Indirect and direct costs of acute coronary syndromes with comorbid atrial fibrillation, heart failure, or both

The Clinical and Economic Burdens of Obesity and the Value of Weight Loss for an EMR-Derived US Cohort: A Modeling Study

Obesity-related comorbidities (ORCs) cause significant economic and clinical burdens for people with obesity and the US health care system. A reduction in weight at the population level may reduce incident ORC diagnoses and associated costs of treatment. The aim of this work is to describe obesity burden in the United States through the prevalence and direct treatment costs of ORCs, as well as the clinical and economic value of 15% weight loss in a population of adults with obesity. The IQVIA Ambulatory US electronic medical record database was used to create a cohort (7,667,023 individuals 20-69 years of age, body mass index of 30-50 kg/m2), utilized to characterize the prevalence of 10 ORCs. Direct treatment costs were collected from literature reports. A risk model was leveraged to estimate the number and cost of additional ORC diagnoses over 5 years from baseline through two scenarios: stable weight and 15% lower body weight at baseline for all members of the population. Prevalence, incidence, and cost data were scaled down to a representative subset of 100,000 individuals. In 2022, the annual treatment costs for all 10 ORCs exceeded $918 million for the representative cohort. In a stable-weight scenario, these costs were estimated to increase to ≈$1.4 billion by 2027. With 15% lower body weight at baseline, $221 million in cumulative savings was estimated, corresponding to $2205 in savings/patient over 5 years. Consequently, weight loss in this population may correspond to significantly reduced numbers of incident ORC complications translating to substantial cost savings.

Cost-Effectiveness Comparison between Ticagrelor and Clopidogrel in Acute Coronary Syndrome in Iran

Background

The present study aimed to determine the cost-effectiveness of ticagrelor compared with clopidogrel in Iranian patients with acute coronary syndrome (ACS).

Methods

A 1-year decision tree model combined with a 20-year Markov transition model was used to simulate the long-term cost and effectiveness of both ticagrelor and clopidogrel in Iran based on an Iranian payer's perspective. Clinical efficacy data were extracted from the PLATO trial and other published studies. Costs were estimated based on local prices in public sectors. Deterministic and probabilistic sensitivity analyses were used to test the robustness of base-case results over the uncertainties of model inputs. All calculations, analyses, and modeling were done in TreeAge 2011 and Microsoft Excel 2013.

Results

Compared with clopidogrel, the treatment of Iranian ACS patients with ticagrelor for 20 years resulted in an additional cost of US$ 2.39 in a hypothetical cohort of 1000 patients. However, ticagrelor led to 7.2 quality-adjusted life-years (QALYs) gained per 1000 hypothetical patients. Accordingly, the estimated incremental cost-effectiveness ratio for this analysis was US$ 332.032 per 1 QALY gained.

Conclusion

Ticagrelor was a cost-effective antiplatelet medicine compared with clopidogrel in Iranian patients with ACS. This could help Iran's policymakers to allocate resources more efficiently to ACS.

Prevalence and determinants of return to work after various coronary events: meta-analysis of prospective studies

Return to work (RTW) after a coronary event remains a major concern. This systematic review and meta-analysis of prospective studies published between January 1988 and August 2020, aim to evaluate the prevalence of RTW after a coronary event (myocardial infarction, acute coronary syndrome, angina pectoris) and to assess the determinants of RTW (such as follow-up duration, date of recruitment, country, gender, occupational factors, etc.). PRISMA and MOOSE guidelines were followed. Study quality was assessed using the Newcastle–Ottawa Scale. Random-effects models were carried out to determine pooled prevalence estimates and 95% confident interval. A total of 43 prospective studies (34,964 patients) were investigated. RTW overall random effects pooled prevalence was estimated at 81.1% [95% CI 75.8–85.8]. Country, year of implementation or gender did not significantly modify the prevalence estimates. Lower level of education and degraded left ventricular ejection fraction decreased RTW prevalence estimates (respectively, 76.1% vs 85.6% and 65.3% vs 77.8%). RTW prevalence estimates were higher for white-collars (81.2% vs 65.0% for blue-collars) and people with low physical workload (78.3% vs 64.1% for elevated physical workload).Occupational physical constraints seem to have a negative role in RTW while psycho-logical factors at work are insufficiently investigated. A better understanding of the real-life working conditions influencing RTW would be useful to maintain coronary patients in the labor market.

