Optimisation of cardiac resynchronisation therapy device selection guided by cardiac magnetic resonance imaging: Cost-effectiveness analysis

Health Economic Analysis of CMR: A Systematic Review

INTRODUCTION

Uptake of cardiac magnetic resonance (CMR) in Australia has been limited by issues of cost and access. There is a need to inform future application of CMR by evaluating pertinent health economic literature. We sought to perform a systematic review on the health economic data as it pertains to CMR.

METHODS

Eight databases (biomedical/health economic) were searched for relevant articles highlighting economic evaluations of CMR. Following screening, studies that reported health economic outcomes (e.g., dollars saved, quality adjusted life years [QALY] and cost effectiveness ratios) were included. Data on cost effectiveness, clinical/disease characteristics, type of modelling were extracted and summarised.

RESULTS

Thirty-eight (38) articles informed the systematic review. Health economic models used to determine cost effectiveness included both trial-based studies (n=14) and Markov modelling (n=24). Comparative strategies ranged from nuclear imaging, stress echocardiography and invasive angiography. The disease states examined included coronary artery disease (23/38), acute coronary syndrome (3/38), heart failure (5/38) and miscellaneous (7/38). The majority of studies (n=29/38) demonstrated CMR as a strategy which is either economically dominant, cost-effective or cost-saving.

CONCLUSION

This systematic review demonstrates that CMR is cost-effective depending on diagnostic strategy, population and disease state. The lack of standardised protocols for application of CMR, economic models used and outcomes reported limits the ability to meta-analyse the available health economic data.

Which Factors Influence the Immensely Fluctuating CRT Implantation Rates in Europe? A Mixed Methods Approach Using Qualitative Content Analysis Based on Expert Interviews

(1) Background: Cardiac resynchronisation therapy (CRT) is nowadays an indispensable treatment option for heart failure. Although the indication is subject to clear cross-national guidelines by the European Society of Cardiology (ESC), there is immense variation in the number of implantations per 100,000 inhabitants in Europe, especially in German-speaking countries (Germany, Austria and Switzerland). The aim of the present study was to identify possible factors for these differences using a qualitative research approach. (2) Methods: Semi-standardized interviews were conducted with 11 experts in the field of CRT therapy (3 experts from Germany, 4 from Austria and 4 from Switzerland) using a pre-prepared interview template and analysed according to Mayring's qualitative content analysis. (3) Results: The main factors identified were the costs of purchasing the devices and the financing systems of the respective healthcare systems, although cost pressure still seems to play a subordinate role in the German-speaking countries. Moreover, "lack of implementation of ESC guidelines", "insufficient training" and "lack of medical infrastructure" could be excluded as potential reasons. (4) Conclusions: Economic factors, but not a lack of adherence to ESC guidelines, seem to have a major influence on the fluctuating implantation figures in German-speaking countries, according to the unanimous assessment of renowned experts.

Impact of socioeconomic aspects on cardiac implantable electronic device treatment and application of the EHRA guidelines : A European comparison

BACKGROUND

Cardiac implantable electronic devices (CIED) have become an indispensable part in everyday clinical practice in cardiology. The indications for CIED implantation are based on the guidelines of the European Heart Rhythm Association (EHRA). Nevertheless, numbers of CIED implantations in Europe are subject to considerable differences. We hypothesized that reimbursements linked to the respective health systems may influence implantation behavior.

METHODS

Based on the EHRA White Book 2017, CIED implantation data as well as socioeconomic key figures were collected, in particular gross domestic product (GDP) and share of gross domestic product spent on healthcare. Implantation numbers for pacemakers, implantable cardioverter defibrillators and cardiac resynchronization treatment as well as all in total were assessed, compared with the health care expenditures and visualized using heat maps.

RESULTS

Total implantation numbers per 100,000 inhabitants varied from 196.53 (Germany) to 2.81 (Kosovo). Higher implantation numbers correlated moderately with a higher GDP (r = 0.456, p 0.002) and higher health expenditure (r = 0.586, p < 0.001). The annual financial resources per inhabitant were also subject to fluctuations ranging from 9476 $ (Switzerland) to 140 $ (Ukraine); however, there were countries with high financial means, such as Switzerland or Scandinavian countries, which showed significantly lower implantation rates.

CONCLUSION

There were considerable differences in CIED implantations in Europe. These seem to be explained in part by socioeconomic disparities within Europe. Also, a potential influence by the respective remuneration system is likely.

Biomarkers-based personalized follow-up in chronic heart failure improves patient's outcomes and reduces care associate cost

BACKGROUND

Heart failure (HF) is a major and growing medical and economic problem, with high prevalence and incidence rates worldwide. Cardiac Biomarker is emerging as a novel tool for improving management of patients with HF with a reduced left ventricular ejection fraction (HFrEF).

METHODS

This is a before and after interventional study, that assesses the impact of a personalized follow-up procedure for HF on patient's outcomes and care associated cost, based on a clinical model of risk stratification and personalized management according to that risk. A total of 192 patients were enrolled and studied before the intervention and again after the intervention. The primary objective was the rate of readmissions, due to a HF. Secondary outcome compared the rate of ED visits and quality of life improvement assessed by the number of patients who had reduced NYHA score. A cost-analysis was also performed on these data.

