Differences in Treatment Patterns and Outcomes of Acute Myocardial Infarction for Low- and High-Income Patients in 6 Countries

Importance

Differences in the organization and financing of health systems may produce more or less equitable outcomes for advantaged vs disadvantaged populations. We compared treatments and outcomes of older high- and low-income patients across 6 countries.

Objective

To determine whether treatment patterns and outcomes for patients presenting with acute myocardial infarction differ for low- vs high-income individuals across 6 countries.

Design, Setting, and Participants

Serial cross-sectional cohort study of all adults aged 66 years or older hospitalized with acute myocardial infarction from 2013 through 2018 in the US, Canada, England, the Netherlands, Taiwan, and Israel using population-representative administrative data.

Exposures

Being in the top and bottom quintile of income within and across countries.

Main Outcomes and Measures

Thirty-day and 1-year mortality; secondary outcomes included rates of cardiac catheterization and revascularization, length of stay, and readmission rates.

Results

We studied 289 376 patients hospitalized with ST-segment elevation myocardial infarction (STEMI) and 843 046 hospitalized with non-STEMI (NSTEMI). Adjusted 30-day mortality generally was 1 to 3 percentage points lower for high-income patients. For instance, 30-day mortality among patients admitted with STEMI in the Netherlands was 10.2% for those with high income vs 13.1% for those with low income (difference, -2.8 percentage points [95% CI, -4.1 to -1.5]). One-year mortality differences for STEMI were even larger than 30-day mortality, with the highest difference in Israel (16.2% vs 25.3%; difference, -9.1 percentage points [95% CI, -16.7 to -1.6]). In all countries, rates of cardiac catheterization and percutaneous coronary intervention were higher among high- vs low-income populations, with absolute differences ranging from 1 to 6 percentage points (eg, 73.6% vs 67.4%; difference, 6.1 percentage points [95% CI, 1.2 to 11.0] for percutaneous intervention in England for STEMI). Rates of coronary artery bypass graft surgery for patients with STEMI in low- vs high-income strata were similar but for NSTEMI were generally 1 to 2 percentage points higher among high-income patients (eg, 12.5% vs 11.0% in the US; difference, 1.5 percentage points [95% CI, 1.3 to 1.8 ]). Thirty-day readmission rates generally also were 1 to 3 percentage points lower and hospital length of stay generally was 0.2 to 0.5 days shorter for high-income patients.

Conclusions and Relevance

High-income individuals had substantially better survival and were more likely to receive lifesaving revascularization and had shorter hospital lengths of stay and fewer readmissions across almost all countries. Our results suggest that income-based disparities were present even in countries with universal health insurance and robust social safety net systems.

Impact of medicaid expansion on disparities in revascularization in patients hospitalized with acute myocardial infarction

INTRODUCTION

Blacks are more likely to live in poverty and be uninsured, and are less likely to undergo revascularization after am acute myocardial infarction compared to whites. The objective of this study was to determine whether Medicaid expansion was associated with a reduction in revascularization disparities in patients admitted with an acute myocardial infarction.

METHODS

Retrospective analysis study using data (2010-2018) from hospitals participating in the University Health Systems Consortium, now renamed the Vizient Clinical Database. Comparative interrupted time series analysis was used to compare changes in the use of revascularization therapies (PCI and CABG) in white versus non-Hispanic black patients hospitalized with either ST-segment elevation (STEMI) or non-ST-segment elevation acute myocardial infarctions (NSTEMI) after Medicaid expansion.

RESULTS

The analytic cohort included 68,610 STEMI and 127,378 NSTEMI patients. The percentage point decrease in the uninsured rate for STEMIs and NSTEMIs was greater for blacks in expansion states compared to whites in expansion states. For patients with STEMIs, differences in black versus white revascularization rates decreased by 2.09 percentage points per year (95% CI, 0.29-3.88, P = 0.023) in expansion versus non-expansion states after adjusting for patient and hospital characteristics. Black patients hospitalized with STEMI in non-expansion states experienced a 7.24 percentage point increase in revascularization rate in 2014 (95% CI, 2.83-11.7, P < 0.001) but did not experience significant annual percentage point increases in the rate of revascularization in subsequent years (1.52; 95% CI, -0.51-3.55, P = 0.14) compared to whites in non-expansion states. Medicaid expansion was not associated with changes in the revascularization rate for either blacks or whites hospitalized with NSTEMIs.

CONCLUSION

Medicaid expansion was associated with greater reductions in the number of uninsured blacks compared to uninsured whites. Medicaid expansion was not associated, however, with a reduction in revascularization disparities between black and white patients admitted with acute myocardial infarctions.

Comparison of NICE and ESC proposed strategies on new onset chest pain and the contemporary clinical utility of pretest probability risk score

AIMS

Patients with de novo chest pain are usually investigated non-invasively. The new UK-National Institute for Health and Care Excellence (NICE) guidelines recommend CT coronary angiography (CTCA) for all patients, while European Society of Cardiology (ESC) recommends functional tests. We sought to compare the clinical utility and perform a cost analysis of these recommendations in two UK centres with different primary investigative strategies.

METHODSRESULTS

We compared two groups of patients, group A (n=667) and group B (n=654), with new onset chest pain in two neighbouring National Health Service hospitals, each primarily following either ESC (group A) or NICE (group B) guidance. We assessed the clinical utility of each strategy, including progression to invasive coronary angiography (ICA) and revascularisation. We present a retrospective cost analysis in the context of UK tariff for stress echo (£176), CTCA (£220) and ICA (£1001). Finally, we sought to identify predictors of revascularisation in the whole population.Baseline characteristics in both groups were similar. The progression to ICA was comparable (9.9% vs 12.0%, p=0.377), with similar requirement for revascularisation (4.0% vs 5.0%.; p=0.532). The average cost of investigations per investigated patient was lower in group A (£279.66 vs £325.77), saving £46.11 per patient. The ESC recommended risk score (RS) was found to be the only predictor of revascularisation (OR 1.05, 95% CI 1.04 to 1.06; p<0.001).

CONCLUSION

Both NICE and ESC-proposed strategies led to similar rates of ICA and need for revascularisation in discrete, but similar groups of patients. The SE-first approach had a lower overall cost by £46.11 per patient, and the ESC RS was the only variable correlated to revascularisation.

Medicare Accountable Care Organizations Are Not Associated With Reductions in the Use of Low-Value Coronary Revascularization

BACKGROUND

Because specialty care accounts for half of Medicare expenditures, improving its value is critical to the success of Medicare accountable care organizations (ACOs) in curbing spending growth. However, whether ACOs have reduced low-value specialty care without compromising use of high-value services remains unknown.

METHODS AND RESULTS

Using national Medicare data, we identified 2 cohorts: beneficiaries for whom the value of coronary revascularization is lower (those with ischemic heart disease without angina, congestive heart failure, or recent admission for acute myocardial infarction) and beneficiaries for whom its value is higher (those with recent acute myocardial infarction admission). We then determined the provider groups who cared for the cohorts, distinguishing between those participating (n=298) and those not participating in a Medicare ACO (1329). After measuring the provider groups' use of coronary artery bypass grafting and percutaneous coronary intervention among the 2 cohorts, we fit multivariable models to test the statistical significance of rates of change in low- and high-value revascularization after ACO participation. During the pre-ACO period, participating and nonparticipating provider groups had similar rates of low- and high-value revascularization. Our multivariable model results show that rates of change for low- and high-value coronary revascularization were not altered by a provider group's participation in a Medicare ACO (lower value: difference, -0.04 per year; 95% confidence interval, -0.11 to 0.03; higher value: difference, 0.96 per year; 95% confidence interval, -0.46 to 2.4).

CONCLUSIONS

We found no association between provider group participation in a Medicare ACO and use of low- or high-value coronary revascularization.

