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Autore C, Omran Y, Nirthanakumaran DR, Negishi K, Kozor R, Pathan F. Health Economic Analysis of CMR: A Systematic Review. Heart Lung Circ 2023; 32:914-925. [PMID: 37479645 DOI: 10.1016/j.hlc.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 05/01/2023] [Accepted: 05/15/2023] [Indexed: 07/23/2023]
Abstract
INTRODUCTION Uptake of cardiac magnetic resonance (CMR) in Australia has been limited by issues of cost and access. There is a need to inform future application of CMR by evaluating pertinent health economic literature. We sought to perform a systematic review on the health economic data as it pertains to CMR. METHODS Eight databases (biomedical/health economic) were searched for relevant articles highlighting economic evaluations of CMR. Following screening, studies that reported health economic outcomes (e.g., dollars saved, quality adjusted life years [QALY] and cost effectiveness ratios) were included. Data on cost effectiveness, clinical/disease characteristics, type of modelling were extracted and summarised. RESULTS Thirty-eight (38) articles informed the systematic review. Health economic models used to determine cost effectiveness included both trial-based studies (n=14) and Markov modelling (n=24). Comparative strategies ranged from nuclear imaging, stress echocardiography and invasive angiography. The disease states examined included coronary artery disease (23/38), acute coronary syndrome (3/38), heart failure (5/38) and miscellaneous (7/38). The majority of studies (n=29/38) demonstrated CMR as a strategy which is either economically dominant, cost-effective or cost-saving. CONCLUSION This systematic review demonstrates that CMR is cost-effective depending on diagnostic strategy, population and disease state. The lack of standardised protocols for application of CMR, economic models used and outcomes reported limits the ability to meta-analyse the available health economic data.
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Affiliation(s)
- Chloe Autore
- Charles Perkins Centre, Sydney Medical School Nepean, The University of Sydney, Sydney, NSW, Australia
| | - Yaseen Omran
- Department of Cardiology Nepean Hospital, Sydney, NSW, Australia
| | - Deva Rajan Nirthanakumaran
- Charles Perkins Centre, Sydney Medical School Nepean, The University of Sydney, Sydney, NSW, Australia; Department of Cardiology Nepean Hospital, Sydney, NSW, Australia
| | - Kazuaki Negishi
- Charles Perkins Centre, Sydney Medical School Nepean, The University of Sydney, Sydney, NSW, Australia; Department of Cardiology Nepean Hospital, Sydney, NSW, Australia
| | - Rebecca Kozor
- Department of Cardiology, Royal North Shore Hospital, Sydney, NSW, Australia; The Kolling Institute, Royal North Shore Hospital, Northern Clinical School, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Faraz Pathan
- Charles Perkins Centre, Sydney Medical School Nepean, The University of Sydney, Sydney, NSW, Australia; Department of Cardiology Nepean Hospital, Sydney, NSW, Australia.
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2
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Wiethoff I, Goversen B, Michels M, van der Velden J, Hiligsmann M, Kugener T, Evers SMAA. A systematic literature review of economic evaluations and cost-of-illness studies of inherited cardiomyopathies. Neth Heart J 2023; 31:226-237. [PMID: 37171710 DOI: 10.1007/s12471-023-01776-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2023] [Indexed: 05/13/2023] Open
Abstract
Hypertrophic cardiomyopathy (HCM) and dilated cardiomyopathy (DCM) are commonly inherited heart conditions associated with a high risk of heart failure and sudden cardiac death. To understand the economic and societal disease burden, this study systematically identified and reviewed cost-of-illness (COI) studies and economic evaluations (EEs) of various interventions for HCM and DCM. A literature search was performed in MEDLINE, EMBASE, NHS EED, EconLit and Web of Science to identify COI studies and EEs published between 1 January 2010 and 28 April 2021. The selection of studies and their critical appraisal were performed jointly by two independent researchers. For the quality assessment, the 'Consensus on Health Economic Criteria' list was used. Two COI studies and 11 EEs were eligible for inclusion. Cost-effectiveness varied among interventions and depended on the targeted patient population. Both COI studies identified only hospitalisation costs in HCM. The mean study quality was high in EEs but low in COI studies. Most studies excluded costs for patients, caregivers and productivity losses. Overall, knowledge of the societal and economic burden of inherited cardiomyopathies is limited. Future research needs to include quality-adjusted life years and a broader range of costs to provide an information base for optimising care for affected patients.
