Clinical and economic outcomes of assigning percutaneous coronary intervention patients to contrast-sparing strategies based on the predicted risk of contrast-induced acute kidney injury

OBJECTIVE

Contrast-sparing strategies have been developed for percutaneous coronary intervention (PCI) patients at increased risk of contrast-induced acute kidney injury (CI-AKI), and numerous CI-AKI risk prediction models have been created. However, the potential clinical and economic consequences of using predicted CI-AKI risk thresholds for assigning patients to contrast-sparing regimens have not been evaluated. We estimated the clinical and economic consequences of alternative CI-AKI risk thresholds for assigning Medicare PCI patients to contrast-sparing strategies.

METHODS

Medicare data were used to identify inpatient PCI from January 2017 to June 2021. A prediction model was developed to assign each patient a predicted probability of CI-AKI. Multivariable modeling was used to assign each patient two marginal predicted values for each of several clinical and economic outcomes based on (1) their underlying clinical and procedural characteristics plus their true CI-AKI status in the data and (2) their characteristics plus their counterfactual CI-AKI status. Specifically, CI-AKI patients above the predicted risk threshold for contrast-sparing were reassigned their no CI-AKI (counterfactual) outcomes. Expected event rates, resource use, and costs were estimated before and after those CI-AKI patients were reassigned their counterfactual outcomes. This entailed bootstrapped sampling of the full cohort.

RESULTS

Of the 542,813 patients in the study cohort, 5,802 (1.1%) had CI-AKI. The area under the receiver operating characteristic curve for the prediction model was 0.81. At a predicted risk threshold for CI-AKI of >2%, approximately 18.0% of PCI patients were assigned to contrast-sparing strategies, resulting in (/100,000 PCI patients) 121 fewer deaths, 58 fewer myocardial infarction readmissions, 4,303 fewer PCI hospital days, $11.3 million PCI cost savings, and $25.8 million total one-year cost savings, versus no contrast-sparing strategies.

LIMITATIONS

Claims data may not fully capture disease burden and are subject to inherent limitations such as coding inaccuracies. Further, the dataset used reflects only individuals with fee-for-service Medicare, and the results may not be generalizable to Medicare Advantage or other patient populations.

CONCLUSIONS

Assignment to contrast-sparing regimens at a predicted risk threshold close to the underlying incidence of CI-AKI is projected to result in significant clinical and economic benefits.

The Association of Socioeconomic Factors With Percutaneous Coronary Intervention Outcomes

BACKGROUND

Numerous studies have identified the association of socioeconomic factors with outcomes of cardiac surgical procedures. Most have focused on easily measured demographic factors or on socioeconomic characteristics of patients' 5-digit zip codes. The impact of socioeconomic information that is derived from smaller geographic regions has rarely been studied.

METHODS

The association of the Area Deprivation Index (ADI) with short-term mortality and readmissions was tested for patients undergoing percutaneous coronary intervention (PCI) in New York while adjusting for numerous patient risk factors, including race, ethnicity, and payer. Changes in hospitals' risk-adjusted outcomes and outlier status with the addition of socioeconomic factors were examined.

RESULTS

After adjustment, patients in the 2 most deprived ADI quintiles were more likely to experience in-hospital and 30-day mortality after PCI (adjusted odds ratios [95% confidence intervals] 1.39 [1.18-1.65] and 1.24 [1.03-1.49], respectively), than patients in the first quintile (least deprived). Also, patients in the second and fifth ADI quintiles had higher 30-day readmissions rates than patients in the first quintile (1.12 [1.01-1.25] and 1.17 [1.04-1.32], respectively). Medicare patients had higher mortality and readmission rates, Hispanics had lower mortality, and Medicaid patients had higher readmission rates.

CONCLUSIONS

Patients with the most deprived ADIs are more likely to experience short-term mortality and readmissions after PCI. Ethnicity and payer are significantly associated with adverse outcomes even after adjusting for ADI. This information should be considered when identifying patients who are at the highest risk for adverse events after PCI and when risk-adjusting hospital outcomes and assessing quality of care.

Cost-Effectiveness of Coronary Artery Bypass Grafting and Percutaneous Coronary Intervention in Patients With Chronic Kidney Disease and Acute Coronary Syndromes in the US Medicare Program

Background Coronary revascularization provides important long-term clinical benefits to patients with high-risk presentations of coronary artery disease, including those with chronic kidney disease. The cost-effectiveness of coronary interventions in this setting is not known. Methods and Results We developed a Markov cohort simulation model to assess the cost-effectiveness of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in patients with chronic kidney disease who were hospitalized with acute myocardial infarction or unstable angina. Model inputs were primarily drawn from a sample of 14 300 patients identified using the Medicare 20% sample. Survival, quality-adjusted life-years, costs, and cost-effectiveness were projected over a 20-year time horizon. Multivariable models indicated higher 30-day mortality and end-stage renal disease with both PCI and CABG, and higher stroke with CABG, relative to medical therapy. However, the model projected long-term gains of 0.72 quality-adjusted life-years (0.97 life-years) for PCI compared with medical therapy, and 0.93 quality-adjusted life-years (1.32 life-years) for CABG compared with PCI. Incorporation of long-term costs resulted in incremental cost-effectiveness ratios of $65 326 per quality-adjusted life-year gained for PCI versus medical therapy, and $101 565 for CABG versus PCI. Results were robust to changes in input parameters but strongly influenced by the background costs of the population, and the time horizon. Conclusions For patients with chronic kidney disease and high-risk coronary artery disease presentations, PCI and CABG were both associated with markedly increased costs as well as gains in quality-adjusted life expectancy, with incremental cost-effectiveness ratios indicating intermediate value in health economic terms.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Conflicting findings between the Mitra-Fr and the Coapt trials: Implications regarding the cost-effectiveness of percutaneous repair for heart failure patients with severe secondary mitral regurgitation

PURPOSE

Two randomized controlled trials (RCTs), Mitra-Fr and Coapt, evaluating the benefit of percutaneous repair (PR) for heart failure (HF) patients with severe mitral regurgitation, have led to conflicting results. We aimed to evaluate the impact of these trial results on the cost-effectiveness of PR using effectiveness inputs from the two RCTs.

METHODS

We developed a time varying Markov type model with three mutually exclusive health states: alive without HF hospitalisation, alive with HF hospitalisation, and dead. Clinically plausible extrapolations beyond observed data were obtained by developing parametric modelling for overall survival and HF hospitalisations using published data from each trial. We adopted the perspective of the French Health System and used a 30-year time horizon. Results were expressed as € / quality-adjusted life year (QALY) gained using utility inputs from literature.

FINDINGS

Results are presented using treatment efficacy measures from Mitra-F and Coapt trials respectively. With the Mitra-Fr data, after annual discounting, the base case model generated an incremental 0.00387 QALY at a cost of €25,010, yielding an incremental cost effectiveness ratio (ICER) of €6,467,032 / QALY. The model was sensitive to changes made to model inputs. There was no potential of PR being cost-effective. With the Coapt data, the model generated 1.19 QALY gain at a cost of €26,130 yielding an ICER of €21,918 / QALY and at a threshold of >€50,000/QALY PR had a probability of 1 of being cost-effective.

IMPLICATIONS

Cost effectiveness results were conflicting; reconciling differences between trials is a priority and could promote optimal cost effectiveness analyses and resource allocation.

Trends and outcomes of non-primary PCI at sites without cardiac surgery on-site: The early Michigan experience

Introduction

Non-primary percutaneous coronary intervention (non-PPCI) recently received certificate of need approval in the state of Michigan at sites without cardiac surgery on-site (cSoS). This requires quality oversight through participation in the BMC2 registry. While previous studies have indicated the safety of this practice, real-world comprehensive outcomes, case volume changes, economic impacts, and readmission rates at diverse healthcare centers with and without cSoS remain poorly understood.

Methods

Consecutive patients undergoing non-PPCI at 47 hospitals (33 cSoS and 14 non-cSoS) in Michigan from April 2016 to March 2018 were included. Using propensity-matching, patients were analyzed to assess outcomes and trends in non-PPCI performance at sites with and without cSOS.

Results

Of 61,864 PCI’s performed, 50,817 were non-PPCI, with 46,096 (90.7%) performed at sites with cSoS and 4,721 (9.3%) at sites without cSoS. From this cohort, 4,643 propensity-matched patients were analyzed. Rates of major adverse cardiac events (2.6% vs. 2.8%; p = 0.443), in-hospital mortality (0.6% vs. 0.5%; p = 0.465), and several secondary clinical and quality outcomes showed no clinically significant differences. Among a small subset with available post-discharge data, there were no differences in 90-day readmission rates, standardized episode costs, or post-discharge mortality. Overall PCI volume remained stable, with a near three-fold rise in non-PPCI at sites without cSoS.

Conclusions

Non-PPCI at centers without cardiac SoS was associated with similar comprehensive outcomes, quality of care, 90-day episode costs, and post-discharge mortality compared with surgical sites. Mandatory quality oversight serves to maintain appropriate equivalent outcomes and may be considered for other programs, including the performance of non-PPCI at ambulatory surgical centers in the near future.

