1
|
Jülicher P, Greenslade JH, Parsonage WA, Cullen L. The organisational value of diagnostic strategies using high-sensitivity troponin for patients with possible acute coronary syndromes: a trial-based cost-effectiveness analysis. BMJ Open 2017; 7:e013653. [PMID: 28601817 PMCID: PMC5577894 DOI: 10.1136/bmjopen-2016-013653] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To evaluate hospital-specific health economic implications of different protocols using high-sensitivity troponin I for the assessment of patients with chest pain. DESIGN A cost prediction model and an economic microsimulation were developed using a cohort from a single centre recruited as part of the (ADAPT) trial, a prospective observational trial conducted from 2008 to 2011. The model was populated with 40 000 bootstrapped samples in five high-sensitivity troponin I-enabled algorithms versus standard care. SETTING Adult emergency department (ED) of a tertiary referral hospital. PARTICIPANTS Data were available for 938 patients who presented to the ED with at least 5 min of symptoms suggestive of acute coronary syndrome. The analyses included 719 patients with complete data. MAIN OUTCOMES/MEASURES This study examined direct hospital costs, number of false-negative and false-positive cases in the assessment of acute coronary syndrome. RESULTS High-sensitivity troponin I-supported algorithms increased diagnostic accuracy from 90.0% to 94.0% with an average cost reduction per patient compared with standard care of $490. The inclusion of additional criteria for accelerated rule-out (limit of detection and the modified 2-hour ADAPT trial rules) avoided 7.5% of short-stay unit admissions or 25% of admissions to a cardiac ward. Protocols using high-sensitivity troponin I alone or high-sensitivity troponin I within accelerated diagnostic algorithms reduced length of stay by 6.2 and 13.6 hours, respectively. Overnight stays decreased up to 43%. Results were seen for patients with non-acute coronary syndrome; no difference was found for patients with acute coronary syndrome. CONCLUSIONS High-sensitivity troponin I algorithms are likely to be cost-effective on a hospital level compared with sensitive troponin protocols. The positive effect is conferred by patients not diagnosed with acute coronary syndrome. Implementation could improve referral accuracy or facilitate safe discharge. It would decrease costs and provide significant hospital benefits. TRIAL REGISTRATION The original ADAPT trial was registered with the Australia-New Zealand Clinical trials Registry, ACTRN12611001069943.
Collapse
Affiliation(s)
- Paul Jülicher
- Health Economics and Outcomes Research, Medical Affairs, Abbott Laboratories, Wiesbaden, Germany
| | - Jaimi H Greenslade
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Herston, Australia
| | - William A Parsonage
- Department of Cardiology, Royal Brisbane and Women’s Hospital, Herston, Australia
| | - Louise Cullen
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Herston, Australia
| |
Collapse
|
2
|
Whyte S, Dixon S, Faria R, Walker S, Palmer S, Sculpher M, Radford S. Estimating the Cost-Effectiveness of Implementation: Is Sufficient Evidence Available? Value Health 2016; 19:138-44. [PMID: 27021746 PMCID: PMC4823278 DOI: 10.1016/j.jval.2015.12.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 12/07/2015] [Accepted: 12/11/2015] [Indexed: 05/14/2023]
Abstract
BACKGROUND Timely implementation of recommended interventions can provide health benefits to patients and cost savings to the health service provider. Effective approaches to increase the implementation of guidance are needed. Since investment in activities that improve implementation competes for funding against other health generating interventions, it should be assessed in term of its costs and benefits. OBJECTIVE In 2010, the National Institute for Health and Care Excellence released a clinical guideline recommending natriuretic peptide (NP) testing in patients with suspected heart failure. However, its implementation in practice was variable across the National Health Service in England. This study demonstrates the use of multi-period analysis together with diffusion curves to estimate the value of investing in implementation activities to increase uptake of NP testing. METHODS Diffusion curves were estimated based on historic data to produce predictions of future utilization. The value of an implementation activity (given its expected costs and effectiveness) was estimated. Both a static population and a multi-period analysis were undertaken. RESULTS The value of implementation interventions encouraging the utilization of NP testing is shown to decrease over time as natural diffusion occurs. Sensitivity analyses indicated that the value of the implementation activity depends on its efficacy and on the population size. CONCLUSIONS Value of implementation can help inform policy decisions of how to invest in implementation activities even in situations in which data are sparse. Multi-period analysis is essential to accurately quantify the time profile of the value of implementation given the natural diffusion of the intervention and the incidence of the disease.