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Affiliation(s)
- Isabell Wiethoff
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands.
| | - Birgit Goversen
- Department of Physiology, Amsterdam UMC, Vrije Universiteit, Amsterdam Cardiovascular Sciences Institute, Amsterdam, The Netherlands
| | - Michelle Michels
- Department of Cardiology, Thoraxcenter, Erasmus MC Rotterdam, Rotterdam, The Netherlands
| | - Jolanda van der Velden
- Department of Physiology, Amsterdam UMC, Vrije Universiteit, Amsterdam Cardiovascular Sciences Institute, Amsterdam, The Netherlands
| | - Mickaël Hiligsmann
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Tom Kugener
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Silvia M A A Evers
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
- Centre for Economic Evaluation and Machine Learning, Trimbos Institute, Netherlands Institute of Mental Health and Addiction, Utrecht, The Netherlands
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3
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Beyond the AJR: Research Showing Successful Implementation of Rapid Cardiac MRI for Cardiomyopathy Evaluation in Low- and Middle-Income Countries. AJR Am J Roentgenol 2022; 219:1004. [PMID: 35583423 DOI: 10.2214/ajr.22.27916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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4
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Charlton V. Justice, Transparency and the Guiding Principles of the UK's National Institute for Health and Care Excellence. HEALTH CARE ANALYSIS 2022; 30:115-145. [PMID: 34750743 PMCID: PMC8575159 DOI: 10.1007/s10728-021-00444-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2021] [Indexed: 11/29/2022]
Abstract
The National Institute for Health and Care Excellence (NICE) is the UK's primary healthcare priority-setting body, responsible for advising the National Health Service in England on which technologies to fund and which to reject. Until recently, the normative approach underlying this advice was described in a 2008 document entitled 'Social value judgements: Principles for the development of NICE guidance' (SVJ). In January 2020, however, NICE replaced SVJ with a new articulation of its guiding principles. Given the significant evolution of NICE's methods between 2008 and 2020, this study examines whether this new document ('Principles') offers a transparent account of NICE's current normative approach. It finds that it does not, deriving much of its content directly from SVJ and failing to fully acknowledge or explain how and why NICE's approach has since changed. In particular, Principles is found to offer a largely procedural account of NICE decision-making, despite evidence of the increasing reliance of NICE's methods on substantive decision-rules and 'modifiers' that cannot be justified in purely procedural terms. Thus, while Principles tells NICE's stakeholders much about how the organisation goes about the process of decision-making, it tells them little about the substantive grounds on which its decisions are now based. It is therefore argued that Principles does not offer a transparent account of NICE's normative approach (either alone, or alongside other documents) and that, given NICE's reliance on transparency as a requirement of procedural justice, NICE does not in this respect satisfy its own specification of a just decision-maker.
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Affiliation(s)
- Victoria Charlton
- Department of Global Health and Social Medicine, King's College London, 40 Aldwych, London, WC2B 4BG, United Kingdom.
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Weiting H, Karthik G, Chua T, Graves N. Is a novel diagnostic pathway for cardiology outpatient clinics in Singapore lower cost than existing practice: a cost modelling study. BMJ Open 2022; 12:e050553. [PMID: 35105569 PMCID: PMC8808421 DOI: 10.1136/bmjopen-2021-050553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 01/13/2022] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To evaluate the potential for change to costs from a decision to adopt a novel diagnostic pathway for referrals to cardiology outpatients with symptoms of chest pain. DESIGN Costs modelling study using existing observational data, with a cost year of 2018. SETTING Specialist Heart Centre in Singapore. PARTICIPANTS All new referrals (n=10 622) to the outpatient clinics for investigation between January 2017 and December 2017. INTERVENTIONS Two competing testing regimes are compared in a decision tree model. Current practice includes classification of patients by their risk and the use of treadmill tests, calcium scores, functional testing and CT angiogram. New practice offers a fundamental difference in use of diagnostics for patients, with some offered angiogram directly and for low-risk patients a calcium score is used to refine risk stratification. OUTCOME MEASURES The expected cost difference between testing alternatives. RESULTS The expected cost saving from 'New Practice' as compared with 'Current Practice' is $S764 per patient. There is a 50% probability the savings per patient range between $S764 and $S824 and a 90% probability they are between $S616 and $S912. The expected savings to Singapore national health services are $S26.8 million annually, with a range of $S16.2 to $S41.1 million. CONCLUSIONS We find some evidence that using a coronary calcium score, which can be performed with a fraction of the time and cost of a CT coronary angiogram, saves costs to health services.
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Affiliation(s)
- Huang Weiting
- Cardiology, National Heart Centre Singapore, Singapore
| | | | - Terrance Chua
- Cardiology, National Heart Centre Singapore, Singapore
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6
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Pandya A, Yu YJ, Ge Y, Nagel E, Kwong RY, Bakar RA, Grizzard JD, Merkler AE, Ntusi N, Petersen SE, Rashedi N, Schwitter J, Selvanayagam JB, White JA, Carr J, Raman SV, Simonetti OP, Bucciarelli-Ducci C, Sierra-Galan LM, Ferrari VA, Bhatia M, Kelle S. Evidence-based cardiovascular magnetic resonance cost-effectiveness calculator for the detection of significant coronary artery disease. J Cardiovasc Magn Reson 2022; 24:1. [PMID: 34986851 PMCID: PMC8734365 DOI: 10.1186/s12968-021-00833-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 11/30/2021] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Although prior reports have evaluated the clinical and cost impacts of cardiovascular magnetic resonance (CMR) for low-to-intermediate-risk patients with suspected significant coronary artery disease (CAD), the cost-effectiveness of CMR compared to relevant comparators remains poorly understood. We aimed to summarize the cost-effectiveness literature on CMR for CAD and create a cost-effectiveness calculator, useable worldwide, to approximate the cost-per-quality-adjusted-life-year (QALY) of CMR and relevant comparators with context-specific patient-level and system-level inputs. METHODS We searched the Tufts Cost-Effectiveness Analysis Registry and PubMed for cost-per-QALY or cost-per-life-year-saved studies of CMR to detect significant CAD. We also developed a linear regression meta-model (CMR Cost-Effectiveness Calculator) based on a larger CMR cost-effectiveness simulation model that can approximate CMR lifetime discount cost, QALY, and cost effectiveness compared to relevant comparators [such as single-photon emission computed tomography (SPECT), coronary computed tomography angiography (CCTA)] or invasive coronary angiography. RESULTS CMR was cost-effective for evaluation of significant CAD (either health-improving and cost saving or having a cost-per-QALY or cost-per-life-year result lower than the cost-effectiveness threshold) versus its relevant comparator in 10 out of 15 studies, with 3 studies reporting uncertain cost effectiveness, and 2 studies showing CCTA was optimal. Our cost-effectiveness calculator showed that CCTA was not cost-effective in the US compared to CMR when the most recent publications on imaging performance were included in the model. CONCLUSIONS Based on current world-wide evidence in the literature, CMR usually represents a cost-effective option compared to relevant comparators to assess for significant CAD.
