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Lu D, Shao Z, Wang Y, Xue D. Do coronary stent policies affect the cost-effectiveness of percutaneous coronary intervention among patients with acute coronary syndrome in Shanghai? A retrospective cohort study based on real-world and propensity score-matched data. BMJ Open 2024; 14:e083456. [PMID: 38904127 PMCID: PMC11191763 DOI: 10.1136/bmjopen-2023-083456] [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: 12/20/2023] [Accepted: 06/04/2024] [Indexed: 06/22/2024] Open
Abstract
OBJECTIVES This study aimed to assess whether the national centralised volume-based procurement policy and the Shanghai government's supportive measures (coronary stent policies) implemented in Shanghai, China, on 20 January 2021 affected the cost-effectiveness of percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS) in the year after surgery. DESIGN A retrospective cohort study based on real-world data and propensity score (PS)-matched data was conducted to compare the cost-effectiveness of PCI before and after policy implementation. PATIENTS AND SETTING Patients with ACS who had undergone first-time PCI over 1 year previously in hospitals in Shanghai and were discharged between 1 March 2019 and 30 April 2022 were included in the study. OUTCOME MEASURES In the present study, cost was defined as total direct medical expenses, and effectiveness was defined as the prevention of major adverse cardiac events (MACEs). Incremental cost-effectiveness ratios (ICERs) were used to measure the cost-effectiveness of PCI in patients with ACS 1 year after surgery. RESULTS The study included 31 760 patients. According to real-world and PS-matched data, the implementation of coronary stent policies in Shanghai reduced the total medical cost of patients with ACS 1 year after PCI by 24.39% (p<0.0001) and 22.26% (p<0.0001), respectively. The ICERs were ¥-1131.72 and ¥-842.00 thousand per MACE avoided, respectively. The ICERs were robust to parameter uncertainty, and there was a substantial chance for policy implementation to improve the cost-effectiveness of PCI among patients with ACS in the short term. CONCLUSIONS The implementation of coronary stent policies has improved the cost-effectiveness of PCI for patients with ACS in the short term. The long-term impact of coronary stent policies on the cost-effectiveness of PCI in patients with ACS or other coronary heart diseases should be assessed in the future.
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Affiliation(s)
- Dongzhe Lu
- Department of Hospital Management, School of Public Health, NHC Key Laboratory of Health Technology Assessment (Fudan University), Fudan University, Shanghai, China
| | - Zhenyi Shao
- Department of Health Statistics, Shanghai Statistics Center for Health, Shanghai, China
| | - Yue Wang
- Department of Health Statistics, Shanghai Statistics Center for Health, Shanghai, China
| | - Di Xue
- Department of Hospital Management, School of Public Health, NHC Key Laboratory of Health Technology Assessment (Fudan University), Fudan University, Shanghai, China
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Tuttle ML, Weiner DE. Coronary Artery Bypass Grafting Versus Percutaneous Coronary Intervention in Patients Receiving Dialysis: Is CABG Worth the Risk? Kidney Med 2024; 6:100787. [PMID: 38317759 PMCID: PMC10840113 DOI: 10.1016/j.xkme.2023.100787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024] Open
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Fong KY, Low CHX, Chan YH, Ho KW, Keh YS, Chin CT, Chin CY, Fam JM, Wong N, Idu M, Wong ASL, Lim ST, Koh TH, Tan JWC, Yeo KK, Yap J. Role of Invasive Strategy for Non-ST-Elevation Myocardial Infarction in Patients With Chronic Kidney Disease: A Systematic Review and Meta-Analysis. Am J Cardiol 2023; 205:369-378. [PMID: 37639763 DOI: 10.1016/j.amjcard.2023.07.178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 07/31/2023] [Indexed: 08/31/2023]
Abstract
Patients with chronic kidney disease (CKD) have traditionally been excluded from randomized trials. We aimed to compare percutaneous coronary intervention versus conservative management, and early intervention (EI; within 24 hours of admission) versus delayed intervention (DI; after 24 to 72 hours of admission) in patients with non-ST-segment elevation myocardial infarction (NSTEMI) and concomitant CKD. An electronic literature search was performed to search for studies comparing invasive management to conservative management or EI versus DI in patients with NSTEMI with CKD. The primary outcome was all-cause mortality; secondary outcomes were acute kidney injury (AKI) or dialysis, major bleeding, and recurrent MI. Hazard ratios (HRs) for