Collapse
Affiliation(s)
- Sophie Whyte
- The School of Health and Related Research, University of Sheffield, Sheffield, UK.
| | - Simon Dixon
- The School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Rita Faria
- Centre for Health Economics, University of York, York, UK
| | - Simon Walker
- Centre for Health Economics, University of York, York, UK
| | - Stephen Palmer
- Centre for Health Economics, University of York, York, UK
| | - Mark Sculpher
- Centre for Health Economics, University of York, York, UK
| | | |
Collapse
|
3
|
Affiliation(s)
- Zirui Song
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Jacob Wallace
- Department of Health Care Policy, Harvard Medical School, Boston, MA
| | - Hannah T. Neprash
- Department of Health Care Policy, Harvard Medical School, Boston, MA
| | | | | | | |
Collapse
|
4
|
Zoccali C, Abd ElHafeez S, Dounousi E, Anastasi R, Tripepi G, Mallamaci F. Life-Time Risk, Screening and The Cost of Cardiovascular Comorbidities in CKD Patients. Pril (Makedon Akad Nauk Umet Odd Med Nauki) 2015; 36:85-90. [PMID: 27442374 DOI: 10.1515/prilozi-2015-0056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
CKD is a problem of epidemic dimension. The risk of death and cardiovascular complications in this condition is of the same order of that by myocardial infarction, which qualifies CKD as "risk equivalent". Calculations made on the basis of the epidemiological data of the MONICA-Augsburg study and analyses of the costs of myocardial infarction in a large health insurance company in Germany show that the economic burden of cardiovascular comorbidities with CKD in this country is substantial. These estimates, which may be valid also for other large member states of the European Community, represent a call for studies looking at the cost-effectiveness of preventive interventions aimed at reducing the risk for CKD and at lowering the concerning incidence rate of death and disability due to CKD-triggered cardiovascular complications in CKD patients.
Collapse
|
5
|
Abstract
Noncommunicable diseases (NCDs), including cardiovascular diseases and diabetes, have emerged as an underappreciated health threat with enormous economic and public health implications for populations in low-resource settings. In order to address these diseases, devices that are to be used in low-resource settings have to conform to requirements that are generally more challenging than those developed for traditional markets. Characteristics and issues that must be considered when working in low- and middle-income countries (LMICs) include challenging environmental conditions, a complex supply chain, sometimes inadequate operator training, and cost. Somewhat counterintuitively, devices for low-resource setting (LRS) markets need to be of at least as high quality and reliability as those for developed countries to be setting-appropriate and achieve impact. Finally, the devices need to be designed and tested for the populations in which they are to be used in order to achieve the performance that is needed. In this review, we focus on technologies for primary and secondary health-care settings and group them according to the continuum of care from prevention to treatment.
Collapse
|
6
|
Collado M. How prevalent and costly are Choosing Wisely low-value services? Evidence from Medicare beneficiaries. Find Brief 2014; 42:1-2. [PMID: 25330546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
(1) Through the Choosing Wisely initiative, medical specialty societies identified non-indicated cardiac testing in low-risk patients and short-interval dual-energy X-ray absorptiometry (DXA) or bone density testing as low-value care. (2) Nationally, 13 percent of low-risk Medicare beneficiaries received non-indicated cardiac tests, and 10 percent of DXAs reimbursed by Medicare were administered at inappropriately short intervals. There is significant geographic variation in the provision of these services. (2) Carefully designed policy and payment changes will likely prove most effective in reducing low-value care.
Collapse
Affiliation(s)
- Megan Collado
- AcademyHealth with the Changes in Health Care Financing and Organization (HCFO) initiative
| |
Collapse
|
7
|
Cherubini A, Mureddu GF, Temporelli PL, Frisinghelli A, Clavario P, Cesana F, Fattirolli F. [Appropriateness of diagnostic tests in cardiovascular prevention: what can we skip?]. G Ital Cardiol (Rome) 2014; 15:253-63. [PMID: 24873815 DOI: 10.1714/1497.16507] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
In recent years, a huge increase in the use of cardiac procedures, both invasive and non-invasive, was observed. Diagnostic tests, mainly non-invasive tests, are often prescribed inappropriately, in most cases replacing the clinical evaluation. The rate of inappropriate tests in cardiology is largely variable, depending on regional issues and different medical approach. When the test entails radiation exposure, the biological risk for both the patient and the environment must be taken into account. For this reason, the test that results in less biological risk should always be preferred as a first step.Moreover, it has not been clearly demonstrated that some diagnostic tests help to improve the outcome, that is to prevent cardiovascular events. As many as one sixth of the patients who undergo stress imaging are not taking proper medication, and very frequently no change in therapy is made after the test, regardless of the outcome. Since the appropriateness of diagnostic evaluation requests is mandatory, we focused on the diagnostic tests usually performed in primary and secondary prevention that carry no contribution to the clinical management of patients. This review addresses the need to optimize available resources, reduce costs and avoid unnecessary cardiovascular assessments, thereby enhancing the more efficient care delivery models.