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Affiliation(s)
- Ankur Pandya
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, 718 Huntington Ave, 2nd Floor, Boston, MA, 02115, USA.
| | - Yuan-Jui Yu
- National Taiwan University Hospital, Taipei, Taiwan
| | - Yin Ge
- Cardiovascular Division of the Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Eike Nagel
- Institute for Experimental and Translational Cardiovascular Imaging, DZHK (German Centre for Cardiovascular Research) Centre for Cardiovascular Imaging, Partner Site RheinMain, University Hospital Frankfurt/Main, Frankfurt am Main, Germany
| | - Raymond Y Kwong
- Cardiovascular Division of the Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Rafidah Abu Bakar
- Department of Cardiology, National Heart Institute, Kuala Lumpur, Malaysia
| | - John D Grizzard
- Department of Radiology, Virginia Commonwealth University Medical Center, Main Hospital, Richmond, VA, USA
| | - Alexander E Merkler
- Department of Neurology, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, NY, USA
| | - Ntobeko Ntusi
- Department of Medicine, University of Cape Town & Groote Schuur Hospital, Cape Town, South Africa
| | - Steffen E Petersen
- William Harvey Research Institute, NIHR Barts Biomedical Research Centre, Queen Mary University of London, London, UK
| | - Nina Rashedi
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Juerg Schwitter
- Division of Cardiology, Cardiovascular Department, CMR Center University Hospital, Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, UniL, Lausanne, Switzerland
| | - Joseph B Selvanayagam
- Department of Medicine, School of Medicine and Public Health, Flinders University, Adelaide, Australia
- Department of Heart Health, South Australian Health and Medical Research Institute, Adelaide, Australia
| | - James A White
- Division of Cardiology, Department of Cardiac Sciences, Stephenson Cardiac Imaging Centre, University of Calgary, Calgary, Canada
| | - James Carr
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Subha V Raman
- Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Orlando P Simonetti
- Departments of Internal Medicine and Radiology, The Ohio State University, Columbus, OH, USA
| | - Chiara Bucciarelli-Ducci
- Royal Brompton and Harefield Hospitals, Guys' and St Thomas NHS Hospitals and School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
| | - Lilia M Sierra-Galan
- Cardiovascular Division, Department of Cardiology, American British Cowdray Medical Center, Mexico City, Mexico
| | - Victor A Ferrari
- Cardiovascular Division and Penn Cardiovascular Institute, Perelman School of Medicine, University of Pennsylvania Medical Center, Philadelphia, PA, USA
| | - Mona Bhatia
- Department of Imaging, Fortis Escorts Heart Institute, New Delhi, India
| | - Sebastian Kelle
- Department of Internal Medicine and Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum, Berlin, Germany
- Department of Internal Medicine and Cardiology, DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, German Heart Institute Berlin (DHZB), Berlin, Germany
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7
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Cardiac-CT and cardiac-MR cost-effectiveness: a literature review. Radiol Med 2020; 125:1200-1207. [PMID: 32970273 DOI: 10.1007/s11547-020-01290-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 09/08/2020] [Indexed: 01/18/2023]
Abstract
Cardiovascular diseases are still among the first causes of death worldwide with a huge impact on healthcare systems. Within these conditions, the correct diagnosis of coronary artery disease with the most appropriate imaging-based evaluations is of utmost importance. The sustainability of the healthcare systems, considering the high economic burden of modern cardiac imaging equipments, makes cost-effective analysis an important tool, currently used for weighing different costs and health outcomes, when policy makers have to allocate funds and to prioritize interventions, getting the most out of their financial resources. This review aims at evaluating cost-effective analysis in the more recent literature, focused on the role of Calcium Score, coronary computed tomography angiography and cardiac magnetic resonance.
