of health-related quality-of-life. Int J Cardiol 2018; 273:34-38. [PMID: 30266352 DOI: 10.1016/j.ijcard.2018.09.060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Revised: 09/07/2018] [Accepted: 09/17/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Type 2 diabetes (T2D) is associated with a high burden of angina. Ranolazine has been shown to reduce angina frequency versus placebo in patients with T2D and stable angina. We sought to estimate the cost-effectiveness of ranolazine when added to standard-of-care (SoC) versus SoC alone in patients with T2D and stable, but symptomatic coronary disease despite treatment with 1-2 antianginals. METHODS A Markov model was developed and evaluated using cohort simulation. The model utilized a US societal perspective, 1-month cycle length and 1-year time horizon and was developed to estimate the cost-effectiveness of ranolazine versus SoC. Patients entered the model in 1 of 4 angina frequency health states based on baseline Seattle Angina Questionnaire Angina Frequency scores (100 = no; 61-99 = monthly; 31-60 = weekly; 0-30 = daily) and could transition between health states (first cycle only) or to death (any cycle) based on probabilities derived from the Type 2 Diabetes Evaluation of Ranolazine in Subjects with Chronic Stable Angina trial. RESULTS Our model estimated patients treated with ranolazine lived a mean of 0.728 quality adjusted life years (QALYs) at a cost of $16,654. Those not receiving ranolazine lived a mean of 0.702 QALYs and incurred costs of $15,476. The incremental cost-effectiveness ratio for the addition of ranolazine to SoC was $45,308/QALY. Short Form-36 data suggest improvements in patients' bodily pain drove the gain in QALYs associated with ranolazine (2.73 versus 3.96, p = 0.01). CONCLUSION Our model suggests the addition of ranolazine to SoC is likely cost-effective from a US societal perspective for the treatment of patients with T2D and stable, symptomatic coronary disease despite treatment with 1-2 antianginals.
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Affiliation(s)
- Elaine Nguyen
- Idaho State University, College of Pharmacy, Meridian, ID, United States of America
| | - Craig I Coleman
- University of Connecticut, Schools of Pharmacy and Medicine, Storrs and Farmington, CT, United States of America
| | - Christine G Kohn
- University of Connecticut, Schools of Pharmacy and Medicine, Storrs and Farmington, CT, United States of America
| | - Erin R Weeda
- Medical University of South Carolina, College of Pharmacy, Charleston, SC, United States of America.
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Inohara T, Numasawa Y, Higashi T, Ueda I, Suzuki M, Hayashida K, Yuasa S, Maekawa Y, Fukuda K, Kohsaka S. Predictors of high cost after percutaneous coronary intervention: A review from Japanese multicenter registry overviewing the influence of procedural complications. Am Heart J 2017; 194:61-72. [PMID: 29223436 DOI: 10.1016/j.ahj.2017.08.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 08/15/2017] [Indexed: 01/21/2023]
Abstract
BACKGROUND Percutaneous coronary intervention (PCI) is widely used; however, factors of high-cost care after PCI have not been thoroughly investigated. We sought to evaluate the in-hospital costs related to PCI and identify predictors of high costs. METHODS We extracted 2,354 consecutive PCI cases (1,243 acute cases, 52.8%) from 3 Japanese cardiovascular centers from 2011 to 2015. In-hospital complications were predefined under consensus definitions (eg, acute kidney injury [AKI]). We extracted the facility cost data for each patient's resource under the universal Japanese insurance system. We classified the patients into total cost quartiles and identified predictors for the highest quartile ("high-cost" group). In addition, incremental costs for procedure-related complications were calculated. RESULTS During the study period, a total of 401 cases (17.0%) experienced procedure-related complications. The in-hospital acute and elective PCI costs per case were US $14,840 (interquartile range [IQR] 11,370-20,070) and US $11,030 (IQR 8929-14,670), respectively. After adjusting for baseline differences, any of the procedure-related complications remained an independent predictor of high costs (acute: odds ratio 1.66, 95% CIs 1.13-2.43; elective: odds ratio 3.73, 95% CIs 1.96-7.11). Notably, incremental costs were mainly attributed to AKI, which accounted for 37.5% of all incremental costs; it increased by US $9,840 for each AKI event, and the total cost increase reached US $2,588,035. CONCLUSIONS Procedure-related complications, particularly postprocedural AKI, were associated with higher costs in PCI. Further studies are required to evaluate prospectively whether the preventive strategy with a personalized risk stratification for AKI could save costs.