Collapse
|
8
|
Bobbio M, Abrignani MG, Caldarola P, Casolo G, Fattirolli F, Gabrielli D, Grimaldi M, Mazzotta G, Roncon L, Tozzi Q, Vallebona A. [Choosing wisely: the Top 5 list of the Italian Association of Hospital Cardiologists (ANMCO)]. G Ital Cardiol (Rome) 2014; 15:244-52. [PMID: 24873814 DOI: 10.1714/1497.16505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
In recent years, a progressive increase in the number of medical diagnostic and interventional procedures has been observed, namely in cardiology. A significant proportion of them appear inappropriate, i.e. potentially redundant, harmful, costly, and useless. Recently, the document Medical Professionalism in the New Millennium: A Physician Charter, the American Board of Internal Medicine (ABIM) Foundation Putting the Charter into Practice program, JAMA's Less Is More and BMJ's Too Much Medicine series, and the American College of Physicians' High-Value, Cost-Conscious Care initiatives, have all begun to provide direction for physicians to address pervasive overuse in health care. In 2010, the Brody's proposal to scientific societies to indicate the five medical procedures at high inappropriateness risk inspired the widely publicized ABIM Foundation's Choosing Wisely campaign. As part of Choosing Wisely, each participating specialty society has created lists of Things Physicians and Patients Should Question that provide specific, evidence-based recommendations physicians and patients should discuss to help make wise decisions about the most appropriate individual care. In Italy, Slow Medicine launched the analogue campaign Fare di più non significa fare meglio. The Italian Association of Hospital Cardiologists (ANMCO) endorsed the initiative by recognizing the need to optimize available resources, reduce costs and avoid unnecessary cardiovascular assessments, thereby enhancing the more efficient care delivery models. An ad hoc ANMCO Working Group prepared a list of five cardiac procedures that seem inappropriate for routine use in our country and, after an internal revision procedure, these are presented here.
Collapse
|
9
|
Affiliation(s)
- Lisa Rosenbaum
- Philadelphia Veterans Affairs Medical Center and the Robert Wood Johnson Foundation Clinical Scholars Program, University of Pennsylvania, Philadelphia, USA
| |
Collapse
|
10
|
Krizner T. Monitoring the beat of ancillary services in cardiac care. Some services can work in tandem with those of cardiologists to heir improve patient care. Med Econ 2013; 90:25, 29-30, 32, passim. [PMID: 23875273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
|
11
|
Chironi G. [Public health implications of high cardiovascular risk screening]. Rev Prat 2012; 62:792-793. [PMID: 22838273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- Gilles Chironi
- AP-HP, hôpital européen Georges-Pompidou, centre de médecine préventive cardiovasculaire.
| |
Collapse
|
12
|
Pierce MA, Hess EP, Kline JA, Shah ND, Breslin M, Branda ME, Pencille LJ, Asplin BR, Nestler DM, Sadosty AT, Stiell IG, Ting HH, Montori VM. The Chest Pain Choice trial: a pilot randomized trial of a decision aid for patients with chest pain in the emergency department. Trials 2010; 11:57. [PMID: 20478056 PMCID: PMC2881067 DOI: 10.1186/1745-6215-11-57] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2010] [Accepted: 05/17/2010] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Chest pain is a common presenting complaint in the emergency department (ED). Despite the frequency with which clinicians evaluate patients with chest pain, accurately determining the risk of acute coronary syndrome (ACS) and sharing risk information with patients is challenging. The aims of this study are (1) to develop a decision aid (CHEST PAIN CHOICE) that communicates the short-term risk of ACS and (2) to evaluate the impact of the decision aid on patient participation in decision-making and resource use. METHODS/DESIGN This is a protocol for a parallel, 2-arm randomized trial to compare an intervention group receiving CHEST PAIN CHOICE to a control group receiving usual ED care. Adults presenting to the Saint Mary's Hospital ED in Rochester, MN USA with a primary complaint of chest pain who are being considered for admission for prolonged ED observation in a specialized unit and urgent cardiac stress testing will be eligible for enrollment. We will measure the effect of CHEST PAIN CHOICE on six outcomes: (1) patient knowledge regarding their short-term risk for ACS and the risks of radiation exposure; (2) quality of the decision making process; (3) patient and clinician acceptability and satisfaction with the decision aid; (4) the proportion of patients who decided to undergo observation unit admission and urgent cardiac stress testing; (5) economic costs and healthcare utilization; and (6) the rate of delayed or missed ACS. To capture these outcomes, we will administer patient and clinician surveys after each visit, obtain video recordings of the clinical encounters, and conduct 30-day phone follow-up. DISCUSSION This pilot randomized trial will develop and evaluate a decision aid for use in ED chest pain patients at low risk for ACS and provide a preliminary estimate of its effect on patient participation in decision-making and resource use. TRIAL REGISTRATION Clinical Trials.gov Identifier: NCT01077037.