the primary outcome and odds ratios for secondary outcomes were pooled in random-effects meta-analyses. Eleven studies (140,544 patients) were analyzed. Invasive management was associated with lower mortality than conservative management (HR 0.62, 95% confidence interval 0.57 to 0.67, p <0.001, I2 = 47%), with consistent benefit across all CKD stages, except CKD 5. There was no significant mortality difference between EI and DI, but subgroup analyses showed significant benefit for EI in stage 1 to 2 CKD (HR 0.75, 95% confidence interval 0.58 to 0.97, p = 0.03, I2 = 0%), with no significant difference in stage 3 and 4 to 5 CKD. Invasive strategy was associated with higher odds of AKI or dialysis and major bleeding, but lower odds of recurrent MI compared with conservative management. In conclusion, in patients with NSTEMI and CKD, an invasive strategy is associated with significant mortality benefit over conservative management in most patients with CKD, but at the expense of higher risk of AKI and bleeding. EI appears to benefit those with early stages of CKD. Trial Registration: PROSPERO CRD42023405491.
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Affiliation(s)
- Khi Yung Fong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Chloe Hui Xuan Low
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Kay Woon Ho
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS Medical School, Singapore
| | - Yann Shan Keh
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS Medical School, Singapore
| | - Chee Tang Chin
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS Medical School, Singapore
| | - Chee Yang Chin
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS Medical School, Singapore
| | - Jiang Ming Fam
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS Medical School, Singapore
| | - Ningyan Wong
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS Medical School, Singapore
| | - Muhammad Idu
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS Medical School, Singapore
| | - Aaron Sung Lung Wong
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS Medical School, Singapore
| | - Soo Teik Lim
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS Medical School, Singapore
| | - Tian Hai Koh
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS Medical School, Singapore
| | - Jack Wei Chieh Tan
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS Medical School, Singapore
| | - Khung Keong Yeo
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS Medical School, Singapore
| | - Jonathan Yap
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS Medical School, Singapore.
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Reza J, Mila A, Ledzian B, Sun J, Silvestry S. Incremental cost-effectiveness of extracorporeal membranous oxygenation as a bridge to cardiac transplant or left ventricular assist device placement in patients with refractory cardiogenic shock. JTCVS OPEN 2022; 11:132-145. [PMID: 36172402 PMCID: PMC9510879 DOI: 10.1016/j.xjon.2022.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/26/2022] [Accepted: 06/27/2022] [Indexed: 11/18/2022]
Abstract
Objective Emerging literature has described using venoarterial extracorporeal membranous oxygenation (ECMO) as a bridge to transplant or left ventricular assist device (LVAD) placement. We sought to identify the incremental cost-effectiveness ratio (ICER) of ECMO used as a bridge to cardiac transplant or LVAD. Methods Patients with refractory cardiogenic shock who received venoarterial ECMO and were bridged to either cardiac transplant (n = 7) or a HeartMate 3 LVAD (n = 6) placement were included. Markov modeling was used, comparing ECMO bridging with non–ECMO-bridged patients. Cohorts entered the model alive and at every 1-year cycle, were exposed to risk of death, and ran forward for 20 years after transplant or LVAD. Results Patients bridged with ECMO to cardiac transplant were stratified as group 1 whereas those bridged with ECMO to LVAD were stratified as group 2. The average ECMO run was 3 days in group 1 versus 11 days in group 2. Among group 1 patients, the ICER was $246,629 but was paired with a longer life expectancy. The ICER of group 2 patients was –$107,088 and was not paired with a longer life expectancy. The average inpatient cost for group 1 was found to be $636,023 versus $769,471 for group 2 patients. The average inpatient costs for patients not bridged to ECMO who received cardiac transplant or LVAD was $538,928 and $325,242, respectively. Conclusions Using ECMO to bridge to transplant or LVAD placement is not cost effective. However, patients bridged to transplant are paired with longer life expectancy in contrast to patients bridged to LVAD.
