Differences in Treatment Patterns and Outcomes of Acute Myocardial Infarction for Low- and High-Income Patients in 6 Countries.

Importance: Differences in the organization and financing of health systems may produce more or less equitable outcomes for advantaged vs disadvantaged populations. We compared treatments and outcomes of older high- and low-income patients across 6 countries. Objective: To determine whether treatment patterns and outcomes for patients presenting with acute myocardial infarction differ for low- vs high-income individuals across 6 countries. Design, Setting, and Participants: Serial cross-sectional cohort study of all adults aged 66 years or older hospitalized with acute myocardial infarction from 2013 through 2018 in the US, Canada, England, the Netherlands, Taiwan, and Israel using population-representative administrative data. Exposures: Being in the top and bottom quintile of income within and across countries. Main Outcomes and Measures: Thirty-day and 1-year mortality; secondary outcomes included rates of cardiac catheterization and revascularization, length of stay, and readmission rates. Results: We studied 289 376 patients hospitalized with ST-segment elevation myocardial infarction (STEMI) and 843 046 hospitalized with non-STEMI (NSTEMI). Adjusted 30-day mortality generally was 1 to 3 percentage points lower for high-income patients. For instance, 30-day mortality among patients admitted with STEMI in the Netherlands was 10.2% for those with high income vs 13.1% for those with low income (difference, -2.8 percentage points [95% CI, -4.1 to -1.5]). One-year mortality differences for STEMI were even larger than 30-day mortality, with the highest difference in Israel (16.2% vs 25.3%; difference, -9.1 percentage points [95% CI, -16.7 to -1.6]). In all countries, rates of cardiac catheterization and percutaneous coronary intervention were higher among high- vs low-income populations, with absolute differences ranging from 1 to 6 percentage points (eg, 73.6% vs 67.4%; difference, 6.1 percentage points [95% CI, 1.2 to 11.0] for percutaneous intervention in England for STEMI). Rates of coronary artery bypass graft surgery for patients with STEMI in low- vs high-income strata were similar but for NSTEMI were generally 1 to 2 percentage points higher among high-income patients (eg, 12.5% vs 11.0% in the US; difference, 1.5 percentage points [95% CI, 1.3 to 1.8 ]). Thirty-day readmission rates generally also were 1 to 3 percentage points lower and hospital length of stay generally was 0.2 to 0.5 days shorter for high-income patients. Conclusions and Relevance: High-income individuals had substantially better survival and were more likely to receive lifesaving revascularization and had shorter hospital lengths of stay and fewer readmissions across almost all countries. Our results suggest that income-based disparities were present even in countries with universal health insurance and robust social safety net systems.

Cost-effectiveness of myocardial perfusion SPECT and stress test according to coronary revascularization therapy, cardiac events and total mortality: Register of 8,496 patients. / Coste-efectividad de la SPECT de perfusión miocárdica y de la prueba de esfuerzo en relación con la revascularización coronaria, eventos cardíacos y mortalidad total. Registro de 8.496 pacientes.

OBJECTIVE: The aim was to analyze the cost-effectiveness ratio (CER) of stress electrocardiogram (ES) and stress myocardial perfusion imaging (SPECT-MPI) according to coronary revascularization (CR) therapy, cardiac events (CE) and total mortality (TM). MATERIAL AND METHODS: A total of 8,496 consecutive patients who underwent SPECT-MPI were followed-up (mean 5.3±3.5years). Cost-effectiveness for coronary bypass (CABG) or percutaneous CR (PCR) (45.6%/54.4%) according to combined electrocardiographic ischemia and scintigraphic ischemia were evaluated. Effectiveness was evaluated as TM, CE, life-year saved observed (LYSO) and CE-LYSO; costs analyses were conducted from the perspective of the health care payer. A sensitivity analysis was performed considering current CABG/PCR ratios (12%/88%). RESULTS: When electrocardiogram and SPECT approaches are combined, the cost-effectiveness values for CABG ranged between 112,589€ (electrocardiographic and scintigraphic ischemia) and 2,814,715€ (without ischemia)/event avoided, 38,664 and 2,221,559€/LYSO; for PCR ranged between 18,824€ (electrocardiographic and scintigraphic ischemia) and 46,377€ (without ischemia)/event avoided, 6,464 and 36,604€/LYSO. To CE: the cost-effectiveness values of the CABG and CPR in presence of electrocardiographic and scintigraphic ischemia were 269,904€/CE-avoided and 24,428€/CE-avoided, respectively; and the €/LYSO of the CABG and PCR were 152,488 and 13,801, respectively. The RCE was maintained for the current proportion of revascularized patients (12%/88%). CONCLUSIONS: Combined ES and SPECT-MPI results, allows differentiation between patient groups, where the PCR and CABG are more cost-effective in different economic frameworks. The major CER in relation to CR, CE and TM occurs in patients with electrocardiographic and scintigraphic ischemia. PCR is more cost-effective than CABG.