Collapse
Affiliation(s)
- Meghan A Pierce
- Knowledge and Encounter Research Unit, Mayo Clinic, Rochester, Minnesota, USA
- Division of Emergency Medicine Research, Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Erik P Hess
- Knowledge and Encounter Research Unit, Mayo Clinic, Rochester, Minnesota, USA
- Division of Emergency Medicine Research, Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jeffrey A Kline
- Emergency Medicine Research, Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC, USA
| | - Nilay D Shah
- Knowledge and Encounter Research Unit, Mayo Clinic, Rochester, Minnesota, USA
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN USA
| | - Maggie Breslin
- Knowledge and Encounter Research Unit, Mayo Clinic, Rochester, Minnesota, USA
- SPARC Design Studio, Center for Innovation, Mayo Clinic, Rochester, Minnesota, USA
| | - Megan E Branda
- Knowledge and Encounter Research Unit, Mayo Clinic, Rochester, Minnesota, USA
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Laurie J Pencille
- Knowledge and Encounter Research Unit, Mayo Clinic, Rochester, Minnesota, USA
| | - Brent R Asplin
- Division of Emergency Medicine Research, Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - David M Nestler
- Division of Emergency Medicine Research, Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Annie T Sadosty
- Division of Emergency Medicine Research, Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ian G Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Henry H Ting
- Knowledge and Encounter Research Unit, Mayo Clinic, Rochester, Minnesota, USA
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Victor M Montori
- Knowledge and Encounter Research Unit, Mayo Clinic, Rochester, Minnesota, USA
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN USA
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Internal Medicine, Mayo Clinic Rochester, MN, USA
| |
Collapse
|
13
|
Jáuregui-Aguilar R. And clinical practice? CIR CIR 2010; 78:1-3. [PMID: 20226122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
|
14
|
Mushlin AI, Ghomrawi HMK. Comparative effectiveness research: a cornerstone of healthcare reform? Trans Am Clin Climatol Assoc 2010; 121:141-155. [PMID: 20697557 PMCID: PMC2917153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Comparative Effectiveness Research (CER) has recently emerged as a major theme in health care reform. Unfortunately, there is a widespread lack of understanding about what it will do and fear that it will do more harm than good. These concerns include threats to individual physician's autonomy and professionalism, as well as fears that care will be rationed based on such findings. In this paper, we argue that the main components of the current healthcare reform (HCR) bills, which include expanding insurance while increasing efficiencies through cost containment, should embrace CER. This type of research will provide a "safeguard" against "blind" cost-containment, so that the new financial incentives being introduced can be actualized effectively and safely. Evidence for this is provided from examples from the authors' prior and current research as well as from the literature. We also argue that the requirement for data from CER will create long-term disincentives for "me-too" drugs and devices and, therefore, become a catalyst for effective innovation.
Collapse
Affiliation(s)
- Alvin I Mushlin
- Department of Public Health, Weill Cornell Medical Center, 402 East 67th Street, New York, NY 10065, USA.
| | | |
Collapse
|
15
|
|
16
|
Math RS, Mishra S, Kumar KS, Bahl VK. Clinical validation of a low-cost telemedicine equipment remote medical diagnostics kit at a tertiary care hospital. J Assoc Physicians India 2008; 56:769-776. [PMID: 19263702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
BACKGROUND The Remote Medical Diagnostics kit is an indigenous and low-cost technology that can measure and transmit via the internet 6 clinical parameters viz. Blood pressure (BP), pulse, temperature, oxygen saturation, 12-lead Electrocardiogram (ECG) and heart/breath sounds. Prior to commercial use, it needs clinical validation. METHODS Fifty three patients (including 1 acute myocardial infarction) were evaluated for the above parameters using accepted standard methods and the Remote Medical Diagnostics kit. RESULTS The intraclass correlation coefficient (ICC) for systolic BP (SBP), diastolic BP (DBP), saturation pulse, manual pulse and temperature was 0.927, 0.904, 0.989, 0.99 and 0.912 indicating a high degree of agreement between the two methods. For oxygen saturation, the ICC was 0.763 indicating a moderately high agreement. For heart sounds, the kappa coefficient (kappa) for inter-rater reliability was 0.48 (observed agreement of 96.1%). For breath sounds, the 'kappa' value was 0.48 indicating moderate agreement. For the breath sounds, the 'kappa' value was 0.38, indicating fair agreement (the observed agreement of 94.2%). For the ECG, the observed agreement was 94.4% by visual assessment. CONCLUSION At the bedside, the Remote Medical Diagnostics kit was clinically validated for the above 6 parameters.