Associations Between Hospital Length of Stay, 30-Day Readmission, and Costs in ST-Segment-Elevation Myocardial Infarction After Primary Percutaneous Coronary Intervention: A Nationwide Readmissions Database Analysis

Background Readmission after ST-segment-elevation myocardial infarction (STEMI) poses an enormous economic burden to the US healthcare system. There are limited data on the association between length of hospital stay (LOS), readmission rate, and overall costs in patients who underwent primary percutaneous coronary intervention for STEMI. Methods and Results All STEMI hospitalizations were selected in the Nationwide Readmissions Database from 2010 to 2014. From the patients who underwent primary percutaneous coronary intervention, we examined the 30-day outcomes including readmission, mortality, reinfarction, repeat revascularization, and hospital charges/costs according to LOS (1-2, 3, 4, 5, and >5 days) stratified by infarct locations. The 30-day readmission rate after percutaneous coronary intervention for STEMI was 12.0% in the anterior wall (AW) STEMI group and 9.9% in the non-AW STEMI group. Patients with a very short LOS (1-2 days) were readmitted less frequently than those with a longer LOS regardless of infarct locations. However, patients with a very short LOS had significantly increased 30-day readmission mortality versus an LOS of 3 days (hazard ratio, 1.91; CI, 1.16-3.16 [P=0.01]) only in the AW STEMI group. Total costs (index admission+readmission) were the lowest in the very short LOS cohort in both the AW STEMI group (P<0.001) and the non-AW STEMI group (P<0.001). Conclusions For patients who underwent primary percutaneous coronary intervention for STEMI, a very short LOS was associated with significantly lower 30-day readmission and lower cumulative cost. However, a very short LOS was associated with higher 30-day mortality compared with at least a 3-day stay in the AW STEMI cohort.

Federal Payments for Coronary Revascularization Procedures Among Dual Enrollees in Medicare Advantage and the Veterans Affairs Health Care System

IMPORTANCE

More than 1 million US veterans are dually enrolled in a Medicare Advantage (MA) plan and in the Veterans Affairs (VA) health care system. The federal government prepays private MA plans to cover veterans; if a dually enrolled veteran receives an MA-covered service at the VA, the government is making 2 payments for the same service. It is not clear what proportion of veterans dually enrolled in VA and MA are undergoing coronary revascularization at VA vs non-VA hospitals.

OBJECTIVE

To describe where veterans who are enrolled in both VA and MA undergo coronary revascularization and the associated costs.

DESIGN, SETTINGS, AND PARTICIPANTS

This is a cohort study consisting of US veterans dually enrolled in VA and MA from January 1, 2010, to December 31, 2013, who had at least 1 VA encounter and underwent coronary revascularization during the study period. Data were analyzed from April 2019 to September 2019.

MAIN OUTCOMES AND MEASURES

Number of coronary artery bypass graft (CABG) operations and percutaneous coronary interventions (PCIs) performed through the VA and through MA during years 2010 to 2013, and the associated VA costs of coronary revascularization. In addition, multivariable logistic regression was performed to assess patient factors associated with receiving care through the VA.

RESULTS

A total of 18 874 VA users with concurrent MA enrollment who underwent coronary revascularization during 2010 to 2013 were identified (mean [SD] age, 75.3 [8.8] years; 18 739 men [99.0%]). Enrollees were predominantly white (17 457 patients [92.0%]). Among patients, 4115 (22.0%) underwent either CABG or PCI through the VA only, 14 281 (75.0%) did so through MA only, and 478 (2.5%) underwent coronary revascularization procedures through both payers. From 2010 to 2013, these veterans underwent 4764 coronary revascularization procedures (721 CABGs and 3043 PCIs) that cost the VA $214.7 million ($115.8 million for CABGs and $99.0 million for PCIs). In multivariable analysis, nonwhite patients were more likely than white patients to undergo coronary revascularization through the VA (odds ratio, 1.73; 95% CI, 1.52-1.96; P < .001), and for each year of age, veterans were less likely to undergo coronary revascularization through the VA (odds ratio, 0.95; 95% CI, 0.94-0.95; P < .001). There was no statistically significant association between undergoing coronary vascularization through the VA and distance in miles to the nearest VA hospital (odds ratio, 1.00; 95% CI, 0.99-1.00; P = .30).

CONCLUSIONS AND RELEVANCE

A substantial share of VA users concurrently enrolled in an MA plan underwent coronary revascularization procedures through the VA, incurring significant duplicative federal health care spending. Given the financial pressures facing both Medicare and the VA, government officials should consider policy solutions to mitigate redundant spending.

The cost-effectiveness of guideline-driven use of drug-eluting stents: propensity-score matched analysis of a seven-year multicentre experience

Background: In routine clinical practice, the implantation of a drug-eluting stent (DES) versus a bare metal stent (BMS) for percutaneous coronary intervention (PCI) has been guided by criteria for appropriate use. The cost-effectiveness (CE) of adopting these guidelines, however, is not clear, and was investigated from the perspective of the Australian healthcare payer.Methods and results: Baseline and 12-month follow-up data of 12,710 PCI patients enrolled in the Melbourne Interventional Group (MIG) registry between 2004 and 2011 were analysed. Costs inputs were derived from a clinical costing database and published sources. Propensity-score-matching was performed for DES and BMS groups within sub-groups. Incremental cost-effectiveness ratios (ICERs) were evaluated for all patients, and sub-groups of patients with '0', 1, 2, or ≥3 indications for a DES. The incremental cost per target vessel revascularization avoided for the overall population was $24,683, and for patients with 0, 1, and 2 indications for a DES was $44,635, $33,335, and $23,788, respectively. However, for those with >3 indications, DES compared with BMS was associated with cost savings. At willingness to pay thresholds of $45,000-$75,000, the probability of cost-effectiveness of DES for the overall cohort was 71-91%, '0' indications, 49-67%, 1 indication, 56-82%, 2 indications, 70-90%, and ≥3 indications, 97-99%.Conclusions: The cost-effectiveness of DES compared with BMS increased with increasing risk profile of patients from those who had 1, 2, to ≥3 indications for a DES. When compared with BMS, DES was least cost effective among patients with '0' indications for a DES. Based on these results, selective use of DES implantation is supported. These findings may be useful for evidence-based clinical decision-making.

Cost-Effectiveness of Multigene Pharmacogenetic Testing in Patients With Acute Coronary Syndrome After Percutaneous Coronary Intervention

OBJECTIVE

To evaluate the cost-effectiveness of multigene testing (CYP2C19, SLCO1B1, CYP2C9, VKORC1) compared with single-gene testing (CYP2C19) and standard of care (no genotyping) in acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI) from Medicare's perspective.

METHODS

A hybrid decision tree/Markov model was developed to simulate patients post-PCI for ACS requiring antiplatelet therapy (CYP2C19 to guide antiplatelet selection), statin therapy (SLCO1B1 to guide statin selection), and anticoagulant therapy in those that develop atrial fibrillation (CYP2C9/VKORC1 to guide warfarin dose) over 12 months, 24 months, and lifetime. The primary outcome was cost (2016 US dollar) per quality-adjusted life years (QALYs) gained. Costs and QALYs were discounted at 3% per year. Probabilistic sensitivity analysis (PSA) varied input parameters (event probabilities, prescription costs, event costs, health-state utilities) to estimate changes in the cost per QALY gained.

RESULTS

Base-case-discounted results indicated that the cost per QALY gained was $59 876, $33 512, and $3780 at 12 months, 24 months, and lifetime, respectively, for multigene testing compared with standard of care. Single-gene testing was dominated by multigene testing at all time horizons. PSA-discounted results indicated that, at the $50 000/QALY gained willingness-to-pay threshold, multigene testing had the highest probability of cost-effectiveness in the majority of simulations at 24 months (61%) and over the lifetime (81%).

CONCLUSIONS

On the basis of projected simulations, multigene testing for Medicare patients post-PCI for ACS has a higher probability of being cost-effective over 24 months and the lifetime compared with single-gene testing and standard of care and could help optimize medication prescribing to improve patient outcomes.

The Value of Transradial: Impact on Patient Satisfaction and Health Care Economics

This review summarizes the impact of transradial access for cardiac catheterization and percutaneous coronary intervention related to patient satisfaction, patient safety, and health care costs. In studies comparing transradial versus transfemoral approach, transradial access causes less bleeding and less vascular access site complications and provides a mortality benefit in patients with acute coronary syndromes. Transradial access improves patient satisfaction related to site tolerability by reducing pain and discomfort, and facilitating early ambulation with reduced length of stay. Taken in total, the existing randomized and observational data strongly support radial access for improved safety, patient satisfaction, and significant cost savings.

Pharmaceutical use and costs in patients with coronary artery disease, using Australian observational data

OBJECTIVES

We aimed to estimate the annual pharmaceutical costs for patients with stable coronary artery disease, using Australian administrative data, comparing patients who had undergone interventional treatment with those had not. We also aimed to compare the duration of dual antiplatelet therapy (DAPT) prescription in the real-world, with recommended guidelines.

DESIGN

An observational study using administrative data.

PARTICIPANTS

We used data from the QSkin study, a population-based prospective study assessing skin cancer risk. Participants were invited from the Queensland population, not based on perceived skin cancer risk, and had consented to future use of their data for approved research projects.