Impact of complications of myocardial revascularization surgery on expenses during Hospital Stay / Impacto das complicações da cirurgia de revascularização do miocárdio nas despesas durante internação hospitalar

Background: Coronary artery bypass grafting (CABG) is an important treatment option for obstructive coronary artery disease, but it represents a high expense for paying sources.The complications of CABG impose an additional expense to the procedure that is not yet clearly established. Objective: To determine the economic impact of postoperative complications of CABG during hospitalization in a hospital of the unified health system (SUS). Methods: This is an observational study involving 240 patients undergoing isolated CABG in a reference hospital in cardiology in 2013. Patients aged over 30 years with proven coronary artery disease and indication to perform CRVM were included. Patients who performed CRVM associated with other procedures were excluded. Results: The average cost of hospitalization was R$ 22,647.24 (SD = R$ 28,105.66). In 97 patients who presented some complication the average cost was R$ 35,400.28 (SD = R$ 40,509.47), and in the 143 patients without complications the average cost was R$ 13,996.57 (SD = R$ 5,800.61) (p < 0.001). Expenditures ranged from R$ 17,344.37 in patients with one complication up to R$ 104,596.52 in patients with five complications (p < 0.001). Conclusions: The occurrence of complications during hospitalization for CABG dignificantly increases the costs of the procedure, but the magnitude of this increase depends on the type of complication developed, and higher expenses related to cardiovascular complications, infections and bleeding. With this information, managers can improve the allocation of resources to health

Impacto dos fatores de risco para doença arterial coronatriana nos gastos hospitalares dos pacientes submetidos à cirurgia de revascularização do miocárdio no SUS / Impact of risk factors for coronary artery disease on hospital costs of patients undergoing myocardial revascularization surgery in the Brazilian Unified Health System (SUS)

Background: Cardiovascular diseases are a major cause of mortality and morbidity. Myocardial revascularization surgery may be indicated for the relief of symptoms and to reduce mortality. However, surgery is a costly procedure and the impact of the number of cardiovascular risk factors on the cost of the procedure has not been established. Objectives: To identify the impact of risk factors for coronary artery disease on myocardial revascularization surgery cost. Methods: We selected 239 patients undergoing myocardial revascularization surgery at the National Institute of Cardiology in the period from 01 January to 31 December 2013. We included patients aged over 30 years, with indication for the procedure. Patients undergoing combined procedures were excluded. Results: Seven patients had only one risk factor, 32 patients had two risk factors, 75 patients had 3 risk factors, 78 patients had four risk factors, 36 patients had 5 risk factors and 11 patients presented 6 risk factors. The total costs, on average, was R$ 14,143.22 in the group with 1 risk factor, R$ 18,380.40 in the group with 2 risk factors, R$ 21,229.51 in the group with 3 risk factors, R$ 24,620.86 in the group with 4 risk factors, R$ 21,337.92 in the group with 5 risk factors and R$ 36,098,35 in the group with 6 risk factors (p = 0.441). Conclusion: This study demonstrates that, in a public referral center for highly complex cardiology procedures, there was no significant correlation between the number of cardiovascular risk factors and hospitalization costs