Revascularization Rates and Associated Costs in Patients With Stable Ischemic Heart Disease Initiating Ranolazine Versus Traditional Antianginals as Add-on Therapy

To assess the frequency and costs of revascularization procedures in patients with stable ischemic heart disease (SIHD) initiating ranolazine versus traditional antianginals. Adults (≥18 years) with a diagnosis of SIHD who initiated ranolazine or a traditional antianginal (beta-blocker [BB], calcium channel blocker [CCB], or long-acting nitrate [LAN]) as second or third line therapy between 2008 and 2016, were selected from the IBM MarketScan Databases. Inverse probability weighting based on propensity score was employed to balance the ranolazine and traditional antianginals cohorts on patient clinical characteristics. Outcomes assessed were frequency and total cost of revascularization procedures over a 12-month follow-up. A total of 108,741 patients with SIHD were included. Of these, 18% initiated treatment with ranolazine, 21% received BBs, 24% received CCBs, and 37% were treated with LANs. Revascularization rates were significantly lower in ranolazine patients (11%) than in BB (16%) and LAN (14%) patients (both p <0.001), and more comparable to CCB patients (10%; p = 0.007). Compared with BB and LAN, those in the ranolazine cohort were less likely to have a revascularization procedure during hospitalization and had a shorter length of stay if hospitalized (all p <0.001). The mean healthcare costs associated with revascularization were lower in ranolazine patients ($2,933) than in BB ($4,465) and LAN ($3,609) patients (p <0.001), but similar to CCB patients ($2,753; p = 0.29). In conclusion, ranolazine treatment in patients with SIHD was associated with fewer revascularization procedures and lower associated healthcare costs compared with patients initiating BB or LAN, and comparable to patients initiating CCBs.

Economic Evaluation of Complete Revascularization for Patients with Multivessel Disease Undergoing Primary Percutaneous Coronary Intervention

OBJECTIVES

To determine the cost-effectiveness of complete revascularization at index admission compared with infarct-related artery (IRA) treatment only, in patients with multivessel disease undergoing primary percutaneous coronary intervention (P-PCI) for ST-segment elevation myocardial infarction.

METHODS

An economic evaluation of a multicenter randomized trial was conducted, comparing complete revascularization at index admission to IRA-only P-PCI in patients with multivessel disease (12-month follow-up). Overall hospital costs (costs for P-PCI procedure(s), hospital length of stay, and any subsequent re-admissions) were estimated. Outcomes were major adverse cardiac events (MACEs, a composite of all-cause death, recurrent myocardial infarction, heart failure, and ischemia-driven revascularization) and quality-adjusted life-years (QALYs) derived from the three-level EuroQol five-dimensional questionnaire. Multiple imputation was undertaken. The mean incremental cost and effect, with associated 95% confidence intervals, the incremental cost-effectiveness ratio, and the cost-effectiveness acceptability curve were estimated.

RESULTS

On the basis of 296 patients, the mean incremental overall hospital cost for complete revascularization was estimated to be -£215.96 (-£1390.20 to £958.29), compared with IRA-only, with a per-patient mean reduction in MACEs of 0.170 (0.044 to 0.296) and a QALY gain of 0.011 (-0.019 to 0.041). According to the cost-effectiveness acceptability curve, the probability of complete revascularization being cost-effective was estimated to be 72.0% at a willingness-to-pay threshold value of £20,000 per QALY.

CONCLUSIONS

Complete revascularization at index admission was estimated to be more effective (in terms of MACEs and QALYs) and cost-effective (overall costs were estimated to be lower and complete revascularization thereby dominated IRA-only). There was, however, some uncertainty associated with this decision.

Cost-minimization analysis of three decision strategies for cardiac revascularization: results of the "suspected CAD" cohort of the european cardiovascular magnetic resonance registry

BACKGROUND

Coronary artery disease (CAD) continues to be one of the top public health burden. Perfusion cardiovascular magnetic resonance (CMR) is generally accepted to detect CAD, while data on its cost effectiveness are scarce. Therefore, the goal of the study was to compare the costs of a CMR-guided strategy vs two invasive strategies in a large CMR registry.

METHODS

In 3'647 patients with suspected CAD of the EuroCMR-registry (59 centers/18 countries) costs were calculated for diagnostic examinations (CMR, X-ray coronary angiography (CXA) with/without FFR), revascularizations, and complications during a 1-year follow-up. Patients with ischemia-positive CMR underwent an invasive CXA and revascularization at the discretion of the treating physician (=CMR + CXA-strategy). In the hypothetical invasive arm, costs were calculated for an initial CXA and a FFR in vessels with ≥50% stenoses (=CXA + FFR-strategy) and the same proportion of revascularizations and complications were applied as in the CMR + CXA-strategy. In the CXA-only strategy, costs included those for CXA and for revascularizations of all ≥50% stenoses. To calculate the proportion of patients with ≥50% stenoses, the stenosis-FFR relationship from the literature was used. Costs of the three strategies were determined based on a third payer perspective in 4 healthcare systems.

RESULTS

Revascularizations were performed in 6.2%, 4.5%, and 12.9% of all patients, patients with atypical chest pain (n = 1'786), and typical angina (n = 582), respectively; whereas complications (=all-cause death and non-fatal infarction) occurred in 1.3%, 1.1%, and 1.5%, respectively. The CMR + CXA-strategy reduced costs by 14%, 34%, 27%, and 24% in the German, UK, Swiss, and US context, respectively, when compared to the CXA + FFR-strategy; and by 59%, 52%, 61% and 71%, respectively, versus the CXA-only strategy. In patients with typical angina, cost savings by CMR + CXA vs CXA + FFR were minimal in the German (2.3%), intermediate in the US and Swiss (11.6% and 12.8%, respectively), and remained substantial in the UK (18.9%) systems. Sensitivity analyses proved the robustness of results.

CONCLUSIONS

A CMR + CXA-strategy for patients with suspected CAD provides substantial cost reduction compared to a hypothetical CXA + FFR-strategy in patients with low to intermediate disease prevalence. However, in the subgroup of patients with typical angina, cost savings were only minimal to moderate.

Regional differences in treatment frequency and case-fatality rates in korean patients with acute myocardial infarction using the Korea national health insurance claims database: findings of a large retrospective cohort study

Issues regarding healthcare disparity continue to increase in connection with access to quality care for acute myocardial infarction (AMI), even though the case-fatality rate (CFR) continues to decrease. We explored regional variation in AMI CFRs and examined whether the variation was due to disparities in access to quality medical services for AMI patients. A dataset was constructed from the Korea National Health Insurance Claims Database to conduct a retrospective cohort study of 95,616 patients who were admitted to a hospital in Korea from 2003 to 2007 with AMI. Each patient was followed in the claims database for information about treatment after admission or death. The procedure rate decreased as the region went "down" from Seoul to the county level, whereas the AMI CFR increased as the county level as a function of proximity to the county level (30-day AMI CFRs: Seoul, 16.4%; metropolitan areas, 16.2%, cities; 18.8%, counties, 39.4%). Even after adjusting for covariates, an identical regional variation in the odds of patients receiving treatment services and dying was identified. After adjusting for invasive and medical management variables in addition to earlier covariates, the death risk in the counties remained statistically significantly higher than in Seoul; however, the degree of the difference decreased greatly and the significant differences in metropolitan areas and cities disappeared. Policy interventions are needed to increase access to quality AMI care in county-level local areas because regional differences in the AMI CFR are likely caused by differences in the performance of medical and invasive management among the regions of Korea. Additionally, a public education program to increase the awareness of early symptoms and the necessity of visiting the hospital early should be established as the first priority to improve the outcome of AMI patents, especially in county-level local areas.