MAIN OUTCOME MEASURES

We calculated 12-month costs of pharmaceutical therapy for coronary artery disease for patients in each of three clinically relevant groups: medical therapy only, following coronary stent implantation and following coronary artery bypass graft surgery. We measured the duration of DAPT following stent implantation and total duration of DAPT, where it was prescribed, in the medical therapy only group.

RESULTS

Estimated mean annual pharmaceutical costs were highest in the stent group at AUD$1920, compared with AUD$1481 in the medical therapy group, and AUD$881 in the coronary artery bypass group. There were similar rates of prescriptions of symptom relief drugs following stent insertion, compared with the medical therapy only group. The median duration of DAPT in the stent group was 16, and 31 months in the medical therapy group.

CONCLUSIONS

Our results suggest that despite the common expectation that the burden of medical therapy is reduced following coronary stent insertion for stable coronary artery disease, this does not occur in practice. Many patients also appear to continue DAPT longer than guidelines recommend, which may put them at unnecessarily elevated risk of bleeding events.

Cardiovascular magnetic resonance in emergency patients with multivessel disease or unobstructed coronary arteries: a cost-effectiveness analysis in the UK

OBJECTIVE

To identify the key drivers of cost-effectiveness for cardiovascular magnetic resonance (CMR) when patients activate the primary percutaneous coronary intervention (PPCI) pathway.

DESIGN

Economic decision models for two patient subgroups populated from secondary sources, each with a 1 year time horizon from the perspective of the National Health Service (NHS) and personal social services in the UK.

SETTING

Usual care (with or without CMR) in the NHS.

PARTICIPANTS

Patients who activated the PPCI pathway, and for Model 1: underwent an emergency coronary angiogram and PPCI, and were found to have multivessel coronary artery disease. For Model 2: underwent an emergency coronary angiogram and were found to have unobstructed coronary arteries.

INTERVENTIONS

Model 1 (multivessel disease) compared two different ischaemia testing methods, CMR or fractional flow reserve (FFR), versus stress echocardiography. Model 2 (unobstructed arteries) compared CMR with standard echocardiography versus standard echocardiography alone.

MAIN OUTCOME MEASURES

Key drivers of cost-effectiveness for CMR, incremental costs and quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios.

RESULTS

In both models, the incremental costs and QALYs between CMR (or FFR, Model 1) versus no CMR (stress echocardiography, Model 1 and standard echocardiography, Model 2) were small (CMR: -£64 (95% CI -£232 to £187)/FFR: £360 (95% CI -£116 to £844) and CMR/FFR: 0.0012 QALYs (95% CI -0.0076 to 0.0093)) and (£98 (95% CI -£199 to £488) and 0.0005 QALYs (95% CI -0.0050 to 0.0077)), respectively. The diagnostic accuracy of the tests was the key driver of cost-effectiveness for both patient groups.

CONCLUSIONS

If CMR were introduced for all subgroups of patients who activate the PPCI pathway, it is likely that diagnostic accuracy would be a key determinant of its cost-effectiveness. Further research is needed to definitively answer whether revascularisation guided by CMR or FFR leads to different clinical outcomes in acute coronary syndrome patients with multivessel disease.

PCI Alternative Using Sustained Exercise (PAUSE): Rationale and trial design

Cardiovascular disease (CVD) currently claims nearly one million lives yearly in the US, accounting for nearly 40% of all deaths. Coronary artery disease (CAD) accounts for the largest number of these deaths. While efforts aimed at treating CAD in recent decades have concentrated on surgical and catheter-based interventions, limited resources have been directed toward prevention and rehabilitation. CAD is commonly treated using percutaneous coronary intervention (PCI), and this treatment has increased exponentially since its adoption over three decades ago. Recent questions have been raised regarding the cost-effectiveness of PCI, the extent to which PCI is overused, and whether selected patients may benefit from optimal medical therapy in lieu of PCI. One alternative therapy that has been shown to improve outcomes in CAD is exercise therapy; exercise programs have been shown to have numerous physiological benefits, and a growing number of studies have demonstrated reductions in mortality. Given the high volume of PCI, its high cost, its lack of effect on survival and the potential for alternative treatments including exercise, the current study is termed "PCI Alternative Using Sustained Exercise" (PAUSE). The primary aim of PAUSE is to determine whether patients randomized to exercise and lifestyle intervention have greater improvement in coronary function and anatomy compared to those randomized to PCI. Coronary function and anatomy is determined using positron emission tomography combined with computed tomographic angiography (PET/CTA). Our objective is to demonstrate the utility of a non-invasive technology to document the efficacy of exercise as an alternative treatment strategy to PCI.

Relation of Length of Stay to Unplanned Readmissions for Patients Who Undergo Elective Percutaneous Coronary Intervention

The cost of inpatient percutaneous coronary interventions (PCI) procedure is related to length of stay (LOS). It is unknown, how LOS may be associated with readmission rates and costs of index PCI and readmissions in elective PCI. This study aims to evaluate rates, predictors, causes, and costs associated with 30-day unplanned readmissions according to lLOS in patients, who underwent elective PCI. We included patients in the Nationwide Readmission Database, who were admitted to hospital from 2010 to 2014, who underwent uncomplicated elective PCI. LOS was defined as 0, 1, 2, and ≥3 days. A total of 324,345 patients were included in the analysis and the 30-day unplanned readmission was 4.75%, 4.67%, 6.44%, and 9.42% in the LOS groups 0, 1, 2, and ≥3 days, respectively. Prolonged LOS was associated with increased average total 30-day cost (index and readmission cost, 0 days $15,063, 1 day $14,693, 2 days $18,136, and ≥3 days $24,336). Compared with 0 days, the odds of readmissions were greater for 2 days (odds ratio 1.41, 95% confidence interval 1.07 to 1.87, p = 0.016) and ≥3 days (odds ratio 1.70, 95% confidence interval 1.28 to 2.24, p <0.001). Comorbidities were strong predictors of LOS and noncardiac causes, account for more than half of all causes for readmission. Longer LOS was associated with reduced incidence of readmissions for noncardiac causes such as noncardiac chest pain, but a greater rate of readmissions for heart failure. In conclusion, shorter length of stay was associated with reduced healthcare costs in elective PCI.

Clinical and Economic Analysis of Lipid Goal Attainments in Chinese Patients with Acute Coronary Syndrome Who Received Post-Percutaneous Coronary Intervention

AIM

The recommended low-density lipoprotein cholesterol (LDL-C) levels of the guideline may be appropriate for Caucasian patients but not for other ethnic groups.

METHODS

A cohort study was conducted in Hong Kong, and acute coronary syndrome (ACS) patients who received percutaneous coronary intervention (PCI) between 2005 and 2015 were enrolled. The primary outcomes of interest were the total cost of care and cardiovascular-related cost during one-year follow-up. The cost difference by lipid goal attainments was analyzed by Poisson regression with multivariate treatment effects. The clinical outcomes achieved by lipid goal attainments in terms of major adverse cardiovascular events were analyzed by multivariate Cox regression.

RESULTS

Among the 4638 patients, 79.50%, 48.64%, and 36.14% attained the LDL-C goals of ＜2.6, ＜2.0, and ＜1.8 mmol/L for one year, respectively. Only about 16% patients achieved the ≥50% reduction from baseline. None of these lipid goals was associated with a significant reduction in the total cost of care. We only identified the clinical benefits associated with the lipid goal of ＜2.6 mmol/L. Other more stringent lipid goals seemed to bring a significant economic burden on cardiovascular-related cost, but their clinical benefits were uncertain.

CONCLUSIONS

Lowering LDL-C to achieve the guideline-recommended target levels for post-PCI ACS patients may lead to fewer cardiovascular events, but it may not necessarily lead to economic benefits within one year of follow-up.

Regional to tertiary inter-hospital transfer versus in-house percutaneous coronary intervention in acute coronary syndrome

RATIONALE

To address the inaccessibility of interventional cardiac services in North Queensland a new cardiac catheterisation laboratory (CCL) was established in Mackay Base Hospital (MBH) in February 2014.

OBJECTIVE

To determine whether the provision of in-house angiography and/or percutaneous coronary intervention (PCI) 1) minimises treatment delays 2) further reduces the risk of mortality, recurrent myocardial infarction (MI) and recurrent ischaemia 3) improves patient satisfaction and 4) minimises cost expenditure compared with inter-hospital transfer for patients with acute coronary syndrome (ACS).

METHODS

We compared ACS patients who were transferred to tertiary centres from July 2012 to June 2013 with those who received in-house angiography and/or PCI from February 2015 to January 2016. The primary outcome was the composite of all-cause mortality, recurrent myocardial infarction (MI) or recurrent ischaemia at six months. Pre-specified secondary outcomes were the composite of all-cause mortality, recurrent MI or recurrent ischaemia at one month, a summated patient satisfaction score and the proportional cost savings generated between 2015 and 2016.