Collapse
Affiliation(s)
- R S Math
- Department of Cardiology, Cardiothoracic Sciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | | | | | | |
Collapse
|
17
|
Bedetti G, Pasanisi EM, Pizzi C, Turchetti G, Loré C. Economic analysis including long-term risks and costs of alternative diagnostic strategies to evaluate patients with chest pain. Cardiovasc Ultrasound 2008; 6:21. [PMID: 18510723 PMCID: PMC2435520 DOI: 10.1186/1476-7120-6-21] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2007] [Accepted: 05/29/2008] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Diagnosis costs for cardiovascular disease waste a large amount of healthcare resources. The aim of the study is to evaluate the clinical and economic outcomes of alternative diagnostic strategies in low risk chest pain patients. METHODS We evaluated direct and indirect downstream costs of 6 strategies: coronary angiography (CA) after positive troponin I or T (cTn-I or cTnT) (strategy 1); after positive exercise electrocardiography (ex-ECG) (strategy 2); after positive exercise echocardiography (ex-Echo) (strategy 3); after positive pharmacologic stress echocardiography (PhSE) (strategy 4); after positive myocardial exercise stress single-photon emission computed tomography with technetium Tc 99m sestamibi (ex-SPECT-Tc) (strategy 5) and direct CA (strategy 6). RESULTS The predictive accuracy in correctly identifying the patients was 83,1% for cTn-I, 87% for cTn-T, 85,1% for ex-ECG, 93,4% for ex-Echo, 98,5% for PhSE, 89,4% for ex-SPECT-Tc and 18,7% for CA. The cost per patient correctly identified results $2.051 for cTn-I, $2.086 for cTn-T, $1.890 for ex-ECG, $803 for ex-Echo, $533 for PhSE, $1.521 for ex-SPECT-Tc ($1.634 including cost of extra risk of cancer) and $29.673 for CA ($29.999 including cost of extra risk of cancer). The average relative cost-effectiveness of cardiac imaging compared with the PhSE equal to 1 (as a cost comparator), the relative cost of ex-Echo is 1.5x, of a ex-SPECT-Tc is 3.1x, of a ex-ECG is 3.5x, of cTnI is x3.8, of cTnT is x3.9 and of a CA is 56.3x. CONCLUSION Stress echocardiography based strategies are cost-effective versus alternative imaging strategies and the risk and cost of radiation exposure is void.
Collapse
Affiliation(s)
| | | | | | | | - Cosimo Loré
- Institute of Legal Medicine, University of Siena, Italy
| |
Collapse
|
18
|
Bogavac-Stanojević N, Ivanova Petrova G, Jelić-Ivanović Z, Memon L, Spasić S. Cost-effectiveness analysis in diagnosis of coronary artery disease: Choice of laboratory markers. Clin Biochem 2007; 40:1180-7. [PMID: 17869234 DOI: 10.1016/j.clinbiochem.2007.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2006] [Revised: 07/04/2007] [Accepted: 07/07/2007] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The aim of our study was to determine the cost-effectiveness of coronary artery disease (CAD) diagnostic parameters in a clinical laboratory setting. DESIGN AND METHODS The effectiveness of apolipoproteins, lipoproteins and high sensitivity C-reactive protein (hs-CRP) supplementary to Framingham scoring data within a CAD risk assessment procedure was established in 221 CAD patients and 289 controls. The total costs of diagnostic procedures were calculated and incremental cost-effectiveness analysis was applied. RESULTS A diagnostic strategy employing Framingham calculation followed by apolipoprotein A-I (apoA-I) had the lowest cost per additional successfully diagnosed patient than the same strategy followed by hs-CRP in the low (2.63 vs. 24.47 euros) and intermediate-risk groups (2.96 vs. 122.85 euros). In the high-risk group the diagnostic strategy employing apoA-I saved 9.14 euros in comparison to the strategy employing hs-CRP. CONCLUSION Cost-effectiveness analysis of different diagnostic markers results in improved identification of at-risk patients at a lower health cost for society.