Cost-effectiveness of universal and platelet reactivity assay-driven antiplatelet therapy in acute coronary syndrome

Assays monitoring P2Y12 platelet reactivity can accurately predict which patients will have a poor response to clopidogrel. We sought to determine the cost-effectiveness of using platelet reactivity assays (PRAs) to select a dual-antiplatelet regimen for patients with acute coronary syndrome. A hybrid decision tree Markov model was developed to determine the cost-effectiveness of universal clopidogrel, ticagrelor, or prasugrel (given to all patients) or PRA-driven ticagrelor or prasugrel (given to patients with high platelet reactivity, defined as >230 on the VerifyNow P2Y12 assay; the others received generic clopidogrel). We assumed a cohort of 65-year-old patients with acute coronary syndrome and an incidence of high platelet reactivity of 32% and 13% at ~24 to 48 hours after revascularization and 1 month, respectively. The 5-year costs, quality-adjusted life-years, and incremental cost-effectiveness ratios were calculated for PRA-driven ticagrelor and prasugrel compared with universal clopidogrel, ticagrelor, or prasugrel. PRA-driven ticagrelor and prasugrel were cost-effective compared with universal clopidogrel (incremental cost-effectiveness ratio $40,100 and $49,143/quality-adjusted life-year, respectively); however, universal ticagrelor and prasugrel were not (incremental cost-effectiveness ratio $61,651 and $96,261/quality-adjusted life-year, respectively). Monte Carlo simulation suggested PRA-driven ticagrelor, PRA-driven prasugrel, universal ticagrelor, and universal prasugrel would have an incremental cost-effectiveness ratio <$50,000/quality-adjusted life-year in 52%, 40%, 23%, and 2% of the iterations compared with universal clopidogrel, respectively. Universal ticagrelor and prasugrel were not cost-effective compared with their respective PRA-driven regimens (incremental cost-effectiveness ratio $68,182; $116,875/quality-adjusted life-year, respectively). Monte Carlo simulation suggested universal ticagrelor and prasugrel would have an incremental cost-effectiveness ratio <$50,000/quality-adjusted life-year in 26% and 4% of iterations compared with their respective PRA-driven regimens. The results were most sensitive to differences in agent costs and drug-specific relative risks of death. In conclusion, even with generic clopidogrel, PRA-driven selection of antiplatelet therapy appeared to be a cost-effective strategy with the potential to decrease the overall acute coronary syndrome-associated healthcare costs.

Beneficiaries with cardiovascular disease and thePart D coverage gap

BACKGROUND

Medicare Part D improved access to cardiovascular medications. Increased cardiovascular drug use and resulting health improvements could be derailed when beneficiaries enter the coverage gap and must pay 100% of drug costs. The coverage gap remains the subject of Congressional debate; evidence regarding its impact on cardiovascular drug use and health outcomes is needed.

METHODS AND RESULTS

We followed 122 255 Medicare beneficiaries with cardiovascular conditions with linked prescription and medical claims who reached the coverage gap spending threshold in 2006 or 2007. Beneficiaries entered the study on reaching the threshold and were followed until an event, the catastrophic coverage spending threshold, or year's end. We matched 3980 beneficiaries who reached the threshold and received no financial assistance (exposed) to 3980 with financial assistance during the gap period (unexposed), using propensity score and high-dimensional propensity score approaches. We compared rates of cardiovascular drug discontinuation, drug switching, and death or hospitalization for acute coronary syndrome (ACS) plus revascularization, congestive heart failure, or atrial fibrillation. In propensity score-matched analyses, exposed beneficiaries were more likely to discontinue (hazard ratio, 1.57; 95% confidence interval, 1.39 to 1.79; risk difference,13.76; 95% confidence interval, 10.99 to 16.54 drugs/100 person-years) but no more or less likely to switch cardiovascular drugs. There were no significant differences in rates of death (propensity score-matched hazard ratio,1.23; 95% confidence interval, 0.89 to 1.71) or other outcomes.

CONCLUSIONS

Part D beneficiaries with cardiovascular conditions with no financial assistance during the coverage gap were at increased risk for cardiovascular drug discontinuation; however, the impact of this difference on health outcomes is not clear.

[Costs of the chain of treatment procedures in acute myocardial infarction in Brazilian reference and specialized hospitals]

OBJECTIVE

To present the methodology and the results of a field survey to assess the chain costs of procedures for treatment of acute myocardial infarction (AMI), carried out in 11 Brazilian reference and specialized hospitals.

METHODS

The cost assessment used the cost per procedure and per pathology systems. The procedures associated with the treatment of AMI were organized and their logical sequence (protocols) was used to create a flowchart. Data collection tools gathered information on prices and quantities in 2008 (private, health insurance, SUS, and Brazilian Medical Association - AMB price lists), as well as the applicable costs.

RESULTS

Overall, the total cost of the procedures involving the 'standard treatment' of AMI was R$ 12,873.69, if percutaneous coronary intervention (PCI) did not involve stent use. If the stent becomes necessary, the cost increases to R$ 23,461.87.

CONCLUSION

Among the results, we emphasize the fact that the costs of the more expensive procedures did not present statistically significant variations between hospitals, regardless of their location, predominant clientele or legal nature, and the fact that hospitals that treat predominantly users of the Brazilian Unified Health System registered the lowest costs, albeit not statistically significant regarding the entire chain of procedures associated with the pathology.

Association of coronary CT angiography or stress testing with subsequent utilization and spending among Medicare beneficiaries

CONTEXT

Coronary computed tomography angiography (CCTA) is a new noninvasive diagnostic test for coronary artery disease (CAD), but its association with subsequent clinical management has not been established.

OBJECTIVE

To compare utilization and spending associated with functional (stress testing) and anatomical (CCTA) noninvasive cardiac testing in a Medicare population.

DESIGN, SETTING, AND PATIENTS

Retrospective, observational cohort study using claims data from a 20% random sample of 2005-2008 Medicare fee-for-service beneficiaries 66 years or older with no claims for CAD in the preceding year, who received nonemergent, noninvasive testing for CAD (n = 282,830).

MAIN OUTCOME MEASURES

Cardiac catheterization, coronary revascularization, acute myocardial infarction, all-cause mortality, and total and CAD-related Medicare spending over 180 days of follow-up.

RESULTS

Compared with stress myocardial perfusion scintigraphy (MPS), CCTA was associated with an increased likelihood of subsequent cardiac catheterization (22.9% vs 12.1%; adjusted odds ratio [AOR], 2.19 [95% CI, 2.08 to 2.32]; P < .001), percutaneous coronary intervention (7.8% vs 3.4%; AOR, 2.49 [2.28 to 2.72]; P < .001), and coronary artery bypass graft surgery (3.7% vs 1.3%; AOR, 3.00 [2.63 to 3.41]; P < .001). CCTA was also associated with higher total health care spending ($4200 [$3193 to $5267]; P < .001), which was almost entirely attributable to payments for any claims for CAD ($4007 [$3256 to $4835]; P < .001). Compared with MPS, there was lower associated spending with stress echocardiography (-$4981 [-$4991 to -$4969]; P < .001) and exercise electrocardiography (-$7449 [-$7452 to -$7444]; P < .001). At 180 days, CCTA was associated with a similar likelihood of all-cause mortality (1.05% vs 1.28%; AOR, 1.11 [0.88 to 1.38]; P = .32) and a slightly lower likelihood of hospitalization for acute myocardial infarction (0.19% vs 0.43%; AOR, 0.60 [0.37 to 0.98]; P = .04).

CONCLUSION

Medicare beneficiaries who underwent CCTA in a nonacute setting were more likely to undergo subsequent invasive cardiac procedures and have higher CAD-related spending than patients who underwent stress testing.

Routine invasive versus ischemia-guided strategy in patients with acute inferior ST-elevation myocardial infarction who received fibrinolytic therapy: a prospective randomized controlled pilot trial

AIMS

We sought to compare a routine invasive strategy of early coronary angiography and intended revascularization, with an ischemia-guided strategy in patients with acute inferior ST-elevation myocardial infarction (STEMI) who received fibrinolytic therapy.

METHODS

We enrolled 60 consecutive patients with acute inferior STEMI who received fibrinolytic therapy within 6 hours. Patients were randomly assigned to either a routine invasive strategy in which coronary angiography was performed within 48 hours with intended revascularization if eligible (Group A), or an ischemia-guided strategy in which catheterization was based on the presence of myocardial ischemia and viability as demonstrated by stress myocardial perfusion imaging (Group B). Patients were prospectively followed up for 6 months. The primary endpoint was a composite of cardiac death, recurrent myocardial infarction, recurrent ischemia or stroke at 6-month follow-up. Total costs per patient were calculated over 6 months.