Fundamentos: As doenças cardiovasculares representam uma importante causa de mortalidade e morbidade. A cirurgia de revascularização do miocárdio pode ser indicada para o alívio dos sintomas e para diminuir a mortalidade. Entretanto, a cirurgia é um procedimento de custo elevado e não está estabelecido o impacto do número de fatores de risco cardiovasculares nos gastos do procedimento. Objetivos: Identificar o impacto dos fatores de risco para a doença arterial coronariana nos gastos com a cirurgia de revascularização do miocárdio. Métodos: Foram selecionados 239 pacientes submetidos à cirurgia de revascularização do miocárdio isolada no Instituto Nacional de Cardiologia no período entre 01 de Janeiro a 31 de Dezembro de 2013. Foram incluídos pacientes com idade superior a 30 anos e indicação de revascularização cirúrgica do miocárdio. Foram excluídos os pacientes submetidos a procedimentos combinados. Resultados: Sete pacientes apresentaram apenas 1 fator de risco, 32 pacientes apresentaram 2 fatores de risco, 75 pacientes apresentaram 3 fatores de risco, 78 pacientes apresentaram 4 fatores de risco, 36 pacientes apresentaram 5 fatores de risco e 11 pacientes apresentaram 6 fatores de risco. O total dos gastos, em média, foi de R$ 14 143,22 no grupo com 1 fator de risco, R$ 18 380,40 no grupo com 2 fatores de risco, R$ 21 229,51 no grupo com 3 fatores de risco, R$ 24 620,86 no grupo com 4 fatores de risco, R$ 21 337,92 no grupo com 5 fatores de risco e R$ 36 098,35 no grupo com 6 fatores de risco (p = 0,441). Conclusão: Este trabalho demonstra que, em uma unidade pública de referência para a realização de procedimentos cardiológicos de alta complexidade, não houve uma correlação significativa entre o número de fatores de risco cardiovascular e os custos da internação

Comparison of Accessibility, Cost, and Quality of Elective Coronary Revascularization Between Veterans Affairs and Community Care Hospitals.

Importance: The Veterans Affairs (VA) Community Care (CC) Program supplements VA care with community-based medical services. However, access gains and value provided by CC have not been well described. Objectives: To compare the access, cost, and quality of elective coronary revascularization procedures between VA and CC hospitals and to evaluate if procedural volume or publicly reported quality data can be used to identify high-value care. Design, Setting, and Participants: Observational cohort study of veterans younger than 65 years undergoing an elective coronary revascularization, controlling for differences in risk factors using propensity adjustment. The setting was VA and CC hospitals. Participants were veterans undergoing elective percutaneous coronary intervention (PCI) and veterans undergoing coronary artery bypass graft (CABG) procedures between October 1, 2008, and September 30, 2011. The analysis was conducted between July 2014 and July 2017. Exposures: Receipt of an elective coronary revascularization at a VA vs CC facility. Main Outcomes and Measures: Access to care as measured by travel distance, 30-day mortality, and costs. Results: In the 3 years ending on September 30, 2011, a total of 13 237 elective PCIs (79.1% at the VA) and 5818 elective CABG procedures (83.6% at the VA) were performed in VA or CC hospitals among veterans meeting study inclusion criteria. On average, use of CC was associated with reduced net travel by 53.6 miles for PCI and by 73.3 miles for CABG surgery compared with VA-only care. Adjusted 30-day mortality after PCI was higher in CC compared with VA (1.54% for CC vs 0.65% for VA, P < .001) but was similar after CABG surgery (1.33% for CC vs 1.51% for VA, P = .74). There were no differences in adjusted 30-day readmission rates for PCI (7.04% for CC vs 7.73% for VA, P = .66) or CABG surgery (8.13% for CC vs 7.00% for VA, P = .28). The mean adjusted PCI cost was higher in CC ($22 025 for CC vs $15 683 for VA, P < .001). The mean adjusted CABG cost was lower in CC ($55 526 for CC vs $63 144 for VA, P < .01). Neither procedural volume nor publicly reported mortality data identified hospitals that provided higher-value care with the exception that CABG mortality was lower in small-volume CC hospitals. Conclusions and Relevance: In this veteran cohort, PCIs performed in CC hospitals were associated with shorter travel distance but with higher mortality, higher costs, and minimal travel savings compared with VA hospitals. The CABG procedures performed in CC hospitals were associated with shorter travel distance, similar mortality, and lower costs. As the VA considers expansion of the CC program, ongoing assessments of value and access gains are essential to optimize veteran outcomes and VA spending.