RESULTS

We included consecutive samples of 203 patients from July 2012 to June 2013 and 229 patients from February 2015 to January 2016. There was a reduction in the median time to treatment of 3.2 days and a reduction in the median length of stay of four days amongst all ACS patients receiving in-house angiography and/or PCI. The primary outcome occurred in 14 (6.9%) patients in the 2012 to 2013 group, as compared with 18 (7.9%) patients in the 2015 to 2016 group (OR = 0.71, 95% CI 0.24-2.1, P = 0.54). The secondary outcome at one month occurred in four (2.0%) patients in the 2012 to 2013 group, as compared with three (1.3%) patients in the 2015 to 2016 group (OR = 1.2, 95% CI 0.11-13.1, P = 0.87). There was a statistically significant improvement in the summated patient satisfaction score amongst patients who received in-house angiography and/or PCI (U = 1918, P <0.05 two tailed). A calculation of estimated cost savings showed a reduction in proportional cost of $14 481 (51%) per ACS patient receiving in house angiography and/or PCI between 2015 and 2016.

CONCLUSION

This study suggests that the provision of regional in-house angiography and/or PCI for the treatment of ACS minimises delays to invasive treatment by 3.2 days, minimises the median length of stay by four days, significantly improves patient satisfaction and reduces proportional treatment costs by $14 481 (51%) per patient. Currently, however, it appears that that in-house treatment does not further reduce the risk of mortality, recurrent MI and recurrent ischaemia at one and six months.

Health Economic Analysis of Access Site Practice in England During Changes in Practice: Insights From the British Cardiovascular Interventional Society

BACKGROUND

Transradial access (TRA) for percutaneous coronary intervention (PCI) is associated with a reduced risk of mortality compared with transfemoral access, access site-related bleeding complications, and shorter length of stay. The budget impact from a healthcare system that has largely transitioned to TRA for PCI has not been previously published.

METHODS AND RESULTS

Data from 323 656 patients undergoing PCI between 2010 and 2014 were obtained from the British Cardiovascular Intervention Society database. Costs for TRA and transfemoral access PCI were estimated based on procedure cost, length of stay, and differences in the rates of complications (major bleeding and vascular complications). In the base case, a propensity-matched data set between transfemoral access and TRA was used to directly compare the cost per PCI, whereas in the real-world analysis, the full data set was used. Across all indications and all years, TRA offered an average cost saving of £250.59 per procedure (22% reduction) versus transfemoral access with the majority of cost saving derived from reduced length of stay (£190.43) rather than direct costs of complications (£3.71). In the real-world analysis, adoption of TRA was estimated to have provided cost savings of £13.31 million across England between 2010 and 2014; however, if operators in all regions had adopted TRA at the rate of the region with the highest utilization, cost savings of £33.40 million could have been achieved.

CONCLUSIONS

The transition to TRA in England has been associated with significant cost savings across the national healthcare system, in addition to the well-established clinical benefits.

Etiologies and predictors of 30-day readmissions in patients undergoing percutaneous mechanical circulatory support-assisted percutaneous coronary intervention in the United States: Insights from the Nationwide Readmissions Database

BACKGROUND

Patients undergoing percutaneous mechanical circulatory support (pMCS)-assisted percutaneous coronary intervention (PCI) represent a high-risk group vulnerable to complications and readmissions.

HYPOTHESIS

Thirty-day readmissions after pMCS-assisted PCI are common among patients with comorbidities and account for a significant amount of healthcare spending.

METHODS

Patients undergoing PCI and pMCS (Impella, TandemHeart, or intra-aortic balloon pump) for any indication between January 1, 2012, and November 30, 2014, were selected from the Nationwide Readmissions Database. Patients were identified using appropriate ICD-9-CM codes. Clinical risk factors and complications were analyzed for association with 30-day readmission.

RESULTS

Our analysis included 29 247 patients, of which 4535 (15.5%) were readmitted within 30 days. On multivariate analysis, age ≥ 65 years, female sex, hypertension, diabetes, chronic lung disease, heart failure, prior implantable cardioverter-defibrillator, liver disease, end-stage renal disease, and length of stay ≥5 days during index hospitalization were independent predictors of 30-day readmission. Cardiac etiologies accounted for ~60% of readmissions, of which systolic or diastolic heart failure (22%), stable coronary artery disease (11.1%), acute coronary syndromes (8.9%), and nonspecific chest pain (4.0%) were the most common causes. In noncardiac causes, sepsis/septic shock (4.6%), hypotension/syncope (3.2%), gastrointestinal bleed (3.1%), and acute kidney injury (2.6%) were among the most common causes of 30-day readmissions. Mean length of stay and cost of readmissions was 4 days and $16 191, respectively.

CONCLUSIONS

Thirty-day readmissions after pMCS-assisted PCI are common and are predominantly associated with increased burden of comorbidities. Reducing readmissions for common cardiac etiologies could save substantial healthcare costs.

Comparison of the treatment practice and hospitalization cost of percutaneous coronary intervention between a teaching hospital and a general hospital in Malaysia: A cross sectional study

Introduction

The increasing disease burden of coronary artery disease (CAD) calls for sustainable cardiac service. Teaching hospitals and general hospitals in Malaysia are main providers of percutaneous coronary intervention (PCI), a common treatment for CAD. Few studies have analyzed the contemporary data on local cardiac facilities. Service expansion and budget allocation require cost evidence from various providers. We aim to compare the patient characteristics, procedural outcomes, and cost profile between a teaching hospital (TH) and a general hospital (GH).

Methods

This cross-sectional study was conducted from the healthcare providers’ perspective from January 1^st to June 30^th 2014. TH is a university teaching hospital in the capital city, while GH is a state-level general hospital. Both are government-funded cardiac referral centers. Clinical data was extracted from a national cardiac registry. Cost data was collected using mixed method of top-down and bottom-up approaches. Total hospitalization cost per PCI patient was summed up from the costs of ward admission and cardiac catheterization laboratory utilization. Clinical characteristics were compared with chi-square and independent t-test, while hospitalization length and cost were analyzed using Mann-Whitney test.

Results

The mean hospitalization cost was RM 12,117 (USD 3,366) at GH and RM 16,289 (USD 4,525) at TH. The higher cost at TH can be attributed to worse patients’ comorbidities and cardiac status. In contrast, GH recorded a lower mean length of stay as more patients had same-day discharge, resulting in 29% reduction in mean cost of admission compared to TH. For both hospitals, PCI consumables accounted for the biggest proportion of total cost.

Conclusions

The high PCI consumables cost highlighted the importance of cost-effective purchasing mechanism. Findings on the heterogeneity of the patients, treatment practice and hospitalization cost between TH and GH are vital for formulation of cost-saving strategies to ensure sustainable and equitable cardiac service in Malaysia.

Protocol for an economic evaluation of the randomised controlled trial of culprit lesion only PCI versus immediate multivessel PCI in acute myocardial infarction complicated by cardiogenic shock: CULPRIT-SHOCK trial

INTRODUCTION

Emergency percutaneous coronary intervention (PCI) of the culprit lesion for patients with acute myocardial infarctions is an accepted practice. A majority of patients present with multivessel disease with additional relevant stenoses apart from the culprit lesion. In haemodynamically stable patients, there is increasing evidence from randomised trials to support the practice of immediate complete revascularisation. However, in the presence of cardiogenic shock, the optimal management strategy for additional non-culprit lesions is unknown. A multicentre randomised controlled trial, CULPRIT-SHOCK, is examining whether culprit vessel only PCI with potentially subsequent staged revascularisation is more effective than immediate multivessel PCI. This paper describes the intended economic evaluation of the trial.

METHODS AND ANALYSIS

The economic evaluation will be conducted using a pre-trial decision model and within-trial analysis. The modelling-based analysis will provide expected costs and health outcomes, and incremental cost-effectiveness ratio over the lifetime for the cohort of patients included in the trial. The within-trial analysis will provide estimates of cost per life saved at 30 days and in 1 year, and estimates of health-related quality of life. Bootstrapping and cost-effectiveness acceptability curves will be used to address any uncertainty around these estimates. Different types of regression models within a generalised estimating equation framework will be used to examine how the total cost and quality-adjusted life years are explained by patients' characteristics, revascularisation strategy, country and centre. The cost-effectiveness analysis will be from the perspective of each country's national health services, where costs will be expressed in euros adjusted for purchasing power parity.

ETHICS AND DISSEMINATION

Ethical approval for the study was granted by the local Ethics Committee at each recruiting centre. The economic evaluation analyses will be published in peer-reviewed journals of the concerned literature and communicated through the profiles of the authors at www.twitter.com and www.researchgate.net.

TRIAL REGISTRATION NUMBER

NCT01927549; Pre-results.

Long-term outcomes after acute myocardial infarction in countries with different socioeconomic environments: an international prospective cohort study

BACKGROUND

Hospital-based data on the impact of socioeconomic environment on long-term survival after myocardial infarction (MI) are lacking. We compared outcome and quality of secondary prevention in patients after MI living in three different socioeconomic environments including patients from three tertiary-care teaching hospitals with similar service population size in Switzerland, Poland and Ukraine.

METHODS

This is a prospective cohort study of patients with a first MI in three different tertiary-care teaching hospitals in Bern (Switzerland), Gdansk (Poland) and Lutsk (Ukraine) during the acute phase in the year 2010 and follow-up of these patients with a questionnaire and, if necessary, telephone interviews 3.5 years after the acute event. The study cohort comprises all consecutive patients hospitalised in every one of the three study centres during the year 2010 for a first MI in the age ≤75 years who survived ≥30 days.