Collapse
|
19
|
Ricci WM, Della Rocca GJ, Combs C, Borrelli J. The medical and economic impact of preoperative cardiac testing in elderly patients with hip fractures. Injury 2007; 38 Suppl 3:S49-52. [PMID: 17723792 DOI: 10.1016/j.injury.2007.08.011] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2007] [Indexed: 02/02/2023]
Abstract
PURPOSE To assess the medical and economic impact of preoperative cardiac testing (stress thallium imaging or echocardiography) on the treatment of elderly patients with hip fractures. MATERIALS AND METHODS 235 consecutive patients over the age of 60 treated for a hip fracture (236 fractures) (OTA 31) at a single Level I trauma centre were identified from a prospective orthopaedic trauma database and studied as part of a retrospective cohort series. 35 (15%) had cardiac testing prior to treatment of their hip fracture. The indication for testing was a newly diagnosed cardiac abnormality in 16 of these cases and a prior history of cardiovascular disease without an acute cardiac problem in 19. RESULTS Cardiac evaluation did not change the orthopaedic management in any case. No patient underwent cardiac surgery or coronary angioplasty as a result of the testing. In 48% of cases, cardiac testing did not lead to new medical treatment. In 52%, recommendations were only made for medical management of previously known cardiac disease. Patients who had cardiac testing had a significantly greater average delay to surgery (3.3 days) than those who did not (1.9 days), (P<.001). The cost of preoperative cardiac testing totalled more than $44,000 for the 35 patients. DISCUSSION AND CONCLUSION Preoperative cardiac testing did not lead to changes in perioperative orthopaedic or medical management of elderly patients with hip fractures. Patients undergoing testing had a significant delay to surgery. Extrapolated to the population of elderly hip fracture patients in the United States (250,000 annually), preoperative cardiac testing (performed in 15% of cases) would cost nearly $47,000,000 annually. Preoperative cardiac testing may add profoundly to the healthcare costs associated with treating this population of patients without influencing orthopaedic or medical management.
Collapse
Affiliation(s)
- William M Ricci
- Department of Orthopedic Surgery, Barnes-Jewish Hospital and Washington University School of Medicine, St. Louis, Missouri, USA.
| | | | | | | |
Collapse
|
20
|
|
21
|
Beller GA. Reduction in industry support for academic research: Implications for assessment of cardiovascular imaging technologies. J Nucl Cardiol 2006; 13:443-4. [PMID: 16919566 DOI: 10.1016/j.nuclcard.2006.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
22
|
|
23
|
Abstract
BACKGROUND Many different approaches are used to diagnose suspected deep-vein thrombosis (DVT), but there has been little formal comparison of strategies. AIM To identify the most cost-effective strategy for the UK National Health Service (NHS). DESIGN Systematic review, meta-analysis and cost-effectiveness analysis. METHODS We identified 18 strategies and estimated the diagnostic performance of constituent tests by systematic review and meta-analysis. Outcomes of testing and treatment were estimated from published data or by an expert panel. Costs were estimated from NHS reference costs and published data. We built a decision-analysis model to estimate, for each strategy, the overall accuracy, costs, and outcomes (valued as quality-adjusted life-years, QALYs), compared to a 'no testing, no treatment' alternative. Probabilistic analysis estimated the net benefit of each strategy at varying thresholds for willingness to pay for health gain. RESULTS At the thresholds for willingness to pay recommended by the National Institute for Clinical Excellence (20,000 pounds sterling-30,000 pounds sterling per QALY), the optimal strategy was to discharge patients with a low or intermediate Wells score and negative D-dimer, limiting ultrasound to those with a high score or positive D-dimer. Strategies using radiological testing for all patients were only cost-effective at 40,000 pound sterling per QALY or more. DISCUSSION The optimal strategy for DVT diagnosis is to use ultrasound selectively in patients with a high clinical risk or positive D-dimer. Radiological testing for all patients does not appear to be a cost-effective use of health service resources.
Collapse
Affiliation(s)
- S Goodacre
- Medical Care Research Unit, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA.
| | | | | | | | | | | |
Collapse
|
24
|
Abstract
In 2003, a lump-sum payment system based on Diagnosis Procedure Combinations (DPC) was introduced to 82 specific function hospitals in Japan. While the US DRG/PPS system is a "per case payment" system, the DPC based payment system adopts a "per day payment." It is generally believed that the Japanese system provides as much of an incentive as the DRG/PPS system to shorten the average length of stay (LOS). We performed an empirical analysis of the effect of LOS shortening on hospital revenue and expenditure under the DPC-based payment system, particularly in cardiovascular diseases. We also point out fundamentally controversial aspects of the current system. A total 109 cases were selected from patients hospitalized at the University of Tokyo Hospital from May to July, 2003 and classified into one of three categories: (1) cardiac catheter interventions, (2) cardiac catheter examinations, and (3) other conservative treatments. We analyzed the changes in profit per day in cases of a reduction in average LOS and an increase in the number of cases. In category (1) profit increased significantly in conjunction with reduced LOS. In category (2) profit increased only minimally. In category (3), profit increased rarely and sometimes decreased. In cases of conservative treatment, profits sometimes decreased because an increase in material costs exceeded the increase in revenue. It therefore became clear that the DPC-based payment system does not decisively provide an economic incentive to reduce LOS in cardiovascular medicine.