Long-term clinical outcomes, health-related quality of life, and costs in different treatment modalities of stable coronary artery disease.

Aims: This study is a prospective, observational 8-year follow-up of 300 stable unselected coronary artery disease patients entering elective coronary angiography in 2002-03. Recorded were clinical outcomes, health-related quality of life (HRQoL), and secondary care costs after coronary artery bypass graft (CABG) surgery, percutaneous coronary intervention (PCI), or medical therapy (MT). Methods and results: HRQoL was measured by the 15D instrument at baseline, 6 months, and 8 years. Regression techniques with an adjustment for relevant baseline characteristics were used to compare the 8-year survival and change in HRQoL between the groups. At baseline, all groups had statistically significantly impaired HRQoL compared with age- and gender-standardized general population. Six months after invasive interventions the mean HRQoL score had improved in a statistically significant and clinically important manner. This improvement was maintained at 8 years as the HRQoL no longer differed from that of the general population, whereas MT patients were still worse off. However, after adjustment for baseline characteristics, the groups no longer differed regarding 8-year survival or change in HRQoL among survivors. Mean 8-year secondary care costs were without (with) adjustment for baseline characteristics: €17 498 (16 730) for CABG, €7245 (6920) for PCI, and €4514 (4580) for MT, respectively. Conclusion: When adjusted for baseline characteristics, no statistically significant differences were found between the patient groups in 8-year survival or change in HRQoL among survivors. The 8-year mean secondary care costs of CABG were over two-fold and almost four-fold, even after adjustment for baseline characteristics, compared with those of PCI and MT.

Clinical and economic burden associated with cardiovascular events among patients with hyperlipidemia: a retrospective cohort study.

BACKGROUND: Annual direct costs for cardiovascular (CV) diseases in the United States are approximately $195.6 billion, with many high-risk patients remaining at risk for major cardiovascular events (CVE). This study evaluated the direct clinical and economic burden associated with new CVE up to 3 years post-event among patients with hyperlipidemia. METHODS: Hyperlipidemic patients with a primary inpatient claim for new CVE (myocardial infarction, unstable angina, ischemic stroke, transient ischemic attack, coronary artery bypass graft, percutaneous coronary intervention and heart failure) were identified using IMS LifeLink PharMetrics Plus data from January 1, 2006 through June 30, 2012. Patients were stratified by CV risk into history of CVE, modified coronary heart disease risk equivalent, moderate- and low-risk cohorts. Of the eligible patients, propensity score matched 243,640 patients with or without new CVE were included to compare healthcare resource utilization and direct costs ranging from the acute (1-month) phase through 3 years post-CVE date (follow-up period). RESULTS: Myocardial infarction was the most common CVE in all the risk cohorts. During the acute phase, among patients with new CVE, the average incremental inpatient length of stay and incremental costs ranged from 4.4-6.2 days and $25,666-$30,321, respectively. Acute-phase incremental costs accounted for 61-75% of first-year costs, but incremental costs also remained high during years 2 and 3 post-CVE. CONCLUSIONS: Among hyperlipidemic patients with new CVE, healthcare utilization and costs incurred were significantly higher than for those without CVE during the acute phase, and remained higher up to 3 years post-event, across all risk cohorts.

Comparison of Index Hospitalization Costs Between Robotic CABG and Conventional CABG: Implications for Hybrid Coronary Revascularization.