RESULTS

The mean age of the whole series was 52 ± 9.8 years (15% females). The primary endpoint occurred more frequently in group A as compared to group B, however, the difference did not meet statistical significance (36.7% versus 23.3%, respectively, p > 0.05). The mean cost per patient at 6-month follow-up was significantly higher in Group A as compared to that in Group B ($4953.5 ± 3108.5 versus $2764.6 ± 2636.7, respectively, p < 0.01).

CONCLUSIONS

In patients presenting with inferior STEMI who received fibrinolytic therapy, a routine invasive strategy with early coronary angiography and intended revascularization, achieved a clinical outcome similar to an ischemia-guided strategy; yet, at a significantly higher cost.

Medical and cost burden of atherosclerosis among patients treated in routine clinical practice

OBJECTIVE

This investigation estimated medical costs attributable to treatment of patients diagnosed with atherosclerosis in routine US clinical practice.

METHODS

Using Medstat MarketScan claims data, direct costs of care and rates of cardiovascular (CV) events (i.e., myocardial infarction, stroke, revascularization) were examined for patients≥18 years of age with and without a diagnostic code for atherosclerosis from 1/1/2002 through 12/31/2004. Patients with an atherosclerosis ICD-9 code who had no history of CV events in the preceding 12 months (n=75,469) were evaluated. A comparison cohort (n=238,702) was matched on age, gender, geographic region, enrollment time period, and Charlson comorbidity index to estimate incremental costs attributable to atherosclerosis. Differences between patient groups were tested for CV event rates per 1,000 patients and monthly costs for 6 and 12 months before and after diagnosis.

RESULTS

Patients had a mean age of 58 years, 52% men, and a comorbidity index of 0.49. Patients diagnosed with atherosclerosis had significantly higher (p<0.001) rates of CV events (240/1000) after diagnosis, compared with patients without atherosclerosis (32/1000). Mean direct cost of care for patients diagnosed with atherosclerosis was $579/month for 12 months before and $1,074/month for 12 months after diagnosis, an 85% increase. Change in mean annual costs pre/post-index date was $5,232 ($436/month) higher among patients with than those without atherosclerosis (p<0.001).

LIMITATIONS

The study population was restricted to patients with diagnosed clinical atherosclerosis based on specific ICD-9 codes. Matching of the patient cohorts was based on observed characteristics and other unobserved differences may exist.

CONCLUSIONS

Patients with diagnosed atherosclerosis incur significant clinical and economic burden, indicating a need for earlier diagnosis and treatment of atherosclerosis to help in reducing this burden.

Cost-effectiveness of the Taxus paclitaxel-eluting stent in the Swedish healthcare system

OBJECTIVE

To analyse the cost-effectiveness of Taxus compared to a bare-metal stent in patients with coronary artery disease in the Swedish healthcare setting.

DESIGN

A decision-analytic model combining clinical data on revascularization rates with Swedish unit costs for medical resources and utility data from the literature.

RESULTS

For patients of moderate risk, the average cost per patient at 12 months is 72,200 SEK for Taxus and 66,900 SEK for a bare-metal stent, while the average cost for high risk patients is nearly equivalent (73,000 vs. 71,700 SEK). The cost per revascularization avoided is generally favourable, while the incremental cost per QALY gained varies depending on the assumptions made; from 2,351,000 SEK for patients of moderate risk at 12-months to cost saving at 24 months for high risk patients. Budget impact scenarios at 12 months are cost-neutral.

CONCLUSION

The Taxus stent is cost-effective in high risk patients, particularly at 24 months. Although it may be less cost-effective for the general population, there is still a substantial offset of initial procedure costs through lower rate of repeat revascularizations.

Long-term economic outcomes associated with intensive versus moderate lipid-lowering therapy in coronary artery disease: results from the Treating to New Targets (TNT) Trial

BACKGROUND

In 10,001 patients with stable coronary artery disease (CAD) enrolled in the Treating to New Targets (TNT) trial, 80 mg/d of atorvastatin (high-dose regimen) reduced the composite primary end point of death from CAD, nonfatal myocardial infarction, resuscitation from cardiac arrest, or stroke by 22% relative to 10 mg/d (low-dose regimen).

METHODS

We performed an economic analysis of this trial from the US perspective using hospital bills and Medicare physician fees to estimate costs for cardiovascular hospitalizations in all US patients (n = 5,308). Atorvastatin costs were assigned using a discounted average wholesale price. Cost-effectiveness was calculated as the within-trial incremental cost required to prevent one primary end point event with high-dose atorvastatin.

RESULTS

During a mean 4.9-year follow-up, the high-dose arm had fewer potential end point cardiovascular hospitalizations (35% vs 41%, P < .001) and revascularization procedures (16% vs 22%, P < .001). The high-dose regimen was $1 per day more expensive. At the end of 5 years, cumulative incremental cost for the high-dose arm was $252 (95% CI-$722 to +$1,276). With an absolute reduction in the primary end point of 2.8 per 100 treated with the high-dose regimen, the cost to prevent one additional primary end point event was $8,964.

CONCLUSION

High-dose atorvastatin treatment of 5 years had only a small net incremental cost because of reduced complications and procedures. The cost to prevent one additional primary end point event with high-dose therapy was similar to that for drug-eluting stents versus bare metal stents in stable CAD and for early invasive versus early conservative therapy in acute coronary syndromes.

Costs of an early intervention versus a conservative strategy in acute coronary syndrome

BACKGROUND

The Randomised Intervention Treatment of unstable Angina (RITA-3) found that non-ST-elevation myocardial infarction and unstable angina patients randomised to routine early arteriography experienced a lower rate of death or myocardial infarction than patients randomised to conservative therapy over a five year period of follow up. This paper uses data from the RITA-3 trial to compare the health service costs of the two strategies.

METHODS

The resource use data included initial arteriography and revascularisation procedures in the early intervention group and subsequently in both groups; in-patient days in hospital for any reason in the first year of follow-up; incidence of myocardial infarction; and cardiac medication.

RESULTS

After five years, the early intervention arm accrued a total mean cost of pound sterling 11,340 (euro 15,592) and the conservative arm a mean of pound sterling 9749(euro 13,405), an additional mean cost in the intervention arm of pound sterling 1591 (95% CI pound sterling 851 to pound sterling 2276) (euro 2188; 95%CI euro 1160 to euro 3228). On average, costs increased with age and were higher in male patients and in patients with severe angina. However, the incremental cost of the intervention strategy was consistent across different patient sub-groups.

CONCLUSION

Over a period of 5 years, the initial additional cost of a strategy of early intervention is only partially offset by subsequent interventions in patients managed conservatively.

Cost of care for new versus recurrent acute coronary syndrome patients

INTRODUCTION

The economic burden of acute coronary syndrome (ACS) continues long after the acute event has resolved. This study compared ACS-related costs between new and recurrent ACS patients using retrospective claims data from a large US health plan.

METHODS

Patients with ACS were identified using ICD-9 codes between the 1st January 2001 and the 30th June 2003. The first diagnosis was defined as the index event. Patient claims were examined 1 year before, and up to 1 year after, the index event. Hospitalisations, revascularisations and costs for new and recurrent cohorts were compared. Multivariate regression was used to examine cost predictors.

RESULTS

In total, 15,508 patients were identified, 82% had new ACS. The new ACS cohort was more likely to have myocardial infarction and be hospitalised for the index event, leading to higher index event costs. However, the recurrent ACS cohort had more re-hospitalisations, longer lengths of inpatient stay and a higher probability of revascularisation during follow-up. The index event cost per patient and per patient-month was higher for new ACS patients. After adjusting for confounding factors, multivariate cost models revealed annualised follow-up medical costs were 9.9% higher (p=0.017) and annualised follow-up pharmacy costs were 8.3% higher (p< or =0.0001) for the new ACS cohort.

CONCLUSION

Newly diagnosed ACS patients had significantly higher adjusted costs in the year following the index event, but recurrent ACS patients still experienced high medical costs. More emphasis by providers and patients on adherence to treatment guidelines may be one step to improving patient outcomes. *This paper was presented in part at the Academy of Managed Care Pharmacy Annual Meeting, 7th April 2006.