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8
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Nudi F, Iskandrian AE, Schillaci O, Nudi A, DI Belardino N, Frati G, Biondi Zoccai G. Noninvasive cardiovascular imaging for myocardial necrosis, viability, stunning and hibernation: evidence from an umbrella review encompassing 12 systematic reviews, 286 studies, and 201,680 patients. Minerva Cardiol Angiol 2020; 69:191-200. [PMID: 32643896 DOI: 10.23736/s2724-5683.20.05158-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION The concomitant presence of myocardial necrosis with myocardial ischemia, stunning or hibernation may complicates appraisal of left ventricular (LV) function and patient management. Several imaging modalities have been proposed for the accurate assessment of myocardial necrosis, viability, stunning and hibernation, with mixed results. We aimed to review the evidence base on myocardial necrosis, stunning and hibernation by conducting an umbrella review (i.e. overview of systematic reviews). EVIDENCE ACQUISITION We searched PubMed and The Cochrane Library for meta-analyses focusing on the diagnostic, prognostic, or management appraisal of myocardial necrosis, viability, stunning and hibernation. Diagnostic test accuracy, prognostic yield, and clinical outcomes were systematically abstracted from shortlisted reviews. EVIDENCE SYNTHESIS From an initial set of 6069 citations, 12 systematic reviews were finally included, encompassing 286 studies and 201,680 patients. Cardiac magnetic resonance imaging (CMR) had favorable results in 4 reviews that focused on the diagnosis of myocardial stunning or hibernation in patients followed for 6±4 months after coronary revascularization (sensitivity 96% and specificity 91%). Positron emission tomography (PET), single photon emission tomography (SPECT) and CMR in 6 meta-analyses had each a significant and independent prognostic role for the prediction of fatal and non-fatal cardiovascular events in patients with follow-up of 2.8±1.7 years. Finally, 2 reviews with 2.3±1.1 years of follow-up showed moderate quality evidence in favor of coronary revascularization in patients with objective signs of myocardial viability. CONCLUSIONS The appraisal of myocardial necrosis and residual viability remains a cornerstone of the modern management of patients with CAD. Current imaging modalities (echocardiography, PET, SPECT and CMR) are widely used. Further trials using contemporary methods are warranted to further clarify the impact of viability assessment on patient management, and the cumulative risk of morbidity and mortality.
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Affiliation(s)
- Francesco Nudi
- Service of Hybrid Cardio Imaging, Madonna della Fiducia Clinic, Rome, Italy.,Replycare, Rome, Italy
| | - Ami E Iskandrian
- Division of Cardiovascular Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Orazio Schillaci
- Department of Biomedicine and Prevention, Tor Vergata University, Rome, Italy
| | - Alessandro Nudi
- Service of Hybrid Cardio Imaging, Madonna della Fiducia Clinic, Rome, Italy
| | | | - Giacomo Frati
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University, Latina, Rome, Italy.,IRCCS Neuromed, Pozzilli, Isernia, Italy
| | - Giuseppe Biondi Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University, Latina, Rome, Italy - .,Mediterranea Cardiocentro, Naples, Italy
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9
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Kolentinis M, Le M, Nagel E, Puntmann VO. Contemporary Cardiac MRI in Chronic Coronary Artery Disease. Eur Cardiol 2020; 15:e50. [PMID: 32612708 PMCID: PMC7312615 DOI: 10.15420/ecr.2019.17] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 02/17/2020] [Indexed: 12/12/2022] Open
Abstract
Chronic coronary artery disease remains an unconquered clinical problem, affecting an increasing number of people worldwide. Despite the improved understanding of the disease development, the implementation of the many advances in diagnosis and therapy is lacking. Many clinicians continue to rely on patient's symptoms and diagnostic methods, which do not enable optimal clinical decisions. For example, echocardiography and invasive coronary catheterisation remain the mainstay investigations for stable angina patients in many places, despite the evidence on their limitations and availability of better diagnostic options. Cardiac MRI is a powerful diagnostic method, supporting robust measurements of crucial markers of cardiac structure and function, myocardial perfusion and scar, as well as providing detailed insight into myocardial tissue. Accurate and informative diagnostic readouts can help with guiding therapy, monitoring disease progress and tailoring the response to treatment. In this article, the authors outline the evidence supporting the state-of-art applications based on cardiovascular magnetic resonance, allowing the clinician optimal use of this insightful diagnostic method in everyday clinical practice.