OBJECTIVES: To compare the direct costs of the index hospitalization and 30-day morbidity and mortality incurred during robotic and conventional coronary artery bypass grafting at a single institution based on hospital clinical and financial records. DESIGN: Retrospective study, propensity-matched groups with one-to-one nearest neighbor matching. SETTING: University hospital, a tertiary care center. PARTICIPANTS: Two thousand eighty-eight consecutive patients who underwent primary coronary artery bypass grafting (CABG) from January 2007 to March 2012. INTERVENTIONS: One hundred forty-one matched pairs were created and analyzed. MEASUREMENTS AND MAIN RESULTS: Robotic CABG was associated with a decrease in operative time (5.61±1.1 v 6.6±1.15 hours, p<0.001), a lower need for blood transfusion (12.8% v 22.6%, p = 0.04), a shorter length of stay (6 [4-9]) v 7 [5-11] days, p = 0.001), a shorter ICU stay (31 [24-49] hours v 52 [32-96.5] hours, p<0.001) and lower NY state complications composite rate (4.26% v 13.48%, p = 0.01). In spite of that, the cost of robotic procedures was not significantly different from matched conventional cases ($18,717.35 [11,316.1-34,550.6] versus $18,601 [13,137-50,194.75], p = 0.13), except 26 hybrid coronary revascularizations in which angioplasty was performed on the same admission (hybrid 25,311.1 [18,537.1-41,167.85] versus conventional 18,966.13 [13,337.75-56,021.75], p = 0.02). CONCLUSION: Robotically assisted CABG does not increase the cost of the index hospitalization when compared to conventional CABG unless hybrid revascularization is performed on the same admission.

Regional differences in treatment frequency and case-fatality rates in korean patients with acute myocardial infarction using the Korea national health insurance claims database: findings of a large retrospective cohort study.

Issues regarding healthcare disparity continue to increase in connection with access to quality care for acute myocardial infarction (AMI), even though the case-fatality rate (CFR) continues to decrease. We explored regional variation in AMI CFRs and examined whether the variation was due to disparities in access to quality medical services for AMI patients. A dataset was constructed from the Korea National Health Insurance Claims Database to conduct a retrospective cohort study of 95,616 patients who were admitted to a hospital in Korea from 2003 to 2007 with AMI. Each patient was followed in the claims database for information about treatment after admission or death. The procedure rate decreased as the region went "down" from Seoul to the county level, whereas the AMI CFR increased as the county level as a function of proximity to the county level (30-day AMI CFRs: Seoul, 16.4%; metropolitan areas, 16.2%, cities; 18.8%, counties, 39.4%). Even after adjusting for covariates, an identical regional variation in the odds of patients receiving treatment services and dying was identified. After adjusting for invasive and medical management variables in addition to earlier covariates, the death risk in the counties remained statistically significantly higher than in Seoul; however, the degree of the difference decreased greatly and the significant differences in metropolitan areas and cities disappeared. Policy interventions are needed to increase access to quality AMI care in county-level local areas because regional differences in the AMI CFR are likely caused by differences in the performance of medical and invasive management among the regions of Korea. Additionally, a public education program to increase the awareness of early symptoms and the necessity of visiting the hospital early should be established as the first priority to improve the outcome of AMI patents, especially in county-level local areas.

The impact of hybrid coronary revascularization on hospital costs and reimbursements.

BACKGROUND: Hybrid coronary revascularization (HCR) combines a minimally invasive, left internal mammary artery-left anterior descending coronary artery (LAD) bypass with percutaneous intervention of non-LAD vessels for patients with multivessel coronary disease. The financial implications of HCR have not been compared with off-pump coronary artery bypass (OPCAB) through sternotomy. METHODS: The contribution margin is a fiduciary calculation (best hospital payment estimate--total variable costs) used by hospitals to determine fiscal viability of services. From 2010 to 2011, 26 Medicare patients underwent HCR at a single United States institution and were compared with 28 randomly selected, contemporaneous Medicare patients undergoing multivessel OPCAB. All HCR patients underwent a robotic-assisted, sternal-sparing, off-pump, left internal mammary artery-LAD anastomosis plus percutaneous intervention to non-LAD vessels. A linear regression model was used to compare fiscal and utilization outcomes of HCR to OPCAB adjusted for hospital length of stay and The Society of Thoracic Surgeons Predicted Risk of Mortality score. RESULTS: On regression analysis controlling for overall length of stay and Predicted Risk of Mortality score, the contribution margin (+$8,771, p<0.0001) was greater for HCR than for OPCAB. Despite higher total cost for HCR compared with OPCAB (+$7,026, p=0.001), the total variable cost (+$2,281, p=0.07) was not significantly different. Best payment estimates (+11,031, p<0.0001) and Medicare reimbursements (+$8,992, p=0.002) were higher for HCR than for OPCAB, and there was a reduction in blood transfusion (-1.5 units, p<0.0001), ventilator time (-10 hours, p=0.001), and postoperative length of stay (-1.2 days, p=0.002) for the HCR group. CONCLUSIONS: Compared with OPCAB, HCR results in a greater contribution margin for hospitals. This may result from higher reimbursement as well as improved resource utilization postoperatively, which may offset more expensive procedural costs associated with HCR.