Cost-effectiveness analysis of apixaban versus vitamin K antagonists for antithrombotic therapy in patients with atrial fibrillation after acute coronary syndrome or percutaneous coronary intervention in Spain

BACKGROUND/OBJECTIVE

AUGUSTUS trial demonstrated that, for patients with atrial fibrillation (AF) having acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI), an antithrombotic regimen with apixaban and P2Y12 resulted in less bleeding, fewer hospitalizations, and similar ischemic events than regimens including a vitamin K antagonist (VKA), aspirin, or both. This study objective was to evaluate long-term health and economic outcomes and the cost-effectiveness of apixaban over VKA, as a treatment option for patients with AF having ACS/PCI.

METHODS

A lifetime Markov cohort model was developed comparing apixaban versus VKA across multiple treatment strategies (triple [with P2Y12 + aspirin] or dual [with P2Y12] therapy followed by monotherapy [apixaban or VKA]; triple followed by dual and then monotherapy; dual followed by monotherapy). The model adopted the Spanish healthcare perspective, with a 3-month cycle length and costs and health outcomes discounted at 3%.

RESULTS

Treatment with apixaban resulted in total cost savings of €883 and higher life years (LYs) and quality-adjusted LYs (QALYs) per patient than VKA (net difference, LYs: 0.13; QALYs: 0.11). Bleeding and ischemic events (per 100 patients) were lower with apixaban than VKA (net difference, -13.9 and -1.8, respectively). Incremental net monetary benefit for apixaban was €3,041, using a willingness-to-pay threshold of €20,000 per QALY. In probabilistic sensitivity analysis, apixaban was dominant in the majority of simulations (92.6%), providing additional QALYs at lower costs than VKA.

CONCLUSIONS

Apixaban was a dominant treatment strategy than VKA from both the Spanish payer's and societal perspectives, regardless of treatment strategy considered.

Effects of health status on work exit and absenteeism among the older working population in China: a secondary analysis of a cohort sample

OBJECTIVES

To analyse the effects of health status on work exit and absenteeism among the older working population in China.

DESIGN

Secondary analysis of a cohort sample.

SETTING AND PARTICIPANTS

Community samples who engaged in either agricultural or non-agriculture work or both in the 2011 wave of the China Health and Retirement Longitudinal Study (CHARLS) and whose age was 45-55 years for women or 45-60 years for men in the 2013 wave.

OUTCOME MEASURES

Work exit and number of absent workdays due to health problems in 2013. To address the problems of measurement error of self-rated health status, we used disability condition, number of chronic diseases and functional limitation to construct an index of health. We divided the sample into four groups according to gender and work types (farmers who conducted any agricultural work in 2011 vs non-farmers who conducted non-agricultural work only) and conducted analyses separately.

RESULTS

Farmers (11.0% for women and 4.9% for men) were less likely to exit from work than non-farmers (18.5% and 12.0%, respectively) but took more absent workdays (16.6 days for women and 15.0 days for men) than non-farmers (5.6 and 4.9). Poor health status in 2011 was significantly associated with the work exit in 2013 of female and male farmers but not non-farmers. Older workers (except female non-farmers) with persistently poor health or recent health deterioration over time were significantly more likely to stop working or missed more workdays than those with persistently good health.

CONCLUSIONS

Poor 2-year lagged health predicts work exit for both male and female farmers, and increases the absent work days in all older working population. Persistently poor health or recent health deterioration over time has detrimental impact on labour market in terms of work exit and absenteeism among all older Chinese workers except for female non-farmers.

Association of income and health-related quality of life in atrial fibrillation

Objective

Health-related quality of life (HRQoL) is a patient-centred benchmark promoted by clinical guidelines in atrial fibrillation (AF). Income is associated with health outcomes, but how income effects HRQoL in AF has limited investigation.

Methods

We enrolled a convenience cohort with AF receiving care at a regional healthcare system and assessed demographics, medical history, AF treatment, income, education and health literacy. We defined income as a categorical variable (<$20 000; $20 000-$49 999; $50 000-$99 999; >$100 000). We used two complementary HRQoL measures: (1) the atrial fibrillation effect on quality of life (AFEQT), measuring composite and domain scores (daily activity, symptoms, treatment concerns, treatment satisfaction; range 0-100); (2) the 12-item Short Form Survey (SF-12), measuring general HRQoL with physical and mental health domains (range 0-100). We related income to HRQoL and adjusted for relevant covariates.

