Clinical Outcomes, Resource Use, and Costs at 1 Year in Patients with Acute Coronary Syndrome Undergoing PCI: Results from the Multinational APTOR Registry

Rethinking rehabilitation after percutaneous coronary intervention: a protocol of a multicentre cohort study on continuity of care, health literacy, adherence and costs at all care levels (the CONCARDPCI)

INTRODUCTION

Percutaneous coronary intervention (PCI) aims to provide instant relief of symptoms, and improve functional capacity and prognosis in patients with coronary artery disease. Although patients may experience a quick recovery, continuity of care from hospital to home can be challenging. Within a short time span, patients must adjust their lifestyle, incorporate medications and acquire new support. Thus, CONCARD^PCI will identify bottlenecks in the patient journey from a patient perspective to lay the groundwork for integrated, coherent pathways with innovative modes of healthcare delivery. The main objective of the CONCARD^PCI is to investigate (1) continuity of care, (2) health literacy and self-management, (3) adherence to treatment, and (4) healthcare utilisation and costs, and to determine associations with future short and long-term health outcomes in patients after PCI.

METHODS AND ANALYSIS

This prospective multicentre cohort study organised in four thematic projects plans to include 3000 patients. All patients undergoing PCI at seven large PCI centres based in two Nordic countries are prospectively screened for eligibility and included in a cohort with a 1-year follow-up period including data collection of patient-reported outcomes (PRO) and a further 10-year follow-up for adverse events. In addition to PROs, data are collected from patient medical records and national compulsory registries.

ETHICS AND DISSEMINATION

Approval has been granted by the Norwegian Regional Committee for Ethics in Medical Research in Western Norway (REK 2015/57), and the Data Protection Agency in the Zealand region (REG-145-2017). Findings will be disseminated widely through peer-reviewed publications and to patients through patient organisations.

TRIAL REGISTRATION NUMBER

NCT03810612.

Early discharge compared with ordinary discharge after percutaneous coronary intervention - a systematic review and meta-analysis of safety and cost

Aim

We aimed to summarize the pooled effect of early discharge compared with ordinary discharge after percutaneous coronary intervention (PCI) on the composite endpoint of re-infarction, revascularization, stroke, death, and incidence of rehospitalization. We also aimed to compare costs for the two strategies.

Methods

The study was a systematic review and a meta-analysis of 12 randomized controlled trials including 2962 patients, followed by trial sequential analysis. An estimation of cost was considered. Follow-up time was 30 days.

Results

For early discharge, pooled effect for the composite endpoint was relative risk of efficacy (RRe)=0.65, 95% confidence interval (CI) (0.52–0.81). Rehospitalization had a pooled effect of RRe=1.10, 95% CI (0.88–1.38). Early discharge had an increasing risk of rehospitalization with increasing frequency of hypertension for all populations, except those with stable angina, where a decreasing risk was noted. Advancing age gave increased risk of revascularization. Early discharge had a cost reduction of 655 Euros per patient compared with ordinary discharge.

Conclusion

The pooled effect supports the safe use of early discharge after PCI in the treatment of a heterogeneous population of patients with coronary artery disease. There was an increased risk of rehospitalization for all subpopulations, except patients with stable angina. Clinical trials with homogeneous populations of acute coronary syndrome are needed to be conclusive on this issue.

Patient-level costs of major cardiovascular conditions: a review of the international literature

OBJECTIVE

Robust cost estimates of cardiovascular (CV) events are required for assessing health care interventions aimed at reducing the economic burden of major adverse CV events. This review synthesizes international cost estimates of CV events.

METHODS

MEDLINE database was searched electronically for English language studies published during 2007-2012, with cost estimates for CV events of interest - unstable angina, myocardial infarction, heart failure, stroke, and CV revascularization. Included studies provided at least one estimate of patient-level direct costs in adults for any identified country. Information on study characteristics and cost estimates were collected. All costs were adjusted for inflation to 2013 values.