Collapse
Affiliation(s)
- Hideo Yasunaga
- Department of Planning, Information & Management, University of Tokyo Hospital, Hongo, Japan
| | | | | | | |
Collapse
|
25
|
Molefi M, Fortuin J, Wynchank S. Tele-cardiology. Cardiovasc J S Afr 2006; 17:27-32. [PMID: 16547558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
After defining tele-medicine, we describe its situation in the public health service of South Africa and its application to cardiology. Methods of communication relevant to tele-cardiology are outlined, together with their bearing on primary healthcare. The range of tele-cardiological applications to electrocardiology, echocardiology, auscultation, imaging and pathology are indicated. Tele-cardiology's contributions to a range of cardiological problems and types of management are described briefly. Finally, a mention is made of the relevance of tele-medicine to education and the costs related to cardiology, with an indication of some future needs for tele-cardiology.
Collapse
Affiliation(s)
- M Molefi
- Tele-Medicine Lead Programme, Medical Research Council, Pretoria, South Africa
| | | | | |
Collapse
|
26
|
Daniel BV, Kelsberg G, Jankowski TA, Crownover B. Clinical inquiries. What is the initial work-up in the diagnosis of hypertension? J Fam Pract 2005; 54:809-10, 812. [PMID: 16144596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
|
27
|
Roeder N, Fürstenberg T, Bunzemeier H, Reinecke H. [Cardiovascular medicine in the updated German diagnosis-related groups (G-DRG) for the year 2004]. Z Kardiol 2004; 93:266-77. [PMID: 15085371 DOI: 10.1007/s00392-004-0076-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2003] [Accepted: 12/17/2003] [Indexed: 04/29/2023]
Abstract
Based on the medical and economical data of 137 German hospitals including 12 university hospitals, the Institut für das Entgeltsystem im Krankenhaus (InEK) was again authorized by the German Ministry of Health to calculate and develop a refined version of the German diagnosis related groups (G-DRG) for the year 2004. The catalogue of these updated GDRGs was published on October 15' 2003. Furthermore, the grouper programs containing the current algorithms and the cost data on which the new G-DRGs were based have been published in the last few weeks. With regard to cardiovascular DRGs, a number of changes have been introduced in the G-DRG system which have profound consequences for all departments that treat patients with these diseases. In this review, we want to present in detail the key points of this update concerning the DRGs, extra reimbursement for special interventions, and new codes for diagnoses and procedures. Furthermore, the new rules for readmissions of patients in the same hospital are summarized. In conclusion, a number of improvements have been implemented in the updated G-DRG system which had in part been suggested by several national medical societies. These provide the basis for more precise and detailed DRGs but require on the other hand, a precise and complete coding to allow correct grouping procedures. From an economical point of view, it could hardly be summarized whether these improvements would lead to an adequate reimbursement for the treatment costs of patients with cardiovascular diseases since the case-mix of the various departments may vary widely.
Collapse
Affiliation(s)
- N Roeder
- DRG-Research-Group, Universitätsklinikum Münster, Münster, Germany
| | | | | | | |
Collapse
|
28
|
|
29
|
Levenson D. Study validates quick blood test for heart failure. Rep Med Guidel Outcomes Res 2002; 13:1-2. [PMID: 12553322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/28/2023]
|
30
|
Affiliation(s)
- Michael A Chizner
- The Heart Center of Excellence, North Broward Hospital District, Fort Lauderdale, Florida, USA
| |
Collapse
|
31
|
Baumbach A, Karsch KR. Pricing a year of life: a necessary exercise in modern health care. Eur Heart J 2002; 23:5-7. [PMID: 11741354 DOI: 10.1053/euhj.2001.2903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
|
32
|
Brown RE, Henderson RA, Koster D, Hutton J, Simoons ML. Cost effectiveness of eptifibatide in acute coronary syndromes; an economic analysis of Western European patients enrolled in the PURSUIT trial. The Platelet IIa/IIb in unstable Angina: Receptor Suppression Using Integrilin Therapy. Eur Heart J 2002; 23:50-8. [PMID: 11741362 DOI: 10.1053/euhj.2001.2711] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
AIMS To assess the direct medical costs and cost effectiveness of routine eptifibatide use amongst patients with unstable angina and myocardial infarction without persistent ST-segment elevation in the Western European subgroup of the PURSUIT trial. METHODS AND RESULTS Health care resources were collected for the Western European PURSUIT trial patients (n=3697). Unit costs for major resources were developed within six countries using a consistent bottom-up methodology. Resource consumption from the Western European population was used to calculate the average direct medical costs per patient in the eptifibatide and placebo arms of the trial. Eptifibatide was estimated to cost 524 Euros per treatment. Long-term survival estimated from the 6-month trial survival data and combined with the cost data was used to calculate cost-effectiveness ratios. Additionally, cost per death and non-fatal myocardial infarction at 30 days was calculated. Sensitivity analyses were conducted on the discount rate and resource consumption. Cost-effectiveness ratios ranged from 9603 Euros to 18 115 Euros per year of life saved with 3% discount. Using resource consumption based on countries with low coronary arteriography rates, the cost per year of life saved was between 3329 Euros and 10 079 Euros. Using resource consumption based on high coronary arteriography rate countries, the cost per year of life saved was between 17 089 Euros and 24 099 Euros. Assuming no difference in treatment costs except for the addition of eptifibatide, the incremental cost per year of life saved was 23 818 Euros. CONCLUSIONS Routine eptifibatide use was associated with a reduction in the combined end-point of death and myocardial infarction at 30 days, which was sustained at 6 months. Long-term projections indicate a modest increase in survival in eptifibatide patients. These data translate into cost-effectiveness ratios that compare favourably with other new technologies that are currently in use.