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Rezende PC, Hueb W, Rahmi RM, Scudeler TL, de Azevedo DFC, Garzillo CL, Segre CAW, Ramires JAF, Filho RK. Myocardial injury in diabetic patients with multivessel coronary artery disease after revascularization interventions. Diabetol Metab Syndr 2017; 9:92. [PMID: 29201152 PMCID: PMC5697213 DOI: 10.1186/s13098-017-0292-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 11/15/2017] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Diabetic patients may be more susceptible to myocardial injury after coronary interventions. Thus, the aim of this study was to assess the release of cardiac biomarkers, CK-MB and troponin, and the findings of new late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR) in patients with type 2 diabetes mellitus after elective revascularization procedures for multivessel coronary artery disease (CAD). METHODS Patients with multivessel CAD and preserved systolic ventricular function underwent either elective percutaneous coronary intervention (PCI), off-pump or on-pump bypass surgery (CABG). Troponin and CK-MB were systematically collected at baseline, 6, 12, 24, 36, 48 and 72 h after the procedures. CMR with LGE was performed before and after the interventions. Patients were stratified according to diabetes status at study entry. Biomarkers and CMR results were compared between diabetic and nondiabetics patients. Analyses of correlation were also performed among glycemic and glycated hemoglobin (A1c) levels and troponin and CK-MB peak levels. Patients were also stratified into tertiles of fasting glycemia and A1c levels and were compared in terms of periprocedural myocardial infarction (PMI) on CMR. RESULTS Ninety (44.5%) of the 202 patients had diabetes mellitus at study entry. After interventions, median peak troponin was 2.18 (0.47, 5.14) and 2.24 (0.69, 5.42) ng/mL (P = 0.81), and median peak CK-MB was 14.1 (6.8, 31.7) and 14.0 (4.2, 29.8) ng/mL (P = 0.43), in diabetic and nondiabetic patients, respectively. The release of troponin and CK-MB over time was statistically similar in both groups and in the three treatments, besides PCI. New LGE on CMR indicated that new myocardial fibrosis was present in 18.9 and 17.3% (P = 0.91), and myocardial edema in 15.5 and 22.9% (P = 0.39) in diabetic and nondiabetic patients, respectively. The incidence of PMI in the glycemia tertiles was 17.9% versus 19.3% versus 18.7% (P = 0.98), and in the A1c tertiles was 19.1% versus 13.3% versus 22.2% (P = 0.88). CONCLUSIONS In this study, diabetes mellitus did not add risk of myocardial injury after revascularization interventions in patients with multivessel coronary artery disease. Trial Registration Name of Registry: Evaluation of cardiac biomarker elevation after percutaneous coronary intervention or coronary artery bypass graft; URL: http://www.controlled-trials.com.ISRCTN09454308.
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Affiliation(s)
- Paulo Cury Rezende
- Heart Institute (InCor) of the University of São Paulo, Avenida Dr. Eneas de Carvalho Aguiar, 44, AB sala 114, Cerqueira César, São Paulo, SP CEP 05403-900 Brazil
| | - Whady Hueb
- Heart Institute (InCor) of the University of São Paulo, Avenida Dr. Eneas de Carvalho Aguiar, 44, AB sala 114, Cerqueira César, São Paulo, SP CEP 05403-900 Brazil
| | - Rosa Maria Rahmi
- Heart Institute (InCor) of the University of São Paulo, Avenida Dr. Eneas de Carvalho Aguiar, 44, AB sala 114, Cerqueira César, São Paulo, SP CEP 05403-900 Brazil