RESULTS

Across the 114 studies included, the average cost was US $6,466 for unstable angina, $11,664 for acute myocardial infarction, $11,686 for acute heart failure, $11,635 for acute ischemic stroke, $37,611 for coronary artery bypass graft, and $13,501 for percutaneous coronary intervention. The ranges for cost estimates varied widely across countries with US cost estimate being at least twice as high as European Union costs for some conditions. Few studies were found on populations outside the US and European Union.

CONCLUSION

This review showed wide variation in the cost of CV events within and across countries, while showcasing the continuing economic burden of CV disease. The variability in costs was primarily attributable to differences in study population, costing methodologies, and reporting differences. Reliable cost estimates for assessing economic value of interventions in CV disease are needed.

Multivariate Meta-Analysis of Preference-Based Quality of Life Values in Coronary Heart Disease

BACKGROUND

There are numerous health-related quality of life (HRQol) measurements used in coronary heart disease (CHD) in the literature. However, only values assessed with preference-based instruments can be directly applied in a cost-utility analysis (CUA).

OBJECTIVE

To summarize and synthesize instrument-specific preference-based values in CHD and the underlying disease-subgroups, stable angina and post-acute coronary syndrome (post-ACS), for developed countries, while accounting for study-level characteristics, and within- and between-study correlation.

METHODS

A systematic review was conducted to identify studies reporting preference-based values in CHD. A multivariate meta-analysis was applied to synthesize the HRQoL values. Meta-regression analyses examined the effect of study level covariates age, publication year, prevalence of diabetes and gender.

RESULTS

A total of 40 studies providing preference-based values were detected. Synthesized estimates of HRQoL in post-ACS ranged from 0.64 (Quality of Well-Being) to 0.92 (EuroQol European"tariff"), while in stable angina they ranged from 0.64 (Short form 6D) to 0.89 (Standard Gamble). Similar findings were observed in estimates applying to general CHD. No significant improvement in model fit was found after adjusting for study-level covariates. Large between-study heterogeneity was observed in all the models investigated.

CONCLUSIONS

The main finding of our study is the presence of large heterogeneity both within and between instrument-specific HRQoL values. Current economic models in CHD ignore this between-study heterogeneity. Multivariate meta-analysis can quantify this heterogeneity and offers the means for uncertainty around HRQoL values to be translated to uncertainty in CUAs.

Prehospital and in-hospital use of healthcare resources in patients surviving acute coronary syndromes: an analysis of the EPICOR registry

Objective

The aim of this report is to provide insight into real-world healthcare resource use (HCRU) during the critical management of patients surviving acute coronary syndromes (ACS), using data from EPICOR (long-tErm follow-up of antithrombotic management Patterns In acute CORonary syndrome patients) (NCT01171404).

Methods

EPICOR was a prospective, multinational, observational study that enrolled 10 568 ACS survivors from 555 hospitals in 20 countries in Europe and Latin America, between September 2010 and March 2011. HCRU was evaluated in patients with ST-segment elevation myocardial infarction (STEMI) or non-ST-segment elevation ACS (NSTE-ACS), with or without a history of cardiovascular disease (CVD). Multivariable analysis was performed to determine factors that affected resource use.

Results

Before hospitalisation, more patients with STEMI than with NSTE-ACS had their first ECG (44.1% vs 36.4%, p<0.0001) and received antithrombotic medication (26.6% vs 15.2%, p<0.0001). Patients with NSTE-ACS with prior CVD were less likely than those without to be catheterised (73.1% vs 82.8%, p<0.0001). More patients with STEMI than with NSTE-ACS had percutaneous coronary intervention (77.1% vs 54.9%, p<0.0001), but fewer underwent coronary artery bypass grafting (1.2% vs 3.7%, p<0.0001). Multivariable analysis showed that resource use, including length of hospital stay and coronary revascularisation, was significantly influenced by multiple factors, including ACS type, site characteristics and region (all p≤0.05).