RESULTS

Admission rates significantly decreased by 19.8% after the intervention (from 30.2 to 10.4), the total hospital admissions were reduced by 32 (from 78 to 46) and the total length of stay was reduced by 7 days (from 15 to 9 days). The rate of ED visits was reduced by 44% (from 64 to 20). Thirty-one percent of patients had an improved functional class score after the intervention, whereas only 7.8% got worse. The overall cost saving associated with the intervention was € 72,769 per patient (from € 201,189 to € 128,420) and €139,717.65 for the whole group over 1 year.

CONCLUSIONS

A personalized follow-up of HF patients led to important outcome benefits and resulted in cost savings, mainly due to the reduction of patient hospitalization readmissions and a significant reduction of care-associated costs, suggesting that greater attention should be given to this high-risk cohort to minimize the risk of hospitalization readmissions.

Economic evaluations of big data analytics for clinical decision-making: a scoping review

OBJECTIVE

Much has been invested in big data analytics to improve health and reduce costs. However, it is unknown whether these investments have achieved the desired goals. We performed a scoping review to determine the health and economic impact of big data analytics for clinical decision-making.

MATERIALS AND METHODS

We searched Medline, Embase, Web of Science and the National Health Services Economic Evaluations Database for relevant articles. We included peer-reviewed papers that report the health economic impact of analytics that assist clinical decision-making. We extracted the economic methods and estimated impact and also assessed the quality of the methods used. In addition, we estimated how many studies assessed "big data analytics" based on a broad definition of this term.

RESULTS

The search yielded 12 133 papers but only 71 studies fulfilled all eligibility criteria. Only a few papers were full economic evaluations; many were performed during development. Papers frequently reported savings for healthcare payers but only 20% also included costs of analytics. Twenty studies examined "big data analytics" and only 7 reported both cost-savings and better outcomes.

DISCUSSION

The promised potential of big data is not yet reflected in the literature, partly since only a few full and properly performed economic evaluations have been published. This and the lack of a clear definition of "big data" limit policy makers and healthcare professionals from determining which big data initiatives are worth implementing.

On the integration of early health technology assessment in the innovation process: reflections from five stakeholders

Early health technology assessment (HTA), which includes all methods used to inform industry and other stakeholders about the potential value of new medical products in development, including methods to quantify and manage uncertainty, has seen many applications in recent years. However, it is still unclear how such early value assessments can be integrated into the technology innovation process. This commentary contributes to the discussion on the purposes early HTA can serve. Similarities and differences in the perspectives of five stakeholders (i.e., the hospital, the patient, the assessor, the medical device industry, and the policy maker) on the purpose, value, and potential challenges of early HTA are described. All five stakeholders agreed that integrating early HTA in the innovation process has the possibility to shape and refine an innovation, and inform research and development decisions. The early assessment, using a variety of methodologies, can provide insights that are relevant for all stakeholders but several challenges, for example, feasibility and responsibility, need to be addressed before early HTA can become standard practice. For early evaluations to be successful, all relevant stakeholders including patients need to be involved. Also, nimble, flexible assessment methods are needed that fit the dynamics of medical technology. Best practices should be shared to optimize both the innovation process and the methods to perform an early value assessment.

Cost-effectiveness of dapagliflozin in chronic heart failure: an analysis from the Australian healthcare perspective

Aim

To assess the cost-effectiveness of dapagliflozin in addition to standard care versus standard care alone in patients with chronic heart failure and reduced ejection fraction.

Methods

A Markov model was constructed based on the Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure trial to assess the clinical outcomes and costs of 1000 hypothetical subjects with established heart failure and reduced ejection fraction. The model consisted of three health states: ‘alive and event-free’, ‘alive after non-fatal hospitalisation for heart failure’ and ‘dead’. Costs and utilities were estimated from published sources. The main outcome was the incremental cost-effectiveness ratio per quality-adjusted life-year gained. An Australian public healthcare perspective was employed. All outcomes and costs were discounted at a rate of 5% annually.

Results

Over a lifetime horizon, the addition of dapagliflozin to standard care in patients with heart failure and reduced ejection fraction prevented 88 acute heart failure hospitalisations (including readmissions) and yielded an additional 416 years of life and 288 quality-adjusted life-years (discounted) at an additional cost of A$3,692,440 (discounted). This equated to an incremental cost-effectiveness ratio of A$12,482 per quality-adjusted life-year gained, well below the Australian willingness-to-pay threshold of A$50,000 per quality-adjusted life-year gained. Subanalyses in subjects with and without diabetes resulted in similar incremental cost-effectiveness ratios of A$13,234 and A$12,386 per quality-adjusted life-year gained, respectively.

Conclusion

Dapagliflozin is likely to be cost-effective when used as an adjunct therapy to standard care compared with standard care alone for the treatment of chronic heart failure and reduced ejection fraction.