Results

In 295 individuals with AF (age 71±10, 40% women), we observed significant differences in HRQoL by income. Higher mean composite AFEQT scores were observed for higher income groups: participants with income <$20 000 had the lowest HRQoL (n=35, 68.2±21.4), and those with income >$100 000 had the highest HRQoL (n=64, 81.9±17.0; p=0.04). We also observed a significant difference by income in the AFEQT daily activity domain (p=0.02). Lower income was also associated with lower HRQoL in the mental health composite score of the SF-12 (59.7±21.5, income <$20 000 vs 79.3±16.3, income >$100 000; p<0.01).

Conclusion

We determined that income was associated with HRQoL in a cohort with prevalent AF. Given the marked differences, we consider income as essential for understanding patient-centred outcomes in AF.

Factors associated with objectively measured exercise participation after hospitalization for acute coronary syndrome

BACKGROUND

Guidelines recommend exercise for secondary prevention of acute coronary syndrome (ACS), however adherence to guidelines is low. A paucity of data examining factors associated with objectively-measured exercise post-discharge in ACS survivors exists. The purpose of this study was to identify factors associated with exercise during the 5 weeks after ACS discharge.

METHODS

A sample of 151 ACS patients treated at a university hospital were enrolled into an observational cohort study and wore an accelerometer for 35 days post-discharge. Days on which participants accumulated ≥30 min of moderate-to-vigorous physical activity in bouts ≥10 min were considered exercise days. Participants were categorized as non-exercisers (0 exercise days) or exercisers (≥1 exercise day). A multi-variable logistic regression model was used to examine the association between exercise and socio-demographics, depression, SF-12 physical and mental health scores, disease severity, length of hospitalization, and percutaneous coronary intervention.

RESULTS

39.7% of participants were non-exercisers. Factors associated with non-exercise were age (OR: 1.11; 95% CI: 1.06-1.17, p < 0.001), female sex (OR: 2.76; 95% CI: 1.10-6.95, p = 0.031), and lower SF-12 physical health score (OR: 0.94; 95% CI: 0.90-0.98, p = 0.005).

CONCLUSION

In ACS patients in whom exercise participation was objectively measured for 5 weeks post-discharge, demographic and poor physical health factors were associated with non-exercise. These findings identify populations (e.g. older adults, women) at especially high risk for being physically inactive in whom more intense intervention may be warranted.

Atrial Fibrillation and Acute Myocardial Infarction – An Inflammation-Mediated Association

Atrial fibrillation (AF) is an increasingly widespread healthcare problem. AF can frequently present as a complication in acute coronary syndromes (ACS), especially in ST-elevation acute myocardial infarction (AMI), in which case it is the most frequent supraventricular rhythm disturbance with an estimated incidence of 6.8-21%. The presence of AF in ACS heralds worse outcomes in comparison to subjects in sinus rhythm, and several studies have shown that in AMI patients, both new-onset and pre-existing AF are associated with a higher risk of major adverse cardiovascular and cerebrovascular events during hospitalization. The cause of newonset AF in AMI is multifactorial. Although still incompletely understood, the mechanisms involved in the development of AF in acute myocardial ischemic events include the neurohormonal activation of the sympathetic nervous system that accompanies the AMI, ischemic involvement of the atrial myocytes, ventricular dysfunction, and atrial overload. The identification of patients at risk for AF is of great significance as it may lead to prompt therapeutic interventions and closer follow-up, thus improving prognosis and decreasing cardiovascular and cerebrovascular events. The present manuscript aims to summarize the current research findings related to new-onset AF in AMI patients, as well as the predictors and prognostic impact of this comorbid association.

Failure to Launch: Targeting Inflammation in Acute Coronary Syndromes

The importance of inflammation and inflammatory pathways in atherosclerotic disease and acute coronary syndromes (ACS) is well established. The success of statin therapy rests not only on potently reducing levels of low-density lipoprotein cholesterol, but also on the many beneficial, pleiotropic effects statin therapy has on various inflammatory mechanisms in atherosclerotic disease, from reducing endothelial dysfunction to attenuating levels of serum C-reactive protein. Due to the growing awareness of the importance of inflammation in ACS, investigators have attempted to develop novel therapies against known markers of inflammation for several decades. Targeted pathways have ranged from inhibiting C5 cleavage with a high-affinity monoclonal antibody against C5 to inhibiting the activation of the p38 mitogen-activated protein kinase signaling cascades. In each of these instances, despite promising early preclinical and mechanistic studies and phase 2 trials suggesting a potential benefit in reducing post-MI complications or restenosis, these novel therapies have failed to show benefits during large, phase 3 clinical outcomes trials. This review discusses several examples of novel anti-inflammatory therapies that failed to show significant improvement on clinical outcomes when tested in large, randomized trials and highlights potential explanations for why targeted therapies against known markers of inflammation in ACS have failed to launch.