RESULTS

The proportion of patients with ST-segment elevation myocardial infarction (STEMI) was high in Gdansk (Poland) (80%) and in Lutsk (Ukraine) (74%), while the ratio of STEMIs to non-STEMIs was nearly 50:50 in Bern (Switzerland) (50.6% STEMIs). Percutaneous coronary intervention (PCI) was the first choice therapy both in Bern (Switzerland) (100%) and in Gdansk (Poland) (92%), while it was not performed at all in Lutsk (Ukraine). We found substantial differences in treatment and also in secondary prevention interventions including cardiac rehabilitation. All-cause mortality at 3.5 year follow-up was 4.6% in Bern (Switzerland), 8.5% in Gdansk (Poland) and 14.6% in Lutsk (Ukraine).

CONCLUSION

Substantial differences in treatment and secondary prevention measures according to low-income, middle-income and high-income socioeconomic situation are associated with a threefold difference in mortality 3.5 years after the acute event. Countries with low socioeconomic environment should increase efforts and be supported to improve care including secondary prevention in particular for MI patients. A greater number of PCIs per million inhabitants itself does not guarantee lower mortality scores.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Manual Compression versus Vascular Closing Device for Closing Access Puncture Site in Femoral Left-Heart Catheterization and Percutaneous Coronary Interventions: A Retrospective Cross-Sectional Comparison of Costs and Effects in Inpatient Care

OBJECTIVES

To compare complication rates, length of hospital stay, and resulting costs between the use of manual compression and a vascular closing device (VCD) in both diagnostic and interventional catheterization in a German university hospital setting.

METHODS

A stratified analysis according to risk profiles was used to compare the risk of complications in a retrospective cross-sectional single-center study. Differences in costs and length of hospital stay were calculated using the recycled predictions method, based on regression coefficients from generalized linear models with gamma distribution. All models were adjusted for propensity score and possible confounders, such as age, sex, and comorbidities. The analysis was performed separately for diagnostic and interventional catheterization.

RESULTS

The unadjusted relative risk (RR) of complications was not significantly different in diagnostic catheterization when a VCD was used (RR = 0.70; 95% confidence interval [CI] 0.22-2.16) but significantly lower in interventional catheterization (RR = 0.44; 95% CI 0.21-0.93). Costs were on average €275 lower in the diagnostic group (95% CI -€478.0 to -€64.9; P = 0.006) and around €373 lower in the interventional group (95% CI -€630.0 to -€104.2; P = 0.014) when a VCD was used. The adjusted estimated average length of stay did not differ significantly between the use of a VCD and manual compression in both types of catheterization.

CONCLUSIONS

In interventional catheterization, VCDs significantly reduced unadjusted complication rates, as well as costs. A significant reduction in costs also supports their usage in diagnostic catheterization on a larger scale.

Cost of elective percutaneous coronary intervention in Malaysia: a multicentre cross-sectional costing study

OBJECTIVES

Limitations in the quality and access of cost data from low-income and middle-income countries constrain the implementation of economic evaluations. With the increasing prevalence of coronary artery disease in Malaysia, cost information is vital for cardiac service expansion. We aim to calculate the hospitalisation cost of percutaneous coronary intervention (PCI), using a data collection method customised to local setting of limited data availability.

DESIGN

This is a cross-sectional costing study from the perspective of healthcare providers, using top-down approach, from January to June 2014. Cost items under each unit of analysis involved in the provision of PCI service were identified, valuated and calculated to produce unit cost estimates.

SETTING

Five public cardiac centres participated. All the centres provide full-fledged cardiology services. They are also the tertiary referral centres of their respective regions.

PARTICIPANTS

The cost was calculated for elective PCI procedure in each centre. PCI conducted for urgent/emergent indication or for patients with shock and haemodynamic instability were excluded.

PRIMARY AND SECONDARY OUTCOME MEASURES

The outcome measures of interest were the unit costs at the two units of analysis, namely cardiac ward admission and cardiac catheterisation utilisation, which made up the total hospitalisation cost.

RESULTS

The average hospitalisation cost ranged between RM11 471 (US$3186) and RM14 465 (US$4018). PCI consumables were the dominant cost item at all centres. The centre with daycare establishment recorded the lowest admission cost and total hospitalisation cost.

CONCLUSIONS

Comprehensive results from all centres enable comparison at the levels of cost items, unit of analysis and total costs. This generates important information on cost variations between centres, thus providing valuable guidance for service planning. Alternative procurement practices for PCI consumables may deliver cost reduction. For countries with limited data availability, costing method tailored based on country setting can be used for the purpose of economic evaluations.

REGISTRATION

Malaysian MOH Medical Research and Ethics Committee (ID: NMRR-13-1403-18234 IIR).

CYP2C19 LOF and GOF-Guided Antiplatelet Therapy in Patients with Acute Coronary Syndrome: A Cost-Effectiveness Analysis

PURPOSE

This study aimed to examine the cost-effectiveness of CYP2C19 loss-of-function and gain-of-function allele guided (LOF/GOF-guided) antiplatelet therapy in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI).

METHODS

A life-long decision-analytic model was designed to simulate outcomes of three strategies: universal clopidogrel (75 mg daily), universal alternative P2Y₁₂ inhibitor (prasugrel 10 mg daily or ticagrelor 90 mg twice daily), and LOF/GOF-guided therapy (LOF/GOF allele carriers receiving alternative P2Y₁₂ inhibitor, wild-type patients receiving clopidogrel). Model outcomes included clinical event rates, quality-adjusted life-years (QALYs) gained and direct medical costs from perspective of US healthcare provider.

RESULTS

Base-case analysis found nonfatal myocardial infarction (5.62%) and stent thrombosis (1.2%) to be the lowest in universal alternative P2Y₁₂ inhibitor arm, whereas nonfatal stroke (0.72%), cardiovascular death (2.42%), and major bleeding (2.73%) were lowest in LOF/GOF-guided group. LOF/GOF-guided arm gained the highest QALYs (7.5301 QALYs) at lowest life-long cost (USD 76,450). One-way sensitivity analysis showed base-case results were subject to the hazard ratio of cardiovascular death in carriers versus non-carriers of LOF allele and hazard ratio of cardiovascular death in non-carriers of LOF allele versus general patients. In probabilistic sensitivity analysis of 10,000 Monte Carlo simulations, LOF/GOF-guided therapy, universal alternative P2Y₁₂ inhibitor, and universal clopidogrel were the preferred strategy (willingness-to-pay threshold = 50,000 USD/QALY) in 99.07%, 0.04%, and 0.89% of time, respectively.

CONCLUSIONS

Using both CYP2C19 GOF and LOF alleles to select antiplatelet therapy appears to be the preferred antiplatelet strategy over universal clopidogrel and universal alternative P2Y₁₂ inhibitor therapy for ACS patients with PCI.

Percutaneous Ventricular Assist Devices: A Health Technology Assessment

BACKGROUND

Percutaneous coronary intervention (PCI)-using a catheter to place a stent to keep blood vessels open-is increasingly used for high-risk patients who cannot undergo surgery. Cardiogenic shock (when the heart suddenly cannot pump enough blood) is associated with a high mortality rate. The percutaneous ventricular assist device can help control blood pressure and increase blood flow in these high-risk conditions. This health technology assessment examined the benefits, harms, and budget impact of the Impella percutaneous ventricular assist device in high-risk PCI and cardiogenic shock. We also analyzed cost-effectiveness of the Impella device in high-risk PCI.

METHODS

We performed a systematic search of the literature for studies examining the effects of the Impella percutaneous ventricular assist device in high-risk PCI and cardiogenic shock, and appraised the evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria, focusing on hemodynamic stability, mortality, major adverse cardiac events, bleeding, and vascular complications. We developed a Markov decision-analytical model to assess the cost- effectiveness of Impella devices versus intra-aortic balloon pumps (IABPs), calculated incremental cost-effectiveness ratios (ICERs) using a 10-year time horizon, and conducted sensitivity analyses to examine the robustness of the estimates. The economic model was conducted from the perspective of the Ontario Ministry of Health and Long-Term Care.

RESULTS

Eighteen studies (one randomized controlled trial and 10 observational studies for high-risk PCI, and one randomized controlled trial and six observational studies for cardiogenic shock) were included in the clinical review. Compared with IABPs, Impella 2.5, one model of the device, improved hemodynamic parameters (GRADE low-very low) but showed no significant difference in mortality (GRADE low), major adverse cardiac events (GRADE low), bleeding (GRADE low), or vascular complications (GRADE low) in high-risk PCI and cardiogenic shock. No randomized controlled trials or prospective observational studies with a control group have studied Impella CP and Impella 5.0 (other models of the device) in patients undergoing high-risk PCI or patients with cardiogenic shock. The economic model predicted that treatment with the Impella device would have fewer quality-adjusted life-years (QALYs) and higher costs than IABP in high-risk PCI patients. These observations were consistent even when uncertainty in model inputs and parameters was considered. We estimated that adopting Impella would increase costs by $2.9 to $11.5 million per year.

CONCLUSIONS

On the basis of evidence of low to very low quality, Impella 2.5 devices were associated with improved hemodynamic stability, but had mortality rates and safety profile similar to IABPs in high-risk PCI and cardiogenic shock. Our cost-effectiveness analysis indicated that Impella 2.5 is likely associated with greater costs and fewer quality-adjusted life years than IABP.