Transfer rates from nonprocedure hospitals after initial admission and outcomes among elderly patients with acute myocardial infarction.

IMPORTANCE: It is unknown whether hospital transfer rates for patients with acute myocardial infarction admitted to nonprocedure hospitals (facilities that do not provide catheterization) vary and whether these rates further influence revascularization rates, length of stay, and mortality. OBJECTIVES: To examine hospital differences in transfer rates for elderly patients with acute myocardial infarction across nonprocedure hospitals and to determine whether these rates are associated with revascularization rates, length of stay, and mortality. DESIGN, SETTING, AND PARTICIPANTS: We used Medicare claims data from January 1, 2006, to December 31, 2008, to assess transfer rates in nonprocedure hospitals, stratified according to transfer rates as low (≤ 20%), mid-low (>20%-30%), mid-high (>30%-40%), or high (>40%). Data were analyzed for 55,962 Medicare fee-for-service patients admitted to 901 nonprocedure US hospitals with more than 25 admissions per year for acute myocardial infarction. MAIN OUTCOMES AND MEASURES: We compared rates of catheterization, percutaneous coronary intervention, and coronary artery bypass graft surgery during hospitalization and within 60 days, as well as hospital total length of stay, across groups. We measured risk-standardized mortality rates at 30 days and 1 year. RESULTS The median transfer rate was 29.4% (interquartile range [25th-75th percentile], 21.8%-37.8%). Higher transfer rates were associated with higher rates of catheterization (P < .001), percutaneous coronary intervention (P < .001), and coronary artery bypass graft surgery (P < .001). Median length of stay was not meaningfully different across the groups. There was no meaningful evidence of associations between transfer rates and risk-standardized mortality at 30 days (mean [SD], 22.3% [2.6%], 22.1% [2.3%], 22.3% [2.4%], and 21.7% [2.1%], respectively; P = .054) or 1 year (43.9% [2.3%], 43.6% [2.2%], 43.5% [2.4%], and 42.8% [2.2%], respectively; P < .001) for low, mid-low, mid-high, and high transfer groups. CONCLUSIONS AND RELEVANCE: Nonprocedure hospitals vary substantially in their use of the transfer process for elderly patients admitted with acute myocardial infarction. High-transfer hospitals had greater use of invasive cardiac procedures after admission compared with low-transfer hospitals. However, higher transfer rates were not associated with a significantly lower risk-standardized mortality rate at 30 days. Moreover, at 1 year there was only a 1.1% difference (42.8% vs 43.9%) between hospitals with higher and lower transfer rates. These findings suggest that, as a single intervention, promoting the transfer of patients admitted with acute myocardial infarction may not improve hospital outcomes.

Cost-effectiveness of universal and platelet reactivity assay-driven antiplatelet therapy in acute coronary syndrome.