Conclusions

In this large-scale, real-life study, findings were generally in line with clinical logic, although site characteristics and region still significantly affected resource use. Moreover, and unexpectedly, resource use tended to be slightly higher in patients without a history of CVD.

Trial registration number

NCT01171404 (ClinicalTrials.gov).

The economic impact of acute coronary syndrome on length of stay: an analysis using the Healthcare Cost and Utilization Project (HCUP) databases

OBJECTIVE

To assess the economic impact of initial and repeat hospitalizations associated with acute coronary syndrome (ACS) over 1 year (2009).

DESIGN AND METHODS

National- and state-level data on length of stay (LOS) and related charges for ACS-associated hospital admissions were assessed using two Healthcare Utilization Project databases. The first, the Nationwide Inpatient Sample (NIS), provided clinical and resource use information from ∼8 million hospital stays, representing a 20% stratified sample of ∼40 million annual hospital stays in the US in 2009. The second, the State Inpatient Databases, provided 100% of inpatient data from nine states that included both patient age and linked information on multiple patient admissions within the same calendar year. For patients with repeat admissions, the LOS, primary diagnosis, and total charges between the first and subsequent admissions were evaluated. All patients≥18 years of age with at least one diagnosis of ACS, defined using the International Classification of Diseases, 9th Revision, were included (code 410.xx [except 410.x2], 411.1x and 411.8x). Variables evaluated for each discharge included demographics, cardiovascular events and procedures, LOS, discharge status, and total charges.

RESULTS

The NIS reported 1,437,735 discharges for ACS in 2009. In this dataset, mean LOS for an initial ACS event was 5.56 days. Patients>65 years of age had the highest numbers of admissions; this group also had the most comorbidities. Approximately 40% of ACS patients with data on repeat visits had more than one admission, >70% of these within 2 months of the primary discharge. Mean charges were $71,336 for the first admission and $53,290 for the second admission.

CONCLUSION

Despite a variety of new therapies to prevent ACS, it remains a common condition. Better therapies are called for if the clinical and cost burden of ACS is to be alleviated.

Determinants of health after hospital discharge: rationale and design of the Vanderbilt Inpatient Cohort Study (VICS)

Background

The period following hospital discharge is a vulnerable time for patients when errors and poorly coordinated care are common. Suboptimal care transitions for patients admitted with cardiovascular conditions can contribute to readmission and other adverse health outcomes. Little research has examined the role of health literacy and other social determinants of health in predicting post-discharge outcomes.

Methods

The Vanderbilt Inpatient Cohort Study (VICS), funded by the National Institutes of Health, is a prospective longitudinal study of 3,000 patients hospitalized with acute coronary syndromes or acute decompensated heart failure. Enrollment began in October 2011 and is planned through October 2015. During hospitalization, a set of validated demographic, cognitive, psychological, social, behavioral, and functional measures are administered, and health status and comorbidities are assessed. Patients are interviewed by phone during the first week after discharge to assess the quality of hospital discharge, communication, and initial medication management. At approximately 30 and 90 days post-discharge, interviewers collect additional data on medication adherence, social support, functional status, quality of life, and health care utilization. Mortality will be determined with up to 3.5 years follow-up. Statistical models will examine hypothesized relationships of health literacy and other social determinants on medication management, functional status, quality of life, utilization, and mortality. In this paper, we describe recruitment, eligibility, follow-up, data collection, and analysis plans for VICS, as well as characteristics of the accruing patient cohort.

Discussion

This research will enhance understanding of how health literacy and other patient factors affect the quality of care transitions and outcomes after hospitalization. Findings will help inform the design of interventions to improve care transitions and post-discharge outcomes.