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Affiliation(s)
- Joseph Reza
- General Surgery Residency Program, AdventHealth Orlando, Orlando, Fla
- Address for reprints: Joseph Reza, MD, 3401 N. Broad St. C501. Philadelphia, PA 19140.
| | - Ashley Mila
- General Surgery Residency Program, AdventHealth Orlando, Orlando, Fla
| | - Bradford Ledzian
- AdventHealth Transplant Institute, Thoracic Transplant and Cardiovascular Surgery, AdventHealth Orlando, Orlando, Fla
| | - Jingwei Sun
- Center for Academic Research, AdventHealth Orlando, Orlando, Fla
| | - Scott Silvestry
- AdventHealth Transplant Institute, Thoracic Transplant and Cardiovascular Surgery, AdventHealth Orlando, Orlando, Fla
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Reynolds MR, Gong T, Li S, Herzog CA, Charytan DM. Cost-Effectiveness of Coronary Artery Bypass Grafting and Percutaneous Coronary Intervention in Patients With Chronic Kidney Disease and Acute Coronary Syndromes in the US Medicare Program. J Am Heart Assoc 2021; 10:e019391. [PMID: 33787323 PMCID: PMC8174359 DOI: 10.1161/jaha.120.019391] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 02/24/2021] [Indexed: 01/24/2023]
Abstract
Background Coronary revascularization provides important long-term clinical benefits to patients with high-risk presentations of coronary artery disease, including those with chronic kidney disease. The cost-effectiveness of coronary interventions in this setting is not known. Methods and Results We developed a Markov cohort simulation model to assess the cost-effectiveness of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in patients with chronic kidney disease who were hospitalized with acute myocardial infarction or unstable angina. Model inputs were primarily drawn from a sample of 14 300 patients identified using the Medicare 20% sample. Survival, quality-adjusted life-years, costs, and cost-effectiveness were projected over a 20-year time horizon. Multivariable models indicated higher 30-day mortality and end-stage renal disease with both PCI and CABG, and higher stroke with CABG, relative to medical therapy. However, the model projected long-term gains of 0.72 quality-adjusted life-years (0.97 life-years) for PCI compared with medical therapy, and 0.93 quality-adjusted life-years (1.32 life-years) for CABG compared with PCI. Incorporation of long-term costs resulted in incremental cost-effectiveness ratios of $65 326 per quality-adjusted life-year gained for PCI versus medical therapy, and $101 565 for CABG versus PCI. Results were robust to changes in input parameters but strongly influenced by the background costs of the population, and the time horizon. Conclusions For patients with chronic kidney disease and high-risk coronary artery disease presentations, PCI and CABG were both associated with markedly increased costs as well as gains in quality-adjusted life expectancy, with incremental cost-effectiveness ratios indicating intermediate value in health economic terms.
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Affiliation(s)
- Matthew R. Reynolds
- Lahey Hospital & Medical CenterBurlingtonMA
- Baim Institute for Clinical ResearchBostonMA
| | - Tingting Gong
- Chronic Disease Research GroupHennepin Healthcare Research InstituteMinneapolisMN
| | - Shuling Li
- Chronic Disease Research GroupHennepin Healthcare Research InstituteMinneapolisMN
| | - Charles A. Herzog
- Chronic Disease Research GroupHennepin Healthcare Research InstituteMinneapolisMN
- Department of MedicineHennepin Healthcare and University of MinnesotaMinneapolisMN
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