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Affiliation(s)
- Michalis Kolentinis
- Institute of Experimental and Translational Cardiovascular Imaging, German Centre for Cardiovascular Research (DZHK) Centre for Cardiovascular Imaging, Partner Site Rhein-Main, University Hospital Frankfurt Frankfurt, Germany
| | - Melanie Le
- Institute of Experimental and Translational Cardiovascular Imaging, German Centre for Cardiovascular Research (DZHK) Centre for Cardiovascular Imaging, Partner Site Rhein-Main, University Hospital Frankfurt Frankfurt, Germany
| | - Eike Nagel
- Institute of Experimental and Translational Cardiovascular Imaging, German Centre for Cardiovascular Research (DZHK) Centre for Cardiovascular Imaging, Partner Site Rhein-Main, University Hospital Frankfurt Frankfurt, Germany
| | - Valentina O Puntmann
- Institute of Experimental and Translational Cardiovascular Imaging, German Centre for Cardiovascular Research (DZHK) Centre for Cardiovascular Imaging, Partner Site Rhein-Main, University Hospital Frankfurt Frankfurt, Germany
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Barreiro-Pérez M, Tundidor-Sanz E, Martín-García A, Díaz-Peláez E, Íscar-Galán A, Merchán-Gómez S, Gallego-Delgado M, Jiménez-Candil J, Cruz-González I, Sánchez PL. Primera resonancia magnética gestionada por cardiología en la red sanitaria pública española: experiencia y dificultades de un modelo innovador. Rev Esp Cardiol 2018. [DOI: 10.1016/j.recesp.2017.11.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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11
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Barreiro-Pérez M, Tundidor-Sanz E, Martín-García A, Díaz-Peláez E, Íscar-Galán A, Merchán-Gómez S, Gallego-Delgado M, Jiménez-Candil J, Cruz-González I, Sánchez PL. First Magnetic Resonance Managed by a Cardiology Department in the Spanish Public Healthcare System. Experience and Difficulties of an Innovative Model. ACTA ACUST UNITED AC 2018; 71:365-372. [PMID: 29598851 DOI: 10.1016/j.rec.2018.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 11/24/2017] [Indexed: 01/03/2023]
Abstract
Magnetic resonance (MR) is considered the gold standard in the assessment of myocardial morphology, function, perfusion, and viability. However, its main limitation is its scarce availability. In 2014, we installed the first MR scanner exclusively managed by a cardiology department within the publicly-funded Spanish healthcare system with the aim of improving patient-care, training and research in the department. In the time interval analyzed, July 2014 to May 2017, 3422 cardiac MR scans were performed (32minutes used per study; 96% with good quality; 75% with contrast media administration). The most prevalent clinical indications were cardiomyopathy (29%) and ischemic heart disease (12%). Twenty-five percent of studies were conducted in the context of research protocols. Follow-up studies predominated among outpatients, while pretherapeutic assessment was more common in hospitalized patients. The presumptive diagnosis was changed by cardiac MR scanning in up to 20% of patients investigated for ischemic heart disease. The installation and operative management of an MR scanner in our cardiology department has allowed us to integrate this technique into daily clinical practice, modify our clinical protocols, optimize access to this technology among cardiac patients, improve training, and conduct clinical research.
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Affiliation(s)
- Manuel Barreiro-Pérez
- Servicio de Cardiología, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Facultad de Medicina, Universidad de Salamanca, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Salamanca, Spain
| | - Elena Tundidor-Sanz
- Servicio de Cardiología, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Facultad de Medicina, Universidad de Salamanca, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Salamanca, Spain
| | - Ana Martín-García
- Servicio de Cardiología, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Facultad de Medicina, Universidad de Salamanca, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Salamanca, Spain
| | - Elena Díaz-Peláez
- Servicio de Cardiología, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Facultad de Medicina, Universidad de Salamanca, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Salamanca, Spain
| | - Alberto Íscar-Galán
- Servicio de Cardiología, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Facultad de Medicina, Universidad de Salamanca, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Salamanca, Spain
| | - Soraya Merchán-Gómez
- Servicio de Cardiología, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Facultad de Medicina, Universidad de Salamanca, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Salamanca, Spain
| | - María Gallego-Delgado
- Servicio de Cardiología, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Facultad de Medicina, Universidad de Salamanca, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Salamanca, Spain
| | - Javier Jiménez-Candil
- Servicio de Cardiología, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Facultad de Medicina, Universidad de Salamanca, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Salamanca, Spain
| | - Ignacio Cruz-González
- Servicio de Cardiología, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Facultad de Medicina, Universidad de Salamanca, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Salamanca, Spain
| | - Pedro L Sánchez
- Servicio de Cardiología, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Facultad de Medicina, Universidad de Salamanca, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Salamanca, Spain.
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12
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Kumarasamy N, Tishbi N, Mukundan S, Shiloh A, Levsky JM, Haramati LB. Cardiothoracic MRI in the ICU: A 10-Year Experience. Acad Radiol 2018; 25:359-364. [PMID: 29426683 DOI: 10.1016/j.acra.2017.09.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 09/26/2017] [Accepted: 09/27/2017] [Indexed: 11/29/2022]
Abstract
RATIONALE AND OBJECTIVE The objective of this study was to identify the feasibility and pitfalls of cardiothoracic magnetic resonance imaging (MRI) in intensive care unit (ICU) patients. MATERIALS AND METHODS This retrospective study identified adult ICU patients scheduled for cardiothoracic MRIs during a 10-year study period. ICU patients scheduled for brain MRIs served as a comparison group. A chart review was performed to identify factors impacting a patient's ability to undergo an MRI. Differences between completed and canceled examinations for both cardiothoracic and brain MRIs were evaluated. For the cardiothoracic group, clinical indications and the diagnostic value of the study performed were also identified. RESULTS A total of 143 cardiothoracic MRIs and 1011 brain MRIs were requested. Cardiothoracic MRI patients were less frequently completed (52% vs 62%), more frequently men (64% vs 43%), younger (55 vs 63 years), less likely mechanically ventilated (8% vs 29%), more likely to require intravenous contrast (83% vs 23%), and had longer examination times compared to brain MRI patients (64 vs 21 minutes). Successful completion of cardiothoracic MRI was associated with lower serum creatinine, higher glomerular filtration rate, and the absence of mechanical ventilation; significant differences were not seen with regard to gender and use of vasoactive agents. Cardiothoracic MRI results were diagnostic in 69% of examinations, most frequently when performed for myocardial disease (84%) and aortic disease (33%), and less frequently for viability (33%). CONCLUSIONS In an ICU population, successful completion of cardiothoracic MRI is challenging but feasible in patients with intact renal function and the absence of mechanical ventilation. Examinations were most frequently diagnostic for myocardial and aortic disease indications.