Cost comparison of four revascularisation procedures for the treatment of multivessel coronary artery disease

OBJECTIVE

An economic evaluation was performed, using modelling techniques, to compare 1-year total costs of four revascularisation procedures in patients with multivessel disease: on-pump coronary artery bypass grafting (CABG); off-pump CABG; percutaneous coronary intervention (PCI) with bare-metal stents (BMS); and PCI with drug-eluting stents (DES).

METHODS

Clinical data were derived from four randomised clinical trials comparing CABG versus PCI, as well as from literature reviews. Resource use and unit cost estimates were modelled to reflect current Canadian practice.

RESULTS

This study demonstrated that 1 year after the initial revascularisation, PCI with BMS is the least costly procedure, followed by off-pump CABG, PCI with DES and on-pump CABG. DES became the most costly procedure if 3.5 or more DES were used or if staged PCI was performed.

The lifetime costs and benefits of medical technology

Measuring the lifetime costs and benefits of medical technologies is essential in evaluating technological change and determining the productivity of medical care. Using data on Medicare beneficiaries with a heart attack in the late 1980s and 17 years of follow up data, I evaluate the long-term costs and benefits of revascularization after a heart attack. I account for non-random selection into treatment with instrumental variables; following McClellan, McNeil, and Newhouse, the instrument is the differential distance to a hospital capable of providing revascularization. The results show that revascularization is associated with over 1 year of additional life expectancy, at a cost of about $40,000. Revascularization, or other treatments correlated with it, appears to be highly cost-effective.

Costs of cardiovascular events of diabetic patients in the French hospitals

AIMS

To test the assumption that hospital management of macro-vascular complications of Diabetes is more resource consuming in diabetic than in non-diabetic patients and to estimate, if relevant, the extra costs for diabetic patients.

METHODS

The French national DRG database (PMSI- 2003) was analysed for the following cardio-vascular events (CVE): Stroke, Myocardial Infarction, Unstable Angina, Cardiac Arrest and Coronary Revascularization. Diabetic patients (Type 1 and 2) were identified using co-morbidity diagnosis. Differences in various indicators of resource consumption were tested between diabetic and non-diabetic patients. Using length of stay (LOS) as a cost driver, the extra hospital costs of each CVE were then estimated by reference to mean costs measured on the whole database.

RESULTS

Average LOS of patients with diabetes were significantly longer than of non diabetic patients. (stroke: +2.5 days, myocardial infarction: +1.5 days, unstable angina: +1.3 days, revascularisation: +2.8 days; P<0.001). The mean numbers of medical procedures by stay were also higher in the diabetic group. Extra hospital costs of CVE for diabetic patients as compared with mean costs were the following: +23.9% (non fatal stroke), +10.4% (non fatal myocardial infarction), +6.1% (unstable angina), +9.1% (coronary revascularization).

CONCLUSION

The hospital costs of CVE in diabetic patients are higher than average. Specific costs for these complications should be used to improve the relevance of economic studies of Diabetes.

Cost effectiveness of clinically appropriate decisions on alternative treatments for angina pectoris: prospective observational study

OBJECTIVE

To assess whether revascularisation that is considered to be clinically appropriate is also cost effective.

DESIGN

Prospective observational study comparing cost effectiveness of coronary artery bypass grafting, percutaneous coronary intervention, or medical management within groups of patients rated as appropriate for revascularisation.

SETTING

Three tertiary care centres in London.

PARTICIPANTS

Consecutive, unselected patients rated as clinically appropriate (using a nine member Delphi panel) to receive coronary artery bypass grafting only (n=815); percutaneous coronary intervention only (n=385); or both revascularisation procedures (n=520).

MAIN OUTCOME MEASURE

Cost per quality adjusted life year gained over six year follow-up, calculated with a National Health Service cost perspective and discounted at 3.5%/year.

RESULTS

Coronary artery bypass grafting cost 22,000 pounds sterling (33,000 euros; $43,000) per quality adjusted life year gained compared with percutaneous coronary intervention among patients appropriate for coronary artery bypass grafting only (59% probability of being cost effective at a cost effectiveness threshold of 30,000 pounds sterling per quality adjusted life year) and 19,000 pounds sterling per quality adjusted life year gained compared with medical management among those appropriate for both types of revascularisation (probability of being cost effective 63%). In none of the three appropriateness groups was percutaneous coronary intervention cost effective at a threshold of 30,000 pounds sterling per quality adjusted life year. Among patients rated appropriate for percutaneous coronary intervention only, the cost per quality adjusted life year gained for percutaneous coronary intervention compared with medical management was 47,000, pounds sterling exceeding usual cost effectiveness thresholds; in these patients, medical management was most likely to be cost effective (probability 54%).

CONCLUSIONS

Among patients judged clinically appropriate for coronary revascularisation, coronary artery bypass grafting seemed cost effective but percutaneous coronary intervention did not. Cost effectiveness analysis based on observational data suggests that the clinical benefit of percutaneous coronary intervention may not be sufficient to justify its cost.

Cost effectiveness analysis of minimally invasive internal thoracic artery bypass versus percutaneous revascularisation for isolated lesions of the left anterior descending artery

OBJECTIVE

To compare the cost effectiveness of percutaneous transluminal coronary artery stenting with minimally invasive internal thoracic artery bypass for isolated lesions of the left anterior descending artery.

DESIGN

Cost effectiveness analysis.

DATA SOURCES

Embase, Medline, Cochrane, Google Scholar, and Health Technology Assessment databases (1966-2005), and reference sources for utility values and economical variables.

METHODS

Decision analytical modelling and Markov simulation were used to model medium and long term costs, quality of life, and cost effectiveness after either intervention using data from referenced sources. Probabilistic sensitivity and alternative analyses were used to investigate the effect of uncertainty about the value of model variables and model structure.

RESULTS

Stenting was the dominant strategy in the first two years, being both more effective and less costly than bypass surgery. In the third year bypass surgery still remained more expensive but became marginally more effective. As the incremental cost effectiveness was 1,108,130.40 pounds sterling (1 682,146.00 euros; $2,179,194) per quality adjusted life year (QALY), the additional effectiveness could not be said to justify the additional cost at this stage. By five years, however, the incremental cost effectiveness ratio of 28,042.95 pounds sterling per QALY began to compare favourably with other interventions. At 10 years the additional effectiveness of 0.132 QALYs (range -0.166 to 0.430) probably justified the additional cost of 829.02 pounds sterling (range 205.56 pounds sterling to 1452.48 pounds sterling), with an incremental cost effectiveness of 6274.02 pounds sterling per QALY. Sensitivity and alternative analysis showed the results were sensitive to the time horizon and stent type.

CONCLUSIONS

Minimally invasive left internal thoracic artery bypass may be a more cost effective medium and long term alternative to percutaneous transluminal coronary artery stenting.

Targeted stent use in clinical practice based on evidence from the BAsel Stent Cost Effectiveness Trial (BASKET)

AIM

It is unknown which patients benefit most from drug-eluting stents (DES) against bare-metal stents (BMS) in a long-term clinical outcome.

METHODS AND RESULTS

To address this question, data from 826 consecutive patients with angioplasty, randomized 2:1 to DES vs. BMS, with an 18-month follow-up for cardiac death/myocardial infarction (MI) and non-MI-related target-vessel revascularization (TVR) were analysed for interactions between stent type and patient/vessel characteristics predicting events. Rates of 18-month TVRs were lower with DES vs. BMS use (7.5 vs. 11.6%, P = 0.05), but similar for both stents regarding cardiac death/MI (DES, 8.4%; BMS, 7.5%; P = 0.70). Significant interactions between stent type and two multivariable event predictors were identified: small stents (<3.0 mm) and bypass graft stenting. In these patient groups together (n = 268, 32%), DES reduced non-MI-related TVR (HR = 0.44; P = 0.02) and cardiac death/MI (HR = 0.44; P = 0.04), whereas in the other 558 patients (68%) TVR rate was similar (HR = 0.75; P = 0.38) and cardiac death/MI rate increased after DES (HR = 2.07; P = 0.05).