Appropriateness-based reimbursement of elective invasive coronary procedures in low- and middle-income countries: Preliminary assessment of feasibility in India

BACKGROUND

Elective coronary interventional procedures are often overused and sometimes inappropriately used. The incentives for overuse are greater in low- and middle-income countries, where much of healthcare is provided by poorly regulated, fee-for-service systems. Overuse and inappropriate use increase healthcare costs and are potentially harmful to patients. Linking appropriate use of elective procedures to their reimbursement might deter overuse.

METHODS

We explored the feasibility of introducing appropriateness criteria as a precondition to settling reimbursement claims in a publicly funded health insurance scheme in Maharashtra, India. Clinical algorithms were developed from the current best-practice criteria and used to determine appropriateness at the time of obtaining pre-authorization for elective percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) surgeries. The number of PCIs as a proportion of the total number of procedures reimbursed under the scheme was the primary outcome measure. This proportion was compared for 1-year periods before and after implementation of appropriateness-based reimbursement, using the chi-square test. Comparisons were also made separately for public and private hospitals. The change in the proportion of CABG surgeries over the same time periods was used as a comparator (as they are less subject to inappropriate use).

RESULTS

The insurance scheme provided cover to a population of 20 424 585 (18.2% of the population of Maharashtra) in 8 districts, through 106 hospitals (73 private and 33 public). There was a 12.3% (95% CI 8.9%-15.5%, p=0.0001) reduction in the proportion of PCIs performed in the 1-year period after the introduction of appropriateness-based reimbursement. The reduction was similar for public and private hospitals. There was no significant change in the proportion of CABG surgeries (2.3% v. 2.2%, p=0.20). At current rates, use of appropriateness-based reimbursement would result in approximately 783 (95% CI 483-1099) less PCIs with potential annual savings of about ₹ 57 million (US$ 0.93 million; 95% CI 0.57-1.3) to the government scheme.

CONCLUSIONS

It seems feasible to implement an appropriateness-based system for reimbursement of elective coronary interventional procedures in a government-funded health insurance scheme in a developing country. This potentially cost-saving approach may reduce inappropriate use.

Cost Savings Associated With Implementation of Peer-Reviewed Appropriate Use Criteria for Percutaneous Coronary Interventions

Appropriate use criteria (AUC) for coronary revascularization have been developed to provide a practical standard to assess the quality of patient selection for percutaneous coronary interventions (PCI). However, the economic impact of AUC implementation has yet to be quantified. A peer-reviewed AUC process was implemented at UnityPoint Trinity in February 2012. Volumes of PCI cases were measured in 12-month intervals for 2 years after AUC implementation and compared with volumes from the corresponding 12-month intervals in the 2 years preceding implementation of AUC. Hospital reimbursement was averaged based on each year's payer mix and reimbursement contracts. In the 2 years preceding AUC implementation, PCI volumes were similar (1,414 in 2010 and 1,411 in 2011). After AUC implementation, volumes of PCI decreased by 17% in both 2012 and 2013. From 2012 to 2013, the relative ratio of elective to acute interventions decreased from 1.36 to 1.02. In the same time frame, the proportion of appropriate PCI significantly increased from 76% to 84% (p <0.001). Total hospital reimbursement for PCI decreased by 36% after AUC implementation. In conclusion, implementation of a peer-reviewed AUC process at the UnityPoint Trinity led to significant cost savings through a large decrease in volume of PCI with concurrent improvement in PCI appropriateness.

Understanding the economic impact of intravascular ultrasound (IVUS)

AIMS

To examine the cost-effectiveness of intravascular ultrasound (IVUS) use during percutaneous coronary intervention (PCI) with drug-eluting stents (DES) in treating coronary artery disease (CAD).

METHODS AND RESULTS

A Markov model was constructed with a lifetime horizon to compare costs and health outcomes between IVUS-guided PCI and PCI guided solely by angiography from an Italian healthcare payer perspective. The population examined included CAD patients undergoing PCI with DES. From a healthcare payer perspective, the resulting incremental cost-effectiveness ratio (ICER) per quality-adjusted life-year was negative in the base-case scenario (i.e., IVUS benefit assumed to persist beyond the first year). When IVUS benefit was assumed to be limited to the first year, the ICER increased to €9,624. This conclusion remained consistent even when scenarios varied regarding the duration of the device's effect. Furthermore, benefits of using IVUS were greater for patients with acute coronary syndrome, renal insufficiency, and diabetes.

CONCLUSIONS

Using IVUS with angiography is a dominant strategy in Italy, and results demonstrate that it is desirable to target those at a greater risk of restenosis (i.e., patients with diabetes, chronic kidney disease, and acute coronary syndrome), who tend to benefit more from accurate stent implantation. Further information is necessary regarding the long-term benefits of IVUS, however sensitivity analysis presented in this research demonstrates a strong argument supporting the cost-effectiveness of IVUS.

Cost-effectiveness of a European ST-segment elevation myocardial infarction network: results from the Catalan Codi Infart network

OBJECTIVES

To evaluate the cost-effectiveness of the ST-segment elevation myocardial infarction (STEMI) network of Catalonia (Codi Infart).

DESIGN

Cost-utility analysis.

SETTING

The analysis was from the Catalonian Autonomous Community in Spain, with a population of about 7.5 million people.

PARTICIPANTS

Patients with STEMI treated within the autonomous community of Catalonia (Spain) included in the IAM CAT II-IV and Codi Infart registries.

OUTCOME MEASURES

Costs included hospitalisation, procedures and additional personnel and were obtained according to the reperfusion strategy. Clinical outcomes were defined as 30-day avoided mortality and quality-adjusted life-years (QALYs), before (N=356) and after network implementation (N=2140).

RESULTS

A substitution effect and a technology effect were observed; aggregate costs increased by 2.6%. The substitution effect resulted from increased use of primary coronary angioplasty, a relatively expensive procedure and a decrease in fibrinolysis. Primary coronary angioplasty increased from 31% to 89% with the network, and fibrinolysis decreased from 37% to 3%. Rescue coronary angioplasty declined from 11% to 4%, and no reperfusion from 21% to 4%. The technological effect was related to improvements in the percutaneous coronary intervention procedure that increased efficiency, reducing the average length of the hospital stay. Mean costs per patient decreased from €8306 to €7874 for patients with primary coronary angioplasty. Clinical outcomes in patients treated with primary coronary angioplasty did not change significantly, although 30-day mortality decreased from 7.5% to 5.6%. The incremental cost-effectiveness ratio resulted in an extra cost of €4355 per life saved (30-day mortality) and €495 per QALY. Below a cost threshold of €30,000, results were sensitive to variations in costs and outcomes.

CONCLUSIONS

The Catalan STEMI network (Codi Infart) is cost-efficient. Further studies are needed in geopolitical different scenarios.

Socio-economic Inequality in the Use of Procedures and Mortality Among AMI Patients: Quantifying the Effects Along Different Paths

It is not known whether inequality in access to cardiac procedures translates into inequality in mortality. In this paper, we use a path analysis model to quantify both the direct effect of socio-economic status on mortality and the indirect effect of socio-economic status on mortality as mediated by the provision of cardiac procedures. The study links microdata from the Finnish and Norwegian national patient registers describing treatment episodes with data from prescription registers, causes-of-death registers and registers covering education and income. We show that socio-economic variables affect access to percutaneous coronary intervention in both countries, but that these effects are only moderate and that the indirect effects of the socio-economic factors on mortality through access to percutaneous coronary intervention are minor. The direct effects of income and education on mortality are significantly larger. We conclude that the socio-economic gradient in the use of percutaneous coronary intervention adds to socio-economic differences in mortality to little or no extent.

Clinical and economic effectiveness of percutaneous ventricular assist devices for high-risk patients undergoing percutaneous coronary intervention

BACKGROUND

Comparative effectiveness research (CER) is taking a more prominent role in formalizing hospital treatment protocols and health-care coverage policies by having health-care providers consider the impact of new devices on costs and outcomes. CER balances the need for innovation with fiscal responsibility and evidence-based care. This study compared the clinical and economic impact of percutaneous ventricular assist devices (pVAD) with intraaortic balloon pumps for high-risk patients undergoing percutaneous coronary intervention (PCI).

METHODS

This study conducted a review of all comparative randomized control trials of the pVADS (Impella and TandemHeart) vs IABP for patients undergoing high-risk percutaneous coronary intervention (PCI). A retrospective analysis of the 2010 and 2011 Medicare MEDPAR data files was also performed to compare procedural costs and hospital length of stay (LOS). Readmission rates between the devices were also studied.

RESULTS

Based on available trials, there is no significant clinical benefit with pVAD compared to IABP. Use of pVADs is associated with increased length of Intensive Care Unit stay and a total longer LOS. The incremental budget impact for pVADs was $33,957,839 for the United States hospital system (2010-2011).

CONCLUSIONS

pVADs are not associated with improved clinical outcomes, reduced hospital length of stay, or reduced readmission rates. Management of high-risk PCI and cardiogenic shock patients with IABP is more cost effective than a routine use of pVADS. Use of IABP as initial therapy in high-risk PCI and cardiogenic shock patients may result in savings of up to $2.5 billion annually of incremental costs to the hospital system.