The cost-utility of point-of-care troponin testing to diagnose acute coronary syndrome in primary care

Background

The added value of using a point-of-care (POC) troponin test in primary care to rule out acute coronary syndrome (ACS) is debated because test sensitivity is inadequate early after symptom onset. This study investigates the potential cost-utility of diagnosing ACS by a general practitioner (GP) when a POC troponin test is available versus GP assessment only.

Methods

A patient-level simulation model was developed, representing a hypothetical cohort of the Dutch population (>35 years) consulting the GP with chest complaints. All health related consequences as well as cost consequences were included. Both symptom duration, selection of patients in whom the POC troponin test is performed, and test performance at different time points were incorporated. Health outcomes were expressed as Quality-Adjusted Life Years (QALYs). The main outcome parameters involve the effect of POC troponin testing on (in)correct hospital referrals, QALYs, and costs.

Results

The POC troponin strategy decreases the referral rate in non-ACS patients from 38.46% to 31.85%. Despite a small increase in non-referral among ACS patients from 0.22% to 0.27%, the overall health effect is negligible. Costs will decrease with €77.25/patient (95% CI €-126.81 to €-33.37).

Conclusions

The POC troponin strategy is likely cost-saving, by reducing hospital referrals. The small increase in missed ACS patients can be partly explained by conservative assumptions used in the analysis. Besides, current developments in POC troponin tests will likely further improve their diagnostic performance. Therefore, future prospective studies are warranted to investigate whether those developments make the POC troponin test to a safe and cost-effective diagnostic tool for diagnosing ACS in general practices.

Electronic supplementary material

The online version of this article (doi:10.1186/s12872-017-0647-6) contains supplementary material, which is available to authorized users.

A Review of the Relationship of Atrial Fibrillation and Acute Coronary Syndrome

Atrial fibrillation (AF) is the most common arrhythmia encountered by clinicians. Clinical decision-making focuses on reducing ischemic stroke risk in AF patients; however, AF is also associated with an increased risk of acute coronary syndromes (ACS). Patients with ACS and concurrent AF are less likely to receive appropriate therapies and more likely to experience adverse outcomes than ACS patients in sinus rhythm (SR). Clinicians may be able to stratify ACS patients at increased risk of AF development based on clinical characteristics. Evidence supporting specific therapeutic options for prevention of ACS in AF patients or for prevention of AF in ACS patients is limited, however there is some evidence of differing effects among oral anticoagulant regimens in these populations. Investigations of the relationship of AF with the full spectrum of ACS are not well described and should be the focus of future research.

The effect of a text message and telephone follow-up program on cardiac self-efficacy of patients with coronary artery disease: A randomized controlled trial

Background:

Cardiac self-efficacy is an essential factor in persistence of healthy behaviors in patients with coronary artery disease (CAD). Today, telenursing methods have numerous applications in health care. Therefore, this study aimed to determine the effect of a text message and telephone follow-up program on cardiac self-efficacy of patients with CAD.

Materials and Methods:

This was a randomized controlled trial on 70 patients with CAD who were hospitalized in Shahid Chamran Hospital (Isfahan, Iran). The participants were randomly assigned to the experimental and control groups. Collection of data on cardiac self-efficacy was performed before, 3 months after, and 4 months after the beginning of the intervention using Cardiac Self-Efficacy Scale designed by Sullivan et al. During the 3 months of intervention, six messages were sent to the subjects each week and calls were made twice a week in the first month and once a week during the second and third months. The statistical analysis of data was performed using independent t-test, Chi-square, Mann-Whitney U test, and repeated measures analysis of variance (ANOVA).

Results:

Before the intervention, there was no significant difference between the mean scores of cardiac self-efficacy of the two groups. However, 3 months and 4 months after the beginning of the intervention, the mean score of cardiac self-efficacy in the experimental group was significantly higher than in the control group (P < 0.001).

Conclusions:

The text message and telephone follow-up program is effective in promoting the cardiac self-efficacy of patients with CAD.