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Affiliation(s)
- Narmadan Kumarasamy
- Montefiore Medical Center, Albert Einstein College of Medicine, 111 E 210th St, Bronx, NY 10467.
| | - Nima Tishbi
- Montefiore Medical Center, Albert Einstein College of Medicine, 111 E 210th St, Bronx, NY 10467
| | - Shey Mukundan
- Montefiore Medical Center, Albert Einstein College of Medicine, 111 E 210th St, Bronx, NY 10467
| | - Ariel Shiloh
- Montefiore Medical Center, Albert Einstein College of Medicine, 111 E 210th St, Bronx, NY 10467
| | - Jeffrey M Levsky
- Montefiore Medical Center, Albert Einstein College of Medicine, 111 E 210th St, Bronx, NY 10467
| | - Linda B Haramati
- Montefiore Medical Center, Albert Einstein College of Medicine, 111 E 210th St, Bronx, NY 10467
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Characterization of viability, scarring and hibernation of the myocardium supplied by epicardial coronary arteries with low flow grades. Nucl Med Commun 2017; 38:657-665. [DOI: 10.1097/mnm.0000000000000683] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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AlMohammad A, Norton MY, Welch AE, Sharp PF, Walton S. Gated metabolic myocardial imaging, a surrogate for dual perfusion-metabolism imaging by positron emission tomography. Open Heart 2017; 4:e000581. [PMID: 28878945 PMCID: PMC5574422 DOI: 10.1136/openhrt-2016-000581] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Revised: 04/17/2017] [Accepted: 06/13/2017] [Indexed: 11/15/2022] Open
Abstract
Objective Perfusion-metabolism mismatch pattern on positron emission tomography (PET) predicts hibernating myocardium. We assess the ECG-gated metabolic PET as a surrogate for the perfusion-metabolism mismatch pattern on PET imaging. Methods 13N-Ammonia (NH3) and 18F-fluorodeoxyglucose (FDG) are respectively perfusion and metabolism PET tracers. We used ECG gating to acquire FDG-PET to collect wall thickening (mechanical) data. These allow detection of metabolic activity in regions with reduced contraction (metabolism-mechanical mismatch pattern). We had two data sets on each patient: perfusion-metabolism and metabolism-mechanical data sets. We tested the hypothesis that metabolism-mechanical pattern on PET could predict perfusion-metabolism mismatch pattern. Results We studied 55 patients (48 males), mean age 62 years. All were in sinus rhythm, and had impaired left ventricular contraction. Perfusion-metabolism mismatch pattern was found in 26 patients. Metabolism-mechanical mismatch pattern was found in 25 patients. The results were concordant in 52 patients (95%). As a surrogate for perfusion-metabolism mismatch pattern, demonstration of metabolism-mechanical mismatch pattern is highly sensitive (92%) and specific (97%). In this cohort, the positive and negative predictive accuracy of the new method are 96% and 93%, respectively. Conclusion Metabolism-mechanical mismatch pattern could predict perfusion-metabolism mismatch pattern in patients with myocardial viability criteria on PET. Prospective validation against the gold standard of improved myocardial contraction after revascularisation is needed.