Comparison of healthcare resource utilization and costs in patients hospitalized for acute coronary syndrome managed with percutaneous coronary intervention and receiving prasugrel or ticagrelor

OBJECTIVE

To compare healthcare resource utilization (HCRU) and healthcare costs in patients with acute coronary syndrome (ACS) managed with percutaneous coronary intervention (PCI) and treated with prasugrel or ticagrelor.

METHODS

Hospital charge master data were used to identify ACS-PCI patients aged ≥ 18 years with ≥ 1 in-hospital claim for prasugrel or ticagrelor between August 1, 2011-April 30, 2013. Treatment groups were propensity matched for baseline and index hospitalization characteristics. HCRU and costs were assessed through 90-days post-discharge. Costs were determined based on hospital-specific cost-to-charge ratios and adjusted to 2013 US dollars.

RESULTS

Before matching, ticagrelor patients were older, more-often female, and had increased cardiovascular (CV) and bleeding risks compared with prasugrel patients. Propensity-matched length of index hospital stay (4.7 vs 4.9 days, p = 0.23) and risk for all-cause [30-day: relative risk (RR) = 0.86; 95% CI = 0.73-1.0; 90-day: RR = 0.90; 95% CI = 0.80-1.0, and CV-related (30-day: RR = 0.77; 95% CI = 0.59-1.0; 90-day: RR = 0.89; 95% CI = 0.73-1.1) re-hospitalizations did not significantly differ between prasugrel and ticagrelor, respectively. Compared to ticagrelor, the propensity-matched risk of re-hospitalization for myocardial infarction (MI) (30-day: RR = 0.39; 95% CI = 0.21-0.75; 90-day: RR = 0.53; 95% CI = 0.34-0.81) and an outpatient medical encounter for dyspnea (30-day: RR = 0.49; 95% CI = 0.33-0.74; 90-day: RR = 0.60; 95% CI = 0.46-0.80) were significantly lower for prasugrel patients, with no significant differences in bleeding encounters between groups (30-day: RR =  0.87; 95% CI = 0.54-1.40; 90-day: RR = 1.0; 95% CI = 0.71-1.50). Matched total healthcare costs were not significantly different between groups during the index hospitalization ($36,011 vs $37,247, p = 0.21), 30-days post-discharge ($2007 vs $2522, p = 0.48), 90-days post-discharge ($4564 vs $5242, p = 0.49), and aggregate of the index hospitalization through 90-day follow-up ($40,576 vs $42,494, p = 0.09) timeframes.

CONCLUSIONS

Re-hospitalization for MI and outpatient encounters for dyspnea were lower in prasugrel treated than in ticagrelor treated ACS-PCI patients up to 90-days post-index hospitalization discharge, with no difference in bleeding encounters or healthcare costs between the two populations. This data supports the utility of prasugrel in routine clinical practice. These findings should be considered within limitations of observational research.

Economic outcomes with prasugrel versus clopidogrel in acute coronary syndrome patients: observations from prasugrel users and matched clopidogrel users

OBJECTIVE

To compare healthcare costs between clopidogrel and prasugrel over 30-day and 365-day periods after discharge from the hospital or emergency room (ER) in patients treated with prasugrel who were hospitalized or had an ER visit for an acute coronary syndrome (ACS) event.

METHODS

This retrospective observational study was based on claims from January 2009-July 2012 in the Truven Health Analytics MarketScan database. Clopidogrel patients were propensity-score matched 1:1 to prasugrel-treated patients. Lin's frequentist cost history method for censored data and Bayesian zero-inflated gamma regression models were used to analyze healthcare costs.

RESULTS

The clopidogrel/prasugrel matched-cohort included 10,963 well-matched pairs of patients. Lin's frequentist analysis showed that outpatient visit costs were significantly lower for clopidogrel than prasugrel after 30 days of follow-up. At 30 days, Bayesian data analysis showed strong evidence that clopidogrel was superior to prasugrel for all-cause and ACS-related hospitalization costs and showed very strong evidence that clopidogrel was superior to prasugrel for all-cause and ACS-related outpatient visit costs. At 365 days, Bayesian data analysis showed strong evidence that clopidogrel was superior to prasugrel for all-cause outpatient visit costs and very strong evidence that clopidogrel was superior to prasugrel for ACS-related outpatient visit costs. Point estimates of the all-cause and ACS-related ER visit costs at 30 days and 365 days were similar, but statistical results were inconclusive because of the large variability in this outcome variable.

CONCLUSION

Based on retrospective observational data in a real-world setting, all-cause and ACS-related hospitalization and outpatient visit costs were lower for clopidogrel than prasugrel over 30 days after discharge from a hospitalization or ER visit associated with ACS in patients treated with prasugrel. At 365 days the difference in all-cause and ACS-related outpatient costs remained, but there was little evidence of a difference in either all-cause or ACS-related hospitalization costs.

Cost implication of an early invasive strategy on weekdays and weekends in patients with acute coronary syndromes

BACKGROUND

Early invasive intervention is associated with shorter length of stay (LOS) and similar outcomes in a delayed strategy in lower-risk patients with non-ST segment elevation acute coronary syndromes (NSTEACS), but is superior in higher-risk patients. However, early invasive intervention might be constrained by the need to mobilize the on-call team on weekends. We evaluated costs associated with an early vs delayed invasive intervention strategy, including patients who present on weekends.

METHODS

Health care utilization was extracted from the Timing of Intervention in Acute Coronary Syndromes (TIMACS) trial for Canadian patients from case report forms. Only direct costs were considered and only hospitalization events were included. Canadian unit costs were applied to health care resources consumed for all patients. Sensitivity and subgroup analyses were performed.

RESULTS

Early invasive intervention reduced LOS costs by $2808 (95% confidence interval [CI], $4,629-$987). Total costs per Canadian patient for early invasive intervention were $16,579 (95% CI, $14,949-$18,209) compared with $19,517 (95% CI, $17,897-$21,136) for the delayed invasive approach. This resulted in a savings of $2938 (95% CI, $5236-$640). Findings were confirmed using bootstrap simulation. Sensitivity analyses confirmed savings regardless of proportion of cases done on weekends. All subgroup costs favoured early intervention.

CONCLUSIONS

Early invasive strategy was cost-saving, even on weekends, for Canadian NSTEACS patients because of significant LOS savings. Because many high-risk NSTEACS patients receive delayed intervention because of weekend catheterization laboratory status, these findings support opening catheterization laboratories on weekends to facilitate the use of early invasive intervention.

Socioeconomic inequalities in quality of care and outcomes among patients with acute coronary syndrome in the modern era of drug eluting stents

BACKGROUND

The rapidly changing landscape of percutaneous coronary intervention provides a unique model for examining disparities over time. Previous studies have not examined socioeconomic inequalities in the current era of drug eluting stents (DES).

METHODS AND RESULTS

We analyzed 835 070 hospitalizations for acute coronary syndrome (ACS) from the Healthcare Cost and Utilization Project across all insurance types from 2008 to 2011, examining whether quality of care and outcomes for patients with ACS differed by income (based on zip code of residence) with adjustment for patient characteristics and clustering by hospital. We found that lower-income patients were less likely to receive an angiogram within 24 hours of a ST elevation myocardial infarction (STEMI) (69.5% for IQ1 versus 73.7% for IQ4, P<0.0001, OR 0.79 [0.68 to 0.91]) or within 48 hours of a Non-STEMI (47.6% for IQ1 versus 51.8% for IQ4, P<0.0001, OR 0.86 [0.75 to 0.99]). Lower income was associated with less use of a DES (64.7% for IQ1 versus 71.2% for IQ4, P<0.0001, OR 0.83 [0.74 to 0.93]). However, no differences were found for coronary artery bypass surgery. Among STEMI patients, lower-income patients also had slightly increased adjusted mortality rates (10.8% for IQ1 versus 9.4% for IQ4, P<0.0001, OR 1.17 [1.11 to 1.25]). After further adjusting for time to reperfusion among STEMI patients, mortality differences across income groups decreased.

CONCLUSIONS

For the most well accepted procedural treatments for ACS, income inequalities have faded. However, such inequalities have persisted for DES use, a relatively expensive and until recently, controversial revascularization procedure. Differences in mortality are significantly associated with differences in time to primary PCI, suggesting an important target for understanding why these inequalities persist.

Evaluation of long-term clinical and health service outcomes following coronary artery revascularisation in Western Australia (WACARP): a population-based cohort study protocol

INTRODUCTION

Coronary artery bypass grafting (CABG) and percutaneous coronary interventions (PCI) are procedures commonly performed on patients with significant obstructive coronary artery disease to relieve symptoms of ischaemia, improve survival or both. Although the efficacy of both procedures at the individual level has been established, the impact of advances in coronary artery revascularisation procedures (CARP) on long-term outcomes and cost-effectiveness at the population level are yet to be assessed. Our aim is to evaluate a minimum of 6-year outcomes and costs for the total population of patients who had CARP in Western Australia (WA) in 2000-2005.