| | - Thiago Luis Scudeler
- Heart Institute (InCor) of the University of São Paulo, Avenida Dr. Eneas de Carvalho Aguiar, 44, AB sala 114, Cerqueira César, São Paulo, SP CEP 05403-900 Brazil
| | - Diogo Freitas Cardoso de Azevedo
- Heart Institute (InCor) of the University of São Paulo, Avenida Dr. Eneas de Carvalho Aguiar, 44, AB sala 114, Cerqueira César, São Paulo, SP CEP 05403-900 Brazil
| | - Cibele Larrosa Garzillo
- Heart Institute (InCor) of the University of São Paulo, Avenida Dr. Eneas de Carvalho Aguiar, 44, AB sala 114, Cerqueira César, São Paulo, SP CEP 05403-900 Brazil
| | - Carlos Alexandre Wainrober Segre
- Heart Institute (InCor) of the University of São Paulo, Avenida Dr. Eneas de Carvalho Aguiar, 44, AB sala 114, Cerqueira César, São Paulo, SP CEP 05403-900 Brazil
| | - Jose Antonio Franchini Ramires
- Heart Institute (InCor) of the University of São Paulo, Avenida Dr. Eneas de Carvalho Aguiar, 44, AB sala 114, Cerqueira César, São Paulo, SP CEP 05403-900 Brazil
| | - Roberto Kalil Filho
- Heart Institute (InCor) of the University of São Paulo, Avenida Dr. Eneas de Carvalho Aguiar, 44, AB sala 114, Cerqueira César, São Paulo, SP CEP 05403-900 Brazil
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Coleman CI, Freemantle N, Kohn CG. Ranolazine for the treatment of chronic stable angina: a cost-effectiveness analysis from the UK perspective. BMJ Open 2015; 5:e008861. [PMID: 26546142 PMCID: PMC4636621 DOI: 10.1136/bmjopen-2015-008861] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES To estimate the cost-effectiveness of ranolazine when added to standard-of-care (SoC) antianginals compared with SoC alone in patients with stable coronary disease experiencing ≥3 attacks/week. SETTING An economic model utilising a UK health system perspective, a 1-month cycle-length and a 1-year time horizon. PARTICIPANTS Patients with stable coronary disease experiencing ≥3 attacks/week starting in 1 of 4 angina frequency health states based on Seattle Angina Questionnaire Angina Frequency (SAQAF) scores (100=no; 61-99=monthly; 31-60=weekly; 0-30=daily angina). INTERVENTION Ranolazine added to SoC or SoC alone. Patients were allowed to transition between SAQAF states (first cycle only) or death (any cycle) based on probabilities derived from the randomised, controlled Efficacy of Ranolazine in Chronic Angina trial and other studies. Patients not responding to ranolazine in month 1 (not improving ≥1 SAQAF health state) discontinued ranolazine and were assumed to behave like SoC patients. PRIMARY AND SECONDARY OUTCOMES MEASURES Costs (£2014) and quality-adjusted life-years (QALYs) for patients receiving and not receiving ranolazine. RESULTS Ranolazine patients lived a mean of 0.701 QALYs at a cost of £5208. Those not receiving ranolazine lived 0.662 QALYs at a cost of £5318. The addition of ranolazine to SoC was therefore a dominant economic strategy. The incremental cost-effectiveness ratio was sensitive to ranolazine cost; exceeding £20,000/QALY when ranolazine's cost was >£203/month. Ranolazine remained a dominant strategy when indirect costs were included and mortality rates were assumed to increase with worsening severity of SAQAF health states. Monte Carlo simulation found ranolazine to be a dominant strategy in ∼71% of 10,000 iterations. CONCLUSIONS Although UK-specific data on ranolazine's efficacy and safety are lacking, our analysis suggest ranolazine added to SoC in patients with weekly or daily angina is likely cost-effective from a UK health system perspective.