A systematic literature review of cardiovascular event utilities

Cardiovascular disease (CVD) results in half of the non-communicable disease-related deaths worldwide. Rising treatment costs have increased the need for cost-utility models designed to compare the value of new and existing therapies. Cost-utility models require utilities, values representing the strength of preferences for various health states. This systematic literature review aimed to identify and evaluate utilities reported for stroke, myocardial infarction (MI) and angina. In total, 83 unique studies were identified that reported utilities for these events. Approximately two-thirds reported utility values for stroke, and most used the EuroQoL five dimension to derive utilities. Utility values were lower in patients who experienced cardiovascular (CV) events than in patients who did not. The utility estimates for each condition varied greatly, likely due to differences in assessment methodologies and patient populations. This variability must be considered when choosing values for cost-utility models. Comparisons among reported utilities are further complicated by inconsistent CV event definitions.

Epidemiology of acute coronary syndromes in Spain: estimation of the number of cases and trends from 2005 to 2049

Acute coronary syndromes are a leading cause of mortality, morbidity, and health care cost in Spain. The aims of this report are to estimate the number of acute coronary syndromes cases in the Spanish population in 2013 and 2021, and the trend from 2005 to 2049. We estimated the number of acute coronary syndromes cases by sex and Spanish autonomous community using data from the most updated population and hospital registries. We present the estimated number of cases with an exact 95% confidence interval, assuming that the number of cases followed a Poisson distribution. There will be 115,752 acute coronary syndromes cases in Spain in 2013 (95% confidence interval, 114,822-116,687). Within 28 days, 39,086 of these patients will die and 85,326 will be hospitalized. Non-ST segment elevation acute coronary syndromes (56%) and acute myocardial infarction (81%) will be the most common admission and discharge diagnoses, respectively. We estimate approximately 109,772 acute coronary syndromes cases in 2021 (95% confidence interval, 108,868-110,635). The trend of acute coronary syndromes cases from 2005 to 2049 will stabilize in the population aged 25 to 74 years, but increase in those older than 74 years. Due to population aging, the number of acute coronary syndrome cases will increase overall until 2049, it may stabilize in the population aged <75 years. The acute coronary syndromes case-fatality has decreased in hospitalized patients but the proportion of sudden deaths remains unchanged.

The cost-effectiveness of a new percutaneous ventricular assist device for high-risk PCI patients: mid-stage evaluation from the European perspective

OBJECTIVE

A new and smaller percutaneous ventricular assist device (pVAD, Impella, Abiomed, Danvers, MA) has been developed to provide circulatory support in hemodynamically unstable patients and to prevent hemodynamic collapse during high-risk percutaneous coronary interventions (PCI). The objective of the study was to assess the cost-effectiveness of this specific device compared to the intra-aortic balloon pump (IABP) from the European perspective. Additional analysis on extracorporeal membrane oxygenation was conducted for observational purposes only, given its use in some European countries.

METHODS

A combination of a decision tree and Markov model was developed to assess the cost-effectiveness of the small, pVAD. The short-term (30-day) effectiveness and safety (early survival, risk of bleeding, and stroke) were modeled, as well as long-term risk of major adverse cardiovascular events (recurrent myocardial infarction, stroke, and heart failure). The short-term effectiveness and safety data for the device were obtained from two registries (the Europella and USpella), both of which are large multi-center studies in high-risk patient groups. Probabilities of long-term major adverse cardiovascular events were obtained from various published clinical studies. The economic analysis was conducted from a German statutory health insurance perspective and only direct medical costs were included. Cost-effectiveness was estimated over a 10-year time horizon.

RESULTS

Compared with IABP, the pVAD generated an incremental quality-adjusted life-year (QALY) of 0.22 (with Euro-registry data) and 0.27 (with US-registry data). The incremental cost-effectiveness ratio (ICER) of the device varied between €38,069 (with Euro-registry data) and €31,727 (with US-registry data) per QALY compared with IABP.

KEY LIMITATIONS

Unadjusted, indirect comparisons of short-term effectiveness and safety between the interventions were used in the model. Cost and utility data were retrieved from various sources. Therefore, differences in patient populations may bias the estimated cost-effectiveness.

CONCLUSIONS

Compared with IABP, the pVAD is a cost-effective intervention for high-risk PCI patients, with ICERs well-below the conventional cost-effectiveness threshold.