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Affiliation(s)
- Abdallah AlMohammad
- South Yorkshire Cardiothoracic Centre, Chesterman Wing, Northern General Hospital, Sheffield, UK
| | - Murdoch Y Norton
- The Department of Medical Physics and Bio-medical Engineering, Aberdeen University, Aberdeen, UK
| | - Andrew E Welch
- The Department of Medical Physics and Bio-medical Engineering, Aberdeen University, Aberdeen, UK
| | - Peter F Sharp
- The Department of Medical Physics and Bio-medical Engineering, Aberdeen University, Aberdeen, UK
| | - Stephen Walton
- The Department of Cardiology, Aberdeen Royal Infirmary, Grampian University Hospitals NHS Trust, Aberdeen, UK
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15
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Shinkins B, Yang Y, Abel L, Fanshawe TR. Evidence synthesis to inform model-based cost-effectiveness evaluations of diagnostic tests: a methodological review of health technology assessments. BMC Med Res Methodol 2017; 17:56. [PMID: 28410588 PMCID: PMC5391551 DOI: 10.1186/s12874-017-0331-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 03/27/2017] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Evaluations of diagnostic tests are challenging because of the indirect nature of their impact on patient outcomes. Model-based health economic evaluations of tests allow different types of evidence from various sources to be incorporated and enable cost-effectiveness estimates to be made beyond the duration of available study data. To parameterize a health-economic model fully, all the ways a test impacts on patient health must be quantified, including but not limited to diagnostic test accuracy. METHODS We assessed all UK NIHR HTA reports published May 2009-July 2015. Reports were included if they evaluated a diagnostic test, included a model-based health economic evaluation and included a systematic review and meta-analysis of test accuracy. From each eligible report we extracted information on the following topics: 1) what evidence aside from test accuracy was searched for and synthesised, 2) which methods were used to synthesise test accuracy evidence and how did the results inform the economic model, 3) how/whether threshold effects were explored, 4) how the potential dependency between multiple tests in a pathway was accounted for, and 5) for evaluations of tests targeted at the primary care setting, how evidence from differing healthcare settings was incorporated. RESULTS The bivariate or HSROC model was implemented in 20/22 reports that met all inclusion criteria. Test accuracy data for health economic modelling was obtained from meta-analyses completely in four reports, partially in fourteen reports and not at all in four reports. Only 2/7 reports that used a quantitative test gave clear threshold recommendations. All 22 reports explored the effect of uncertainty in accuracy parameters but most of those that used multiple tests did not allow for dependence between test results. 7/22 tests were potentially suitable for primary care but the majority found limited evidence on test accuracy in primary care settings. CONCLUSIONS The uptake of appropriate meta-analysis methods for synthesising evidence on diagnostic test accuracy in UK NIHR HTAs has improved in recent years. Future research should focus on other evidence requirements for cost-effectiveness assessment, threshold effects for quantitative tests and the impact of multiple diagnostic tests.
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Affiliation(s)
- Bethany Shinkins
- Test Evaluation Group, Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Worsely Building, Clarendon Way, Leeds, LS2 9LJ, UK.
| | - Yaling Yang
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Lucy Abel
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Thomas R Fanshawe
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
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Spartera M, Damascelli A, Mozes F, De Cobelli F, La Canna G. Three-dimensional speckle tracking longitudinal strain is related to myocardial fibrosis determined by late-gadolinium enhancement. Int J Cardiovasc Imaging 2017; 33:1351-1360. [DOI: 10.1007/s10554-017-1115-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 03/09/2017] [Indexed: 01/09/2023]
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Abstract
PURPOSE OF REVIEW Spurred by numerous recent technological advances, cardiac MRI (CMR) is now the gold standard for anatomic evaluation, quantitative assessment of chamber size and function, flow quantification, and tissue characterization. This review focuses on recent advances in pediatric and congenital CMR, highlighting recent safety data, and discussing future directions. RECENT FINDINGS CMR has become an important component of risk stratification and procedural planning in numerous congenital and pediatric heart diseases. Innovative approaches to image acquisition and reconstruction are leading the way toward fast, high-resolution, three- and four-dimensional datasets for delineation of cardiac anatomy, function, and flow. In addition, techniques for assessing the composition of the myocardium may help elucidate the pathophysiology of late complications, identify patients at risk for heart failure, and assist in the evaluation of therapeutic strategies. SUMMARY CMR provides invaluable morphologic, hemodynamic, and functional data that help guide diagnosis, assessment, and management of pediatric and adult congenital heart disease. As imaging techniques advance and data accumulate on the relative and additive value of CMR in patient care, its role in a multimodality approach to the care of this population of patients is becoming clear and is likely to continue to evolve.
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Campbell B, Tabiri-Essuman J, Gallo H, Verdiel V, Mandava L, Azhar MA, Powell J. Public consultation changes guidance on the use of health-care interventions. An observational study. Health Expect 2016; 20:361-368. [PMID: 27312870 PMCID: PMC5354025 DOI: 10.1111/hex.12476] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2016] [Indexed: 11/29/2022] Open
Abstract
Objectives To investigate the responses to public consultation on draft guidance on interventional procedures (IP) for the UK National Health Services, and the changes made as a result of consultation. Design Retrospective review of responses received during public consultation for 183 pieces of draft guidance, and subsequent changes made. Setting The National Institute for Health and Care Excellence in the UK. Guidance produced December 2009–December 2014. Main outcome measures Numbers (%) of public consultations receiving responses, and resulting changes made to draft guidance. Results Responses were received during 159 (86.9%) periods of public consultation, from a total of 853 people or organizations (median number per consultation 3; range 0–82; interquartile range 1–5). Changes were made to draft guidance following 136 (74.3%) consultations. These changes were to the category (2.7%) or wording (8.7%) of the main recommendation; to other recommendations (about consent, patient selection, training and future research) (31.1%); and to other sections of guidance (description of the procedure and of the evidence on its efficacy and safety) (70.5%). Additional published evidence was proffered for 22.4%. Health‐care professionals or their specialist societies were the most frequent responders to consultation (68.8%), patients or patient organizations accounted for 22.4% and medical device companies accounted for 8.8%. Conclusions This study shows substantial engagement with public consultation and frequent changes made to draft guidance as a result. These findings are likely to be relevant to other areas of health‐care and national policymaking that seek to be responsive to their stakeholders.