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Affiliation(s)
- Craig I Coleman
- University of Connecticut, School of Pharmacy and Evidence-Based Practice Center, Storrs, Connecticut, USA
| | | | - Christine G Kohn
- University of Saint Joseph, School of Pharmacy, Hartford, Connecticut, USA
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Percutaneous Coronary Intervention and the Various Coronary Artery Disease Syndromes. Coron Artery Dis 2015. [DOI: 10.1007/978-1-4471-2828-1_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Takematsu Y, Hasebe Y, Moriwaki Y, Kotera N, Yamada C, Nakagami T, Shinoda K, Furubayashi A, Kato S, Sugimoto I, Shibayama K. Evaluation of quality of life among patients with ischemic heart disease who practiced self-care activities at home after elective percutaneous coronary intervention. Cardiovasc Interv Ther 2014; 30:115-20. [DOI: 10.1007/s12928-014-0294-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Accepted: 07/30/2014] [Indexed: 11/25/2022]
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Cost-effectiveness of ranolazine added to standard-of-care treatment in patients with chronic stable angina pectoris. Am J Cardiol 2014; 113:1306-11. [PMID: 24560062 DOI: 10.1016/j.amjcard.2014.01.407] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2013] [Revised: 01/03/2014] [Accepted: 01/03/2014] [Indexed: 11/24/2022]
Abstract
Ranolazine has been shown to decrease angina pectoris frequency and nitroglycerin consumption. We assessed the cost-effectiveness of ranolazine when added to standard-of-care (SoC) antianginals compared with SoC alone in patients with stable coronary disease experiencing ≥3 attacks/week. A Markov model utilizing a societal perspective, a 1-month cycle length, and a 1-year time horizon was developed to estimate costs (2013 US$) and quality-adjusted life years (QALYs) for patients receiving and not receiving ranolazine. Patients entered the model in 1 of the 4 angina frequency health states based upon Seattle Angina Questionnaire angina frequency (SAQAF) scores (100=no; 61 to 99=monthly; 31 to 60=weekly; and 0 to 30=daily angina) and were allowed to transition between states or to death based upon probabilities derived from the Efficacy of Ranolazine in Chronic Angina and other studies. Patients not responding to ranolazine in month 1 (not improving ≥1 SAQAF health state) were assumed to discontinue ranolazine and behave like SoC patients. Ranolazine patients lived a mean of 0.700 QALYs at a cost of $15,661. Those not receiving ranolazine lived 0.659 QALYs and at a cost of $14,321. The incremental cost-effectiveness ratio (ICER) for the addition of ranolazine was $32,682/QALY. The ICER was most sensitive to ranolazine cost but only exceeded $50,000/QALY when the cost of ranolazine increased >32% above base case. The ICER remained <$50,000/QALY when indirect costs were excluded, and mortality rates were assumed equivalent between SAQAF health states. Monte Carlo simulation found ranolazine cost-effective in 97% of 10,000 iterations at a $50,000/QALY willingness-to-pay threshold. In conclusion, ranolazine added to SoC is cost-effective in patients with weekly or daily angina.
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Kohn CG, Parker MW, Limone BL, Coleman CI. Impact of angina frequency on health utility values of patients with chronic stable angina. Health Qual Life Outcomes 2014; 12:39. [PMID: 24628859 PMCID: PMC3995582 DOI: 10.1186/1477-7525-12-39] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Accepted: 03/10/2014] [Indexed: 02/08/2023] Open
Abstract
Background Chronic angina is a profoundly symptomatic disease. We evaluated the relationship between angina frequency and health utility. Methods We used data from stable angina patients reporting ≥3 attacks/week enrolled in the Efficacy of Ranolazine in Chronic Angina (ERICA) trial. Angina frequency was classified using the Seattle Angina Questionnaire angina frequency (SAQAF) domain into no (100); monthly (61-99); weekly (31-60); and daily (0-30) angina. EuroQol (EQ)-5D health utility scores were derived from SAQ data using two mapping equations. Median EQ-5D utility scores for each SAQAF classification after the 6-week trial period were calculated (reported as: Equation 1/Equation 2). Changes in EQ-5D utility scores from baseline to end-of-trial for patients achieving and not achieving a ≥20-point improvement in SAQAF score and improving and not improving ≥1 SAQAF classification were compared. Results Median EQ-5D utility scores (n = 548) were 0.68/0.60. Compared to patients reporting no angina symptoms (n = 28; 0.89/0.87) patients reporting monthly (n = 188; 0.80/0.76), weekly (n = 283; 0.72/0.65) and daily (n = 49; 0.65/0.54) symptoms had poorer health utility (p < 0.001 for both equations). Patients improving ≥1SAQAF classification (n = 254/541, 47%) experienced a median 0.05/0.07 greater improvement in EQ-5D health utility compared to those not improving ≥1 classification (p < 0.001 for both equations). Patients improving ≥20-points on the SAQAF (n = 355/541, 66%) experienced a median 0.06/0.07 greater improvement in health utility compared to those not achieving a ≥20-point improvement (p < 0.001 for both). Conclusions Chronic angina patient health utility decreases as angina frequency increases. Patients reporting clinically important improvement in angina frequency experience a tangible improvement in health utility. Clinical trial registration NCT00091429
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Affiliation(s)
| | | | | | - Craig I Coleman
- University of Connecticut School of Pharmacy, Storrs, CT, USA.