CONCLUSION

Patients with angioplasty of small vessels or bypass grafts seem to benefit from DES use, in long-term outcome, in contrast to patients with large native vessel stenting where there might even be late harm. Still, this hypothesis needs to be tested prospectively.

Cost-Effectiveness of Coronary Artery Bypass Grafts Versus Percutaneous Coronary Intervention for Revascularization of High-Risk Patients

BACKGROUND

A Department of Veterans Affairs Cooperative Study randomized high-risk patients with medically refractory myocardial ischemia, a group largely excluded from previous trials, to urgent revascularization with either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). The present study examined the cost-effectiveness of PCI versus CABG for these high-risk patients.

METHODS AND RESULTS

Of 454 patients at 16 Department of Veterans Affairs medical centers, 445 were available for the economic analysis (218 PCI and 227 CABG patients). Total costs were assessed at 3 and 5 years from the third-party payer's perspective, and effectiveness was measured by survival. After 3 years, average total costs were 63,896 dollars for PCI versus 84,364 dollars for CABG patients, a difference of 20,468 dollars (95% confidence interval [CI] 13,918 dollars to 27,569 dollars). CIs were estimated by bootstrapping. Survival at 3 years was 0.82 for PCI versus 0.79 for CABG patients (P=0.34). Precision of the cost-effectiveness estimates were assessed by bootstrapping. PCI was less costly and more effective at 3 years in 92.6% of the bootstrap replications. After 5 years, average total costs were 81,790 dollars for PCI versus 100,522 dollars for CABG patients, a difference of 18,732 dollars (95% CI 9873 dollars to 27,831 dollars), whereas survival at 5 years was 0.75 for PCI patients versus 0.70 for CABG patients (P=0.21). At 5 years, PCI remained less costly and more effective in 89.4% of the bootstrap replications.

CONCLUSIONS

PCI was less costly and at least as effective for the urgent revascularization of medically refractory, high-risk patients over 5 years.

More is not better in the early care of acute myocardial infarction: a prospective cohort analysis on administrative databases

AIMS

To assess the outcome and costs of patients with acute myocardial infarction (AMI) after initial admission to hospitals with or without catheterization facilities in Belgium.

METHODS AND RESULTS

From a nationwide hospital register, we retrieved the data of 34 961 patients discharged during 1999-2001 with a principal diagnosis of AMI. They were initially admitted to hospitals without catheterization facilities (A), with diagnostic (B1) or interventional catheterization facilities (B2). Mortality has been recorded till the end of 2003 and re-admissions till the end of 2001. The mortality hazard ratio and 95% CI of 5 years mortality of A vs. B2 was 1.01 (0.97, 1.06) and of B1 vs. B2 was 1.03 (0.98, 1.09). Re-admission rates and 95% CI for cardiovascular reason per 100 patient-years were 23.5 (22.7, 24.3) for A, 23.8 (22.5, 25.1) for B1, and 22.0 (21.2, 22.9) for B2. The mean cost in hospital of a patient at low risk with a single stay was in A 4072 euro (median: 3,861; IQR: 4467-3476), in B1 5083 euro (median: 5153; IQR: 5769-4340), and in B2 7741 euro (median: 7553; IQR: 8211-7298).

CONCLUSION

Services with catheterization facilities compared with services without them showed no better health outcomes, but delivered more expensive care.

Economic evaluation of alternative strategies to treat patients with diabetes mellitus and coronary artery disease

Diabetes mellitus and coronary artery disease (CAD) commonly coexist, and thus effective, cost-effective management strategies are needed. Intensive management of diabetes has been shown to increase medical costs while yielding better outcomes, with an acceptable cost-effectiveness ratio of <50,000 dollars per life-year added. On the basis of clinical trial findings in the 1970s and 1980s, coronary bypass surgery was cost-effective compared with medical therapy in the treatment of extensive CAD. Few trials have compared angioplasty with medical therapy, and its cost-effectiveness is not well established. The economic outcomes of contemporary coronary revascularization, especially angioplasty, compared with contemporary medical therapy must be evaluated. The Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial will collect extensive economic data and examine the cost-effectiveness of alternative strategies to manage diabetes and CAD in patients with both disorders.

Trial-based cost-utility comparison of percutaneous myocardial laser revascularisation and continued medical therapy for treatment of refractory angina pectoris

This study examined from a health service perspective whether percutaneous myocardial laser revascularisation (PMR) plus standard medical management is cost-effective when compared with standard medical management alone in the treatment of refractory angina. This involved a cost-utility analysis using patient-specific data from a single-centre, randomised, controlled trial carried out in the United Kingdom. Of 73 patients diagnosed as having refractory angina and not suitable for conventional forms of revascularisation, 36 were randomised to PMR plus medical management and 37 to medical management alone. We collected costs to the health service of PMR and all secondary sector health care contacts and cardiac-related medication in the 12 months following randomisation. Patient utility, measured using the EuroQol EQ-5D questionnaire, was combined with 12-month survival data to generate quality-adjusted life years (QALYs). The mean 12-month cost per patient for PMR was 8,307 pounds, and that for medical management was 1,888 pounds, giving a cost difference of 6,410 pounds. The mean QALY difference favoured PMR at 0.126, giving an incremental cost per QALY of 50,873 pounds. The cost-effectiveness acceptability curve indicates that the probability of PMR being cost-effective over the first 12 months is quite low. Whilst a longer period of follow-up might indicate continued benefit from PMR, which would make the intervention economically more attractive, PMR could not be considered cost-effective based on 1-year follow-up data.

Cost-effectiveness of drug-eluting coronary stents in Quebec, Canada

Objectives:The aim of this investigation was to assess the incremental cost-effectiveness of replacing bare metal coronary stents (BMS) with drug-eluting stents (DES) in the Province of Quebec, Canada.

Methods:The strategy used was a cost-effectiveness analysis from the perspective of the health-care provider, in the province of Quebec, Canada (population 7.5 million). The main outcome measure was the cost per avoided revascularization intervention.

Results:Based on the annual Quebec rate of 14,000 angioplasties with an average of 1.7 stents per procedure and a purchase cost of $2,600 Canadian dollar (CDN) for DES, 100 percent substitution of BMS with DES would require an additional $45.1 million CDN of funding. After the benefits of reduced repeat revascularization interventions are included, the incremental cost would be $35.2 million CDN. The cost per avoided revascularization intervention (18 percent coronary artery bypass graft, 82 percent percutaneous coronary intervention [PCI]) would be $23,067 CDN. If DES were offered selectively to higher risk populations, for example, a 20 percent subgroup with a relative restenosis risk of 2.5 times the current bare metal rate, the incremental cost of the program would be $4.9 million CDN at a cost of $7,800 per avoided revascularization procedure. Break-even costs for the program would occur at DES purchase cost of $1,161 for 100 percent DES use and $1,627 for selective 20 percent DES use for high-risk patients for restenosis (RR = 2.5). Univariate and Monte Carlo sensitivity analyses indicate that the parameters most affecting the analysis are the capacity to select patients at high risk of restenosis, the average number of stents used per PCI, baseline restenosis rates for BMS, the effectiveness ratio of restenosis prevention for DES versus BMS, the cost of DES, and the revascularization rate after initial PCI. Sensitivity analyses suggest little additional health benefits but escalating cost-effectiveness ratios once a DES penetration of 40 percent has been attained.

Conclusions:Under current conditions in Quebec, Canada, selective use of DES in high-risk patients is the most acceptable strategy in terms of cost-effectiveness. Results of such an analysis would be expected to be similar in other countries with key model parameters similar to those used in this model. This model provides an example of how to evaluate the cost-effectiveness of selective use of a new technology in high-risk patients.

Mental disorders and revascularization procedures in a commercially insured sample

OBJECTIVE

The objective of this study was to determine if receipt of revascularization was similar among commercially insured adults with mental disorders compared with people without mental disorders.

METHODS

This was a retrospective analysis of a 100% sample of Blue Cross/Blue Shield of Iowa administrative claims data, 1996 to 2001. Logistic regression was used to calculate unadjusted and adjusted odds ratios (OR) for receipt of angioplasty (PTCA) and bypass graft surgery (CABG) within 30 days of discharge.

