Angina and associated healthcare costs following percutaneous coronary intervention: A real-world analysis from a multi-payer database.

OBJECTIVES: To study the contemporary, real-world clinical and economic burden associated with angina after percutaneous coronary intervention (PCI). BACKGROUND: Angina adversely affects quality of life and medical costs, yet data on real-world prevalence of angina following PCI and its associated economic consequences are limited. METHODS: In a multi-payer administrative claims database, we identified adults with incident inpatient PCI admissions between 2008 and 2011 who had at least 12 months of continuous medical and pharmacy benefits before and after the procedure. Patients were followed for up to 36 months. Using claims, we ascertained post-PCI outcomes: angina or chest pain, acute myocardial infarction, acute coronary syndrome, repeat PCI, healthcare service utilization, and costs. RESULTS: Among 51,710 study patients (mean age 61.8, 72% male), post-PCI angina or chest pain was present in 28% by 12 months and 40% by 36 months. Compared with patients who did not experience chest pain, angina or ACS, total healthcare costs in the first year after the index PCI were 1.8 times greater for patients with angina or chest pain ($32,437 vs. $17,913, P < 0.001). These cost differentials continued to 36 months. CONCLUSIONS: Angina after PCI is a frequent and expensive outcome. Further research is needed to identify risk factors and potentially improve outcomes for post-PCI angina. © 2016 Wiley Periodicals, Inc.

Costs and clinical outcomes for non-invasive versus invasive diagnostic approaches to patients with suspected in-stent restenosis.

This study compared costs and clinical outcomes of invasive versus non-invasive diagnostic evaluations for patients with suspected in-stent restenosis (ISR) after percutaneous coronary intervention. We developed a decision model to compare 2 year diagnosis-related costs for patients who presented with suspected ISR and were evaluated by: (1) invasive coronary angiography (ICA); (2) non-invasive stress testing strategy of myocardial perfusion imaging (MPI) with referral to ICA based on MPI; (3) coronary CT angiography-based testing strategy with referral to ICA based on CCTA. Costs were modeled from the payer's perspective using 2014 Medicare rates. 56 % of patients underwent follow-up diagnostic testing over 2 years. Compared to ICA, MPI (98.6 %) and CCTA (98.1 %) exhibited lower rates of correct diagnoses. Non-invasive strategies were associated with reduced referrals to ICA and costs compared to an ICA-based strategy, with diagnostic costs lower for CCTA than MPI. Overall 2-year costs were highest for ICA for both metallic as well as BVS stents ($1656 and $1656, respectively) when compared to MPI ($1444 and $1411) and CCTA. CCTA costs differed based upon stent size and type, and were highest for metallic stents >3.0 mm followed by metallic stents <3.0 mm, BVS < 3.0 mm and BVS > 3.0 mm ($1466 vs. $1242 vs. $855 vs. $490, respectively). MPI for suspected ISR results in lower costs and rates of complications than invasive strategies using ICA while maintaining high diagnostic performance. Depending upon stent size and type, CCTA results in lower costs than MPI.

US hospital payment adjustments for innovative technology lag behind those in Germany, France, and Japan.

Medicare pioneered add-on payments to facilitate the adoption of innovative technologies under its hospital prospective payment system. US policy makers are now experimenting with broader value-based payment initiatives, but these have not been adjusted for innovation. This article examines the structure, processes, and experience with Medicare's hospital new technology add-on payment program since its inception in 2001 and compares it with analogous payment systems in Germany, France, and Japan. Between 2001 and 2015 CMS approved nineteen of fifty-three applications for the new technology add-on payment program. We found that the program resulted in $201.7 million in Medicare payments in fiscal years 2002-13-less than half the level anticipated by Congress and only 34 percent of the amount projected by CMS. The US program approved considerably fewer innovative technologies, compared to analogous technology payment mechanisms in Germany, France and Japan. We conclude that it is important to adjust payments for new medical innovations within prospective and value-based payment systems explicitly as well as implicitly. The most straightforward method to use in adjusting value-based payments is for the insurer to retrospectively adjust spending targets to account for the cost of new technologies. If CMS made such retrospective adjustments, it would not financially penalize hospitals for adopting beneficial innovations.