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Bikdeli B, Ranasinghe I, Chen R, Gupta A, Lampropulos JF, Kulkarni VT, Mody PS, Dharmarajan K. Most important outcomes research papers on treatment of stable coronary artery disease. Circ Cardiovasc Qual Outcomes 2013; 6:e17-25. [PMID: 23674308 DOI: 10.1161/circoutcomes.113.000310] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The following are highlights from the new series, Circulation: Cardiovascular Quality and Outcomes Topic Review. This series will summarize the most important manuscripts, as selected by the Editor, that have been published in the Circulation portfolio. The objective of this series is to provide our readership with a timely, comprehensive selection of important papers that are relevant to the quality and outcomes, and general cardiology audience. The studies included in this article represent the most significant research related to treatment of stable coronary artery disease (CAD).
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William Edward Boden, MD: a conversation with the editor. Am J Cardiol 2012; 110:145-59. [PMID: 22704294 DOI: 10.1016/j.amjcard.2012.02.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2012] [Accepted: 03/22/2012] [Indexed: 11/22/2022]
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Blankenship JC, Marshall JJ, Pinto DS, Lange RA, Bates ER, Holper EM, Grines CL, Chambers CE. Effect of percutaneous coronary intervention on quality of life: A consensus statement from the society for cardiovascular angiography and interventions. Catheter Cardiovasc Interv 2012; 81:243-59. [DOI: 10.1002/ccd.24376] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Accepted: 02/12/2012] [Indexed: 11/11/2022]
Affiliation(s)
| | | | - Duane S. Pinto
- Beth Israel Deaconess Medical Center; Boston; Massachusetts
| | - Richard A. Lange
- University of Texas Health Science Center at San Antonio; San Antonio; Texas
| | - Eric R. Bates
- University of Michigan Hospitals and Health Centers; Ann Arbor; Michigan
| | | | - Cindy L. Grines
- Detroit Medical Center Cardiovascular Institute; Detroit; Michigan
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Dharmarajan K, Lampropulos J, Bikdeli B, Mody P, Gupta A. Most Important Papers in Health Costs, Cost-Effectiveness, and Resource Utilization. Circ Cardiovasc Qual Outcomes 2012; 5:e9-15. [DOI: 10.1161/circoutcomes.112.965830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The following are highlights from the new series,
Circulation: Cardiovascular Quality and Outcomes Topic Review
. This series will summarize the most important manuscripts (as selected by the Editor) that have published in the
Circulation
portfolio. The objective of this new series is to provide our readership with a timely, comprehensive selection of important papers that are relevant to the quality and outcomes, and general cardiology audience. The studies included in this article represent the most significant research in the area of health costs, cost-effectiveness, and resource utilization.
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A Framework for the Evaluation of “Value” and Cost-Effectiveness in the Management of Critical Limb Ischemia. J Am Coll Surg 2011; 213:552-66.e5. [DOI: 10.1016/j.jamcollsurg.2011.07.011] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2011] [Revised: 07/11/2011] [Accepted: 07/14/2011] [Indexed: 11/20/2022]
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Jaffery Z, Prasad A, Lee JH, White CJ. Drug-eluting coronary stents - focus on improved patient outcomes. PATIENT-RELATED OUTCOME MEASURES 2011; 2:161-74. [PMID: 22915977 PMCID: PMC3417932 DOI: 10.2147/prom.s24796] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2011] [Indexed: 01/12/2023]
Abstract
The development of stent has been a major advance in the treatment of obstructive coronary artery disease since the introduction of balloon angioplasty. Subsequently, neointimal hyperplasia within the stent leading to in-stent restenosis emerged as a major obstacle in long-term success of percutaneous coronary intervention. Recent introduction of drug-eluting stents is a major breakthrough to tackle this problem. This review article summarizes stent technology, reviews progress of drug-eluting stents and discusses quality of life, patient satisfaction, and acceptability of percutaneous coronary intervention.
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Affiliation(s)
- Zehra Jaffery
- Department of Cardiovascular Diseases, The John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans, LA, USA
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