RESULTS

A total of 3368 adults, aged 18 to 64 years, were hospitalized for myocardial infarction (MI) and 40% (n = 1342) had a mental disorder. Subjects with mental disorders were more likely to be younger, female, urban residents, and to have increased cardiovascular and medical comorbidity. They were similarly likely as subjects without mental disorders to have received PTCA (OR, 1.10; 95% confidence interval [CI], 0.95-1.29) and CABG (OR, 0.89; 95% CI, 0.71-1.11) in analyses adjusted for demographic and clinical characteristics. Revascularization rates did not differ by mental disorder type, with few exceptions.

CONCLUSIONS

Receipt of revascularization was similar for patients with and without mental disorders. Our results may differ from previous findings as a result of the younger population studied and increased comorbidity in people with mental disorders, which may have resulted in a contraindication for surgical intervention. Conversely, the increased burden of comorbidity could suggest that these patients should have received PTCA at higher rates because of the better prognosis associated with revascularization as compared with medical management. Prospective analyses with review of clinical data and behavioral risk factors are necessary to determine why some patients with mental illness may be less likely to receive cardiac interventions.

Cost of care for new-onset acute coronary syndrome patients who undergo coronary revascularization

OBJECTIVES

This study examines demographic, health characteristics, and total health care utilization in acute coronary syndrome (ACS) patients who underwent coronary revascularization within the first year of follow-up.

BACKGROUND

Revascularization during or after the index ACS event is becoming more common, and it is important to further characterize these patients.

METHODS

A retrospective claims analysis was conducted (July 1, 1999-June 30, 2001) with new onset ACS patients, defined as an emergency room visit or hospitalization with an ICD-9 code for unstable angina (UA) or acute myocardial infarction (AMI), but without an ACS claim in the previous 6 months. Patients were followed up to 12 months to identify total resource utilization (medical, pharmacy, revascularization procedures).

RESULTS

A total of 6,929 patients were included and 69% had revascularization performed during the index hospitalization. Mean age was 55 years; 72.9% were male. Revascularization was percutaneous coronary intervention (PCI) in 5,002 and bypass surgery in 1,927. The index ACS event was AMI in 48.9%; 13.5% had both AMI and UA. Total first-year cost was 210.7 million dollars (30,402 dollars per patient); hospitalization costs were 161.7 million dollars (23,331 dollars per patient). During follow-up, 75.5% received a statin, 75.8% a beta-blocker, and 63.5% of all patients received clopidogrel (84.8% of PCI patients). Mean days of clopidogrel therapy were 83.5.

CONCLUSIONS

Early revascularization is a frequent therapeutic strategy in these relatively young managed care patients. The majority of costs were medical and a majority of procedures were PCI. Many patients experienced AMI as their initial cardiovascular event. Drug utilization of statins, beta-blockers, and clopidogrel, according to practice guidelines, was acceptable.

Effect of difficulty affording health care on health status after coronary revascularization

BACKGROUND

An objective of the United States' Healthy People 2010 Initiative is to eliminate disparities based on socioeconomic status. We assessed the effect of difficulty affording health care on the health status (symptoms, function, and quality of life) of patients treated with percutaneous coronary intervention or CABG.

METHODS AND RESULTS

A consecutive, single-center cohort of 480 patients undergoing coronary revascularization received the Seattle Angina Questionnaire at the time of their procedure and at subsequent monthly intervals for 6 months. At baseline, patients who reported somewhat of a burden to a severe burden in affording health care had significantly lower scores on the Seattle Angina Questionnaire (mean+/-SD) with respect to angina (55+/-29 versus 68+/-25, P<0.0001), physical limitation (55+/-26 versus 72+/-24, P<0.0001), and quality of life (46+/-22 versus 56+/-22, P<0.0001) than those who did not perceive healthcare costs to be burdensome. Although both groups of patients improved after revascularization, poorer health status persisted among those with difficulty affording health care after percutaneous coronary intervention (6-month mean+/-SE: angina 79+/-2.5 versus 88+/-1.9, P=0.002; physical function 61+/-2.7 versus 80+/-2.0, P<0.0001; quality of life 67+/-2.4 versus 82+/-1.8, P<0.0001) but not after CABG (angina 91+/-2.5 versus 93+/-1.6, P=0.47; physical function 75+/-3.4 versus 81+/-2.2, P=0.13; quality of life 84+/-3.1 versus 84+/-2.0, P=0.81). Similar differences remained after adjustment for demographic and clinical characteristics.

CONCLUSIONS

Patients reporting difficulty affording health care have worse health status at the time of coronary revascularization. A persistent disparity exists after percutaneous but not surgical revascularization. Additional inquiry into the mechanism of this disparity is needed so that the goals of equitable health care, irrespective of treatment strategy, can be achieved.

Total first-year costs of acute coronary syndrome in a managed care setting

OBJECTIVE

There is a limited amount of literature examining the burden and cost of illness of acute coronary syndrome (ACS) in the managed care population. The goal of this study was to estimate the total cost of health care utilization (health plan plus patient) in the 12-month period following newly onset ACS. The demographic and health characteristics of these patients are compared with the similar data from 2 large clinical trials: CURE (Clopidogrel in Unstable Angina to Prevent Recurrent Events) and PROVE IT-TIMI 22 (Pravastatin or Atorvastatin Evaluation and Infection Therapy--Thrombolysis in Myocardial Infarction 22).

METHODS

A retrospective claims analysis was conducted for the 2-year period from July 1, 1999, through June 30, 2001. ACS was defined as an emergency room visit or hospitalization with a primary International Classification of Diseases, 9th Edition/Revision (ICD-9) diagnosis of 410.xx (acute myocardial infarction) or 411.1x (intermediate coronary syndrome). Patients were required to be free of any ACS claim in the previous 6 months. Patients without 6 months of prior continuous enrollment or those patients younger than 18 years were excluded. Patients were followed up to 12 months to identify total medical and pharmacy costs, revascularization procedures, and medication use.

RESULTS

A total of 13,731 patients met the inclusion criteria, yielding 133,814 months of follow-up (mean: 9.75 months per patient) and representing approximately 0.4% of the managed care members in the database during the study period. The mean age was 54 years and 68% were male. The total direct cost incurred by the health plan and patients was dollar 309 million (dollar 2,312 per patient-month of follow-up); 72% of total costs were attributable to hospitalizations. The majority of costs were medical (dollar 286 million, 93%), and dollar 23 million (7%) were pharmacy costs. Fifty-one percent of patients had a revascularization procedure, which was typically performed during the index hospitalization (median time to revascularization was 0 days). Coronary artery stent implantation was the most common revascularization procedure (68%). During follow-up, 490 patients (3.6%) had a detectable death, 58% of patients received a beta-blocker, 60% received one or more cholesterol-lowering medications, and 36% of patients received clopidogrel therapy. Aspirin therapy was not measured.

CONCLUSIONS

These managed-care patients with newly onset ACS incurred substantial costs in the 12 months following initial presentation. Revascularization was a common therapeutic intervention for these patients. There appear to be opportunities to improve medication therapy after an acute ACS event. There were some demographic and health characteristics that were different in these commercially insured patients from those in 2 large clinical trials.

Cost effectiveness of drug eluting coronary artery stenting in a UK setting: cost-utility study

OBJECTIVE

To assess the cost effectiveness of drug eluting stents (DES) compared with conventional stents for treatment of symptomatic coronary artery disease in the UK.

DESIGN

Cost-utility analysis of audit based patient subgroups by means of a simple economic model.

SETTING

Tertiary care.

PARTICIPANTS

12 month audit data for 2884 patients receiving percutaneous coronary intervention with stenting at the Cardiothoracic Centre Liverpool between January 2000 and December 2002.

MAIN OUTCOME MEASURES

Risk of repeat revascularisation within 12 months of index procedure and reduction in risk from use of DES. Economic modelling was used to estimate the cost-utility ratio and threshold price premium.