Collapse
Affiliation(s)
- R E Brown
- MEDTAP International Inc, London, U.K
| | | | | | | | | |
Collapse
|
33
|
Gotto AM, Boccuzzi SJ, Cook JR, Alexander CM, Roehm JB, Meyer GS, Clearfield M, Weis S, Whitney E. Effect of lovastatin on cardiovascular resource utilization and costs in the Air Force/Texas Coronary Atherosclerosis Prevention Study (AFCAPS/TexCAPS). AFCAPS/TexCAPS Research Group. Am J Cardiol 2000; 86:1176-81. [PMID: 11090787 DOI: 10.1016/s0002-9149(00)01198-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
This cost-consequences analysis of the Air Force/Texas Coronary Atherosclerosis Prevention Study compares the costs of lovastatin treatment with the costs of cardiovascular hospitalizations and procedures. The cost of lovastatin treatment was defined as the average retail price and the cost of drug safety monitoring and adverse experiences. Costs were determined by actual rates of hospitalizations and procedures. Within a trial, lovastatin treatment cost approximately $4,654/patient. Lovastatin treatment significantly reduced the cumulative rate of cardiovascular hospitalizations and procedures (p = 0.002). Over the duration of the study, the cumulative number of cardiovascular hospitalizations and related therapeutic procedures was significantly reduced by 29%. The time to first cardiovascular-related hospitalization or procedure was significantly extended by lovastatin (p = 0.002). Lovastatin reduced the frequency of cardiovascular hospitalization (28%), and cardiovascular therapeutic (32%) and diagnostic procedures (23%). Among therapeutic procedures, treatment reduced coronary artery bypass graft surgery by 19% and percutaneous transluminal coronary angioplasty by 37%. Total cardiovascular-related hospital days were reduced by 26% (p = 0.025). The between-group offset in direct medical costs was $524, which resulted in a 11% cost offset of lovastatin therapy over the mean study duration of 5.2 years. Lovastatin provides meaningful reductions in cardiovascular-related resource utilization and reductions in direct cardiovascular-related costs associated with the onset of coronary disease.
Collapse
Affiliation(s)
- A M Gotto
- Weill Medical College of Cornell University, New York, New York 10021, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
34
|
Affiliation(s)
- D C Levin
- Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA
| |
Collapse
|
35
|
Wolfe CD, Stojcevic N, Rudd AG, Warburton F, Beech R. The uptake and costs of guidelines for stroke in a district of southern England. J Epidemiol Community Health 1997; 51:520-5. [PMID: 9425462 PMCID: PMC1060538 DOI: 10.1136/jech.51.5.520] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
STUDY OBJECTIVE To assess the impact of guidelines for stroke management on the utilisation of services by patients and the cost consequences of implementation. DESIGN Prospective audit. SETTING District health authority in southern England. PATIENTS A total of 468 live non-comatose stroke patients registered between November 1991 and May 1993. MAIN OUTCOME MEASURES A comparison between the three, six month periods for investigations performed and rehabilitation received and their associated costs. RESULTS The appropriateness of the use of investigations improved over time to between 88 and 92% except for computed tomography (CT) (24%). Younger, more severely impaired patients in a medical bed were more likely to have CT. Overall levels of rehabilitation were low. There was no change in use of physiotherapy (61% to 63%), a significant increase in occupational therapy (26% to 39%) and a non significant change in speech therapy (34% to 25%) over time. Guideline introduction caused a modest 23 Pounds increase in costs per patient in the 2nd six months and 41 Pounds in the 3rd six months but this sum could rise to 430 Pounds per patient if full implementation of the guidelines occurred which is still only around 13% of the costs of nursing care while in hospital. CONCLUSIONS This 18 month aduit shows only modest changes in practice compared with guidelines, and overall levels of rehabilitation were low. The costs of full implementation seem considerable, but in fact constitute only a small proportion of nursing care costs.
Collapse
Affiliation(s)
- C D Wolfe
- Division of Public Health Sciences, St Thomas's Hospital, London
| | | | | | | | | |
Collapse
|