METHODS AND ANALYSIS

This retrospective population cohort study will link clinical and administrative health data for a previously defined cohort including all patients in WA who had a CARP in the period 2000-2005. The cohort consists of 19,014 patients who had 21,175 procedures (15,429 PCI and 5746 CABG). We are now collecting a minimum of 6 years follow-up of morbidity and mortality data for the cohort using the WA Data Linkage System, clinical registries and hospital records, with 12 years follow-up for cases in the year 2000. Comparison of long-term outcomes for different CARP will be reported (PCI vs CABG; bare metal stents vs drug-eluting stents vs CABG). Cost-effectiveness analysis of CARP from the perspective of the healthcare sector will be performed using individual level cost data and average costs from Australian Refined Diagnosis Related Groups.

ETHICS AND DISSEMINATION

This study has received ethics approval from the University of Western Australia, the Western Australian Department of Health and all participating hospitals. Being a large population cohort study, approval included a waiver of informed consent. All findings will be presented at local, national and international healthcare/academic conferences and published in peer-reviewed journals.

Cardiologist service volume, percutaneous coronary intervention and hospital level in relation to medical costs and mortality in patients with acute myocardial infarction: a nationwide study

BACKGROUND

We explore whether cardiologist service volume, hospital level and percutaneous coronary intervention (PCI) are associated with medical costs and acute myocardial infarction (AMI) mortality.

METHODS

From the 1997-2010 Taiwan National Health Insurance Research Database of the National Health Research Institute, we identified AMI patients and performed multiple regression analyses to explore the relationships among the different hospital levels and treatment factors.

RESULTS

We identified 2942 patients with AMI in medical centers and 4325 patients with AMI in regional hospitals. Cardiologist service volume, performing PCI and medical costs per patient were higher in medical centers than in regional hospitals (P < 0.0001). However, the two hospital levels did not differ significantly in in-hospital mortality (P = 0.1557). Post hoc analysis showed significant differences in in-hospital mortality rate and in medical costs among the eight groups subdivided on the basis of hospital level, cardiologist service volume, and whether PCI was performed (P < 0.001 and P = 0.001, respectively).

CONCLUSIONS

These results highlight the importance of encouraging hospitals to develop PCI capability and increase their cardiologist service volume after taking medical costs into account. Transferring AMI patients to hospitals with higher cardiologist service volume and PCI performed can also be very important.

Treatment for stable coronary artery disease: a network meta-analysis of cost-effectiveness studies

Introduction and Objectives

Numerous studies have assessed cost-effectiveness of different treatment modalities for stable angina. Direct comparisons, however, are uncommon. We therefore set out to compare the efficacy and mean cost per patient after 1 and 3 years of follow-up, of the following treatments as assessed in randomized controlled trials (RCT): medical therapy (MT), percutaneous coronary intervention (PCI) without stent (PTCA), with bare-metal stent (BMS), with drug-eluting stent (DES), and elective coronary artery bypass graft (CABG).

Methods

RCT comparing at least two of the five treatments and reporting clinical and cost data were identified by a systematic search. Clinical end-points were mortality and myocardial infarction (MI). The costs described in the different trials were standardized and expressed in US $ 2008, based on purchasing power parity. A network meta-analysis was used to compare costs.

Results

Fifteen RCT were selected. Mortality and MI rates were similar in the five treatment groups both for 1-year and 3-year follow-up. Weighted cost per patient however differed markedly for the five treatment modalities, at both one year and three years (P<0.0001). MT was the least expensive treatment modality: US $3069 and 13 864 after one and three years of follow-up, while CABG was the most costly: US $27 003 and 28 670 after one and three years. PCI, whether with plain balloon, BMS or DES came in between, but was closer to the costs of CABG.

Conclusions

Appreciable savings in health expenditures can be achieved by using MT in the management of patients with stable angina.

[Clinical and economical comparison between in-house (Make) and outsourcing (Buy) management of the cardiac catheterization laboratory from two high-volume diagnostic and interventional centers: immediate and 6-month results]

BACKGROUND

Percutaneous coronary interventions (PCI) are widespread procedures in the Italian Healthcare System, but concerns are raised about their economic sustainability. In the last decade, public hospitals have outsourced the PCI services (building and maintaining the technological instruments and the personnel) "buying" them from private companies (Buy) rather than building and maintaining them through public expenditure (Make). The aim of this study was to compare the economic and clinical impact of these two management solutions (Buy and Make) in two community hospitals located in the Turin metropolitan area (Italy).

METHODS

We conducted: 1) a quantitative assessment in order to compare differences in the economic impact between Buy and Make for providing PCI; 2) a qualitative assessment comparing the clinical characteristics of two inpatient populations undergoing PCI and then analyzing the efficacy of the procedure in-hospital and at 6-month follow-up.

RESULTS

Between January and June 2010, a total of 332 patients underwent PCI at the "degli Infermi" Hospital in Rivoli and 340 at the "Maria Vittoria" Hospital in Turin (Italy). There were no significant differences between the two populations neither about the clinical characteristics nor in procedural efficacy (either immediate or at follow-up). For 600 units of diagnostic-therapeutic pathway, the net present value at a discount rate of 3.5% of the Make project is higher than that of the Buy by €278.402,25, and is therefore the less convenient of the two solutions. The Buy solution is still the more convenient of the two at volumes <700 units.

CONCLUSIONS

Our findings show that the Buy solution, if tailored to the specific local needs, provides access to sophisticated technology without making worse quality of services and may save capital expenditure below 700 PCI/years.

Impacts of health insurance benefit design on percutaneous coronary intervention use and inpatient costs among patients with acute myocardial infarction in Shanghai, China

BACKGROUND

Currently, the most popular hospital payment method in China is fee-for-service (FFS) with a global budget cap. As of December 2009, a policy change means that heart stents are covered by public health insurance, whereas previously they were not. This policy change provides us an opportunity to study how a change in insurance benefit affected the quantity and quality of hospital services. The new policy introduced incentives for both patients and providers: it encourages patient demand for percutaneous coronary intervention (PCI) services and stent use (moral hazard effect), and discourages hospital supply due to the financial pressures of the global cap (provider gaming effect). If the provider's gaming effect dominates the moral hazard effect, actual utilisation and costs might go down, and vice versa. Our hypothesis is that patients in the higher reimbursement groups will have fewer PCIs and lower inpatient costs.

OBJECTIVE

We aimed to examine the impact of health insurance benefit design on PCI and stent use, and on inpatient costs and out-of-pocket expenses for patients with acute myocardial infarction (AMI) in Shanghai.

METHODS

We included 720 patients with AMI (467 before the benefit change and 253 after) from a large teaching tertiary hospital in Shanghai. Data were collected via review of hospital medical charts, and from the hospital billing database. Patient information collected included demographic characteristics, medical history and procedure information. All patients were categorised into four groups according to their actual reimbursement ratio: high (90-100 %), moderate (80-90 %), low (0-80 %) and none (self-paid patients). Multiple regression and difference-in-difference (DID) models were used to investigate the impacts of the health insurance benefit design on PCI and stent use, and on total hospital costs and patients' out-of-pocket expenses.

RESULTS

After the change in insurance benefit policy, compared with the self-paid group, PCI rates for the moderate and low reimbursement groups increased by 22.2 and 20.3 %, respectively, and decreased by 48.7 % for the high reimbursement group. The change in insurance benefit policy had no impact on the number of stents used. The high reimbursement group had the lowest hospital costs, and the low reimbursement group had the highest hospital costs, regardless of benefit policy change. The general linear regression results showed that the high reimbursement group had higher total hospital costs than the self-paid group, but were the lowest among all reimbursement groups after the benefit policy change (DIDh = 1,202.21, P = 0.0096). There were no significant changes in the other two groups, and there were no differences in the out-of-pocket costs across any of the insured groups.

CONCLUSIONS

Our results suggest that the benefit policy change did not impact life-saving procedures or reduce patients' burden of disease among AMI patients. The effect of 'provider gaming' was the strongest for the high reimbursement group as a result of the global budget cap pressure. The current FFS with a global budget cap is of low efficiency for cost containment and equity improvement. Payment method reforms with alignment of financial incentives to improve provider behaviour in practicing evidence-based medicine are needed in China.

Antiplatelet therapy in patients undergoing percutaneous coronary intervention: economic considerations

Percutaneous coronary intervention (PCI) is one of the most common medical procedures performed for treatment of coronary artery disease. Antiplatelet medications as adjunctive therapy for PCI are used routinely, with indications for specific agents or their combinations varying depending on the clinical scenario. While the cost-effectiveness of well-established agents has been extensively studied, newer drugs have not been evaluated as thoroughly. In addition, the clinical application of some antiplatelet drugs has recently changed, thus making older studies of cost effectiveness less applicable to the current landscape of clinical practice. This article reviews cost-effectiveness considerations of antiplatelet therapies in the treatment of coronary artery disease in patients undergoing PCI. Aspirin, P2Y12 inhibitors including clopidogrel and the newer agents prasugrel and ticagrelor, as well as glycoprotein (GP) IIb/IIIa inhibitors, are discussed. Overall, the use of dual antiplatelet therapy with aspirin and a P2Y12 inhibitor in patients undergoing PCI improves ischaemic outcomes and appears to be cost effective. The few available studies suggest that the recently approved medications prasugrel and ticagrelor are cost-effective alternatives to clopidogrel. However, no direct comparison between these two newer agents is available. The indications for GP IIb/IIIa inhibitors have changed in the current PCI era, and there is a paucity of cost-effectiveness data for their use in contemporary care.