RESULTS

Four factors were identified for patients undergoing elective surgery (n = 1951) and two for non-elective surgery (n = 933) to predict risk of repeat revascularisation within 12 months. Most patients fell within the subgroup with lowest risk (57% of the elective surgery group with 5.6% risk and 91% of the non-elective surgery group with 9.9% risk). Modelled cost-utility ratios were acceptable for only one group of high risk patients undergoing non-elective surgery (only one patient in audit data). Restricting the number of DES for each patient improved results marginally: 4% of stents could then be drug eluting on economic grounds. The threshold price premium justifying 90% substitution of conventional stents was estimated to be 112 pound sterling (212 USD, 162 pound sterling) (sirolimus stents) or 89 pound sterling (167 USD, 130 pound sterling) (paclitaxel stents).

CONCLUSIONS

At current UK prices, DES are not cost effective compared with conventional stents except for a small minority of patients. Although the technology is clearly effective, general substitution is not justified unless the price premium falls substantially.

Pre-discharge stress echocardiography and exercise ECG for risk stratification after uncomplicated acute myocardial infarction: results of the COSTAMI-II (cost of strategies after myocardial infarction) trial

OBJECTIVE

To compare in a prospective, randomised, multicentre trial the relative merits of pre-discharge exercise ECG and early pharmacological stress echocardiography concerning risk stratification and costs of treating patients with uncomplicated acute myocardial infarction.

DESIGN

262 patients from six participating centres with a recent uncomplicated myocardial infarction were randomly assigned to early (day 3-5) pharmacological stress echocardiography (n = 132) or conventional pre-discharge (day 7-9) maximum symptom limited exercise ECG (n = 130).

RESULTS

No complication occurred during either stress echocardiography or exercise ECG. At one year follow up there were 26 events (1 death, 5 non-fatal reinfarctions, 20 patients with unstable angina requiring hospitalisation) in patients randomly assigned to early stress echocardiography and 18 events (2 reinfarctions, 16 unstable angina requiring hospitalisation) in the group randomly assigned to exercise ECG (not significant). The negative predictive value was 92% for stress echocardiography and 88% for exercise ECG (not significant). Total costs of the two strategies were similar (not significant).

CONCLUSION

Early pharmacological stress echocardiography and conventional pre-discharge symptom limited exercise ECG have similar clinical outcome and costs after uncomplicated infarction. Early pharmacological stress echocardiography should be considered a valid alternative even for patients with interpretable baseline ECG who can exercise.

Changing treatment patterns for coronary artery revascularization in Canada: the projected impact of drug eluting stents

Background

To evaluate current treatment patterns for coronary artery revascularization in Canada and explore the potential impact of drug eluting stents (DES) on these treatment patterns.

Methods

Eleven cardiologists at multiple Canadian academic centers completed a questionnaire on coronary artery revascularization rates and treatment patterns.

Results

Participating physicians indicated slightly higher rates of PTCA, CABG, and stent implantation than reported in CCN publications. Participants estimated that 24% of all patients currently receiving bare metal stents (BMS) would receive DES in the first year following DES approval in Canada, although there was a large range of estimates around this value (5% to 65%). By the fifth year following DES approval, it was estimated that 85% of BMS patients would instead receive DES. Among diabetic patients, estimates ranged from 43% in the first year following approval to 91% in the fifth year. For all patients currently receiving CABG, mean use of DES instead was estimated at 12% in the first year to 42% at five years; rates among diabetic patients currently undergoing CABG were 17% in the first year to 49% in the fifth year.

Conclusions

These results suggest a continued increase in revascularization procedures in Canada. Based on the panel's responses, it is likely that a trend away from CABG towards PTCA will continue in Canada, and will be augmented by the availability of DES as a treatment option. The availability of DES as a treatment option in Canada may change the threshold at which revascularization procedures are considered.

What reimbursement for coronary revascularization with drug-eluting stents?

We investigated the clinical and economic impact of sirolimus-eluting coronary stents (SES) at a nationwide level as to advice about the feasible reimbursement policy for the Italian Health Care System (SSN). A decision model compared bare metal stents (BMS) and SES in terms of costs and repeat coronary revascularizations incurred in 12 months following the first revascularization. The model was compiled for eight subgroups of patients. Rates of events were derived from randomized trials and an 1,809-patient survey. National charges were used to evaluate resources consumption. Compared with BMS, the number of averted revascularizations with SES is 0.16 per patient. SES also save Euro 1,371 per patient. Total savings to SSN are proportional to the rate of SES adoption by Italian hospitals: assuming a complete replacement of BMS with SES, the model estimates that 7,095 revascularizations would be averted and more than Euro 60 million saved by the SSN in 1 year. To stimulate SES adoption a SES-specific DRG might by introduced with a reimbursement value 23% higher than the current charge. SES is thus a cost-saving strategy in the perspective of the SSN that could therefore support the introduction of the new technology by reimbursing about 80% of its current incremental acquisition cost.

Willingness to pay for avoiding coronary restenosis and repeat revascularization: results from a contingent valuation study

BACKGROUND

Despite technological improvements, percutaneous coronary intervention (PCI) remains limited by restenosis requiring further revascularization procedures during the ensuing year. New technologies aiming to reduce restenosis are expensive and may increase net healthcare costs. Economic evaluations of such therapies have been performed, but have been hindered by the need to assess the disutility of short-term health care events and repeat coronary revascularization as well as the lack of benchmark standards for intermediate health outcomes. The contingent valuation approach may offer particular advantages when evaluating treatments that improve short-term health outcomes.

OBJECTIVE

To examine patients' willingness to pay (WTP) for treatments that may reduce the risk of restenosis and repeat revascularization after PCI.

METHODS

We used a contingent valuation approach to evaluate WTP among participants in two large clinical trials evaluating new PCI devices. The baseline scenario described a 30% probability of repeat revascularization following the initial procedure. Patients were asked to indicate, using a close-ended (referendum) question, their out of pocket WTP for an improved treatment that would reduce this risk. Three different prices (500 dollars, 1000 dollars, and 1500 dollars) and three levels of absolute risk reduction (10, 20, and 30%) were randomly varied creating nine sub-samples of patients. Patients' responses were analyzed using both parametric and non-parametric methods.

RESULTS

1642 patients completed the WTP question. The WTP medians for the 10 and 20% risk reductions were 273 dollars and 366 dollars, respectively; the median WTP for the 30% risk reduction was significantly higher at 1162 dollars (P<0.001). Higher household income (OR=1.57, P<0.001) was independently associated with a higher WTP.

CONCLUSIONS

Although short-lived, avoidance of coronary restenosis may have considerable value to patients undergoing percutaneous coronary interventions. These findings may have important implications for emerging technologies such as drug-eluting stents.

Cost considerations in selecting coronary artery revascularization therapy in the elderly

This article presents some of the cost factors involved in selecting coronary artery revascularization therapy in an elderly patient. With the percentage of gross national product allocated to healthcare continuing to rise in the US, resource allocation has become an issue. Percutaneous coronary intervention continues to be a viable option for many patients, with lower initial costs. However, long-term angina-free results often require further interventions or eventual surgery. Once coronary artery revascularization therapy is selected, it is worthwhile to evaluate the cost considerations inherent to various techniques. Off-pump coronary artery bypass graft surgery has seen a resurgence, with improved technology and lower hospital costs than on-pump bypass surgery. Numerous factors contributing to cost in coronary surgery have been studied and several are documented here, including the potential benefits of early extubation and the use of standardized optimal care pathways. A wide range of hospital-level cost variation has been noted, and standardization issues remain. With the advent of advanced computer-assisted robotic techniques, a push toward totally endoscopic bypass surgery has begun, with the eventual hope of reducing hospital stays to a minimum while maximizing outcomes, thus reducing intensive care unit and stepdown care times, which contribute a great deal toward overall cost. At the present time, these techniques add a significant premium to hospital charges, outweighing any potential length-of-stay benefits from a cost standpoint. As our elderly population continues to grow, use of healthcare resource dollars will continue to be heavily scrutinized. Although the clinical outcome remains the ultimate benchmark, cost containment and optimization of resources will take on a larger role in the future.