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Affiliation(s)
- Bruce Campbell
- Interventional Procedures Advisory Committee, National Institute for Health and Care Excellence, London, UK.,Royal Devon and Exeter Hospital, Exeter, UK
| | - Jeffrey Tabiri-Essuman
- Centre for Health Technology Evaluation, National Institute for Health and Care Excellence, London, UK
| | - Helen Gallo
- Centre for Health Technology Evaluation, National Institute for Health and Care Excellence, London, UK
| | - Vassilia Verdiel
- Centre for Health Technology Evaluation, National Institute for Health and Care Excellence, London, UK
| | - Lakshmi Mandava
- Centre for Health Technology Evaluation, National Institute for Health and Care Excellence, London, UK
| | | | - John Powell
- Centre for Health Technology Evaluation, National Institute for Health and Care Excellence, London, UK.,Health Experiences Research Group, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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López-Sendón J, González-Juanatey JR, Pinto F, Cuenca Castillo J, Badimón L, Dalmau R, González Torrecilla E, López-Mínguez JR, Maceira AM, Pascual-Figal D, Pomar Moya-Prats JL, Sionis A, Zamorano JL. Indicadores de calidad en cardiología. Principales indicadores para medir la calidad de los resultados (indicadores de resultados) y parámetros de calidad relacionados con mejores resultados en la práctica clínica (indicadores de práctica asistencial). INCARDIO (Indicadores de Calidad en Unidades Asistenciales del Área del Corazón): Declaración de posicionamiento de consenso de SEC/SECTCV. CIRUGIA CARDIOVASCULAR 2015. [DOI: 10.1016/j.circv.2015.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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20
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López-Sendón J, González-Juanatey JR, Pinto F, Cuenca Castillo J, Badimón L, Dalmau R, González Torrecilla E, López-Mínguez JR, Maceira AM, Pascual-Figal D, Pomar Moya-Prats JL, Sionis A, Zamorano JL. Indicadores de calidad en cardiología. Principales indicadores para medir la calidad de los resultados (indicadores de resultados) y parámetros de calidad relacionados con mejores resultados en la práctica clínica (indicadores de práctica asistencial). INCARDIO (Indicadores de Calidad en Unidades Asistenciales del Área del Corazón): Declaración de posicionamiento de consenso de SEC/SECTCV. Rev Esp Cardiol 2015. [DOI: 10.1016/j.recesp.2015.07.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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21
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López-Sendón J, González-Juanatey JR, Pinto F, Cuenca Castillo J, Badimón L, Dalmau R, González Torrecilla E, López-Mínguez JR, Maceira AM, Pascual-Figal D, Pomar Moya-Prats JL, Sionis A, Zamorano JL. Quality Markers in Cardiology. Main Markers to Measure Quality of Results (Outcomes) and Quality Measures Related to Better Results in Clinical Practice (Performance Metrics). INCARDIO (Indicadores de Calidad en Unidades Asistenciales del Área del Corazón): A SEC/SECTCV Consensus Position Paper. ACTA ACUST UNITED AC 2015; 68:976-995.e10. [PMID: 26315766 DOI: 10.1016/j.rec.2015.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 07/21/2015] [Indexed: 02/06/2023]
Abstract
Cardiology practice requires complex organization that impacts overall outcomes and may differ substantially among hospitals and communities. The aim of this consensus document is to define quality markers in cardiology, including markers to measure the quality of results (outcomes metrics) and quality measures related to better results in clinical practice (performance metrics). The document is mainly intended for the Spanish health care system and may serve as a basis for similar documents in other countries.
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Affiliation(s)
- José López-Sendón
- Servicio de Cardiología, Hospital Universitario La Paz, IdiPaz, Madrid, Spain.
| | - José Ramón González-Juanatey
- Sociedad Española de Cardiología, Madrid, Spain; Servicio de Cardiología, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | - Fausto Pinto
- European Society of Cardiology; Department of Cardiology, University Hospital Santa Maria, Lisbon, Portugal
| | - José Cuenca Castillo
- Sociedad Española de Cirugía Torácica-Cardiovascular; Servicio de Cirugía Cardiaca, Complexo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - Lina Badimón
- Centro de Investigación Cardiovascular (CSIC-ICCC), Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Regina Dalmau
- Unidad de Rehabilitación Cardiaca, Servicio de Cardiología, Hospital Universitario La Paz, IdiPaz, Madrid, Spain
| | - Esteban González Torrecilla
- Unidad de Electrofisiología y Arritmias, Servicio de Cardiología, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - José Ramón López-Mínguez
- Unidad de Cardiología intervencionista, Servicio de Cardiología, Hospital Infanta Crsitina, Badajoz, Spain
| | - Alicia M Maceira
- Unidad de Imagen Cardiaca, Servicio de Cardiología, ERESA Medical Center, Valencia, Spain
| | - Domingo Pascual-Figal
- Servicio de Cardiología, Hospital Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
| | | | - Alessandro Sionis
- Unidad de Cuidados Intensivos Cardiológicos, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - José Luis Zamorano
- Servicio de Cardiología, Hospital Universitario Ramón y Cajal, Madrid, Spain
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