Assays monitoring P2Y12 platelet reactivity can accurately predict which patients will have a poor response to clopidogrel. We sought to determine the cost-effectiveness of using platelet reactivity assays (PRAs) to select a dual-antiplatelet regimen for patients with acute coronary syndrome. A hybrid decision tree Markov model was developed to determine the cost-effectiveness of universal clopidogrel, ticagrelor, or prasugrel (given to all patients) or PRA-driven ticagrelor or prasugrel (given to patients with high platelet reactivity, defined as >230 on the VerifyNow P2Y12 assay; the others received generic clopidogrel). We assumed a cohort of 65-year-old patients with acute coronary syndrome and an incidence of high platelet reactivity of 32% and 13% at ~24 to 48 hours after revascularization and 1 month, respectively. The 5-year costs, quality-adjusted life-years, and incremental cost-effectiveness ratios were calculated for PRA-driven ticagrelor and prasugrel compared with universal clopidogrel, ticagrelor, or prasugrel. PRA-driven ticagrelor and prasugrel were cost-effective compared with universal clopidogrel (incremental cost-effectiveness ratio $40,100 and $49,143/quality-adjusted life-year, respectively); however, universal ticagrelor and prasugrel were not (incremental cost-effectiveness ratio $61,651 and $96,261/quality-adjusted life-year, respectively). Monte Carlo simulation suggested PRA-driven ticagrelor, PRA-driven prasugrel, universal ticagrelor, and universal prasugrel would have an incremental cost-effectiveness ratio <$50,000/quality-adjusted life-year in 52%, 40%, 23%, and 2% of the iterations compared with universal clopidogrel, respectively. Universal ticagrelor and prasugrel were not cost-effective compared with their respective PRA-driven regimens (incremental cost-effectiveness ratio $68,182; $116,875/quality-adjusted life-year, respectively). Monte Carlo simulation suggested universal ticagrelor and prasugrel would have an incremental cost-effectiveness ratio <$50,000/quality-adjusted life-year in 26% and 4% of iterations compared with their respective PRA-driven regimens. The results were most sensitive to differences in agent costs and drug-specific relative risks of death. In conclusion, even with generic clopidogrel, PRA-driven selection of antiplatelet therapy appeared to be a cost-effective strategy with the potential to decrease the overall acute coronary syndrome-associated healthcare costs.

The aging Canadian population and hospitalizations for acute myocardial infarction: projection to 2020.

BACKGROUND: The risk of experiencing an acute myocardial infarction (AMI) increases with age and Canada's population is aging. The objective of this analysis was to examine trends in the AMI hospitalization rate in Canada between 2002 and 2009 and to estimate the potential increase in the number of AMI hospitalizations over the next decade. METHODS: Aggregated data on annual AMI hospitalizations were obtained from the Canadian Institute for Health Information for all provinces and territories, except Quebec, for 2002/03 and 2009/10. Using these data in a Poisson regression model to control for age, gender and year, the rate of AMI hospitalizations was extrapolated between 2010 and 2020. The extrapolated rate and Statistics Canada population projections were used to estimate the number of AMI hospitalizations in 2020. RESULTS: The rates of AMI hospitalizations by gender and age group showed a decrease between 2002 and 2009 in patients aged ≥ 65 years and relatively stable rates in those aged < 64 years in both males and females. However, the total number of AMI hospitalizations in Canada (excluding Quebec) is projected to increase by 4667 from 51847 in 2009 to 56514 in 2020, a 9.0% increase. Inflating this number to account for the unavailable Quebec data results in an increase of approximately 6200 for the whole of Canada. This would amount to an additional cost of between $46 and $54 million and sensitivity analyses indicate that it could be between $36 and $65 million. CONCLUSIONS: Despite projected decreasing or stable rates of AMI hospitalization, the number of hospitalizations is expected to increase substantially as a result of the aging of the Canadian population. The cost of these hospitalizations will be substantial. An increase of this extent in the number of AMI hospitalizations and the ensuing costs would significantly impact the already over-stretched Canadian healthcare system.

[Costs of the chain of treatment procedures in acute myocardial infarction in Brazilian reference and specialized hospitals]. / Custos da cadeia de procedimentos no tratamento do infarto agudo do miocárdio em hospitais Brasileiros de excelência e especializados.

OBJECTIVE: To present the methodology and the results of a field survey to assess the chain costs of procedures for treatment of acute myocardial infarction (AMI), carried out in 11 Brazilian reference and specialized hospitals. METHODS: The cost assessment used the cost per procedure and per pathology systems. The procedures associated with the treatment of AMI were organized and their logical sequence (protocols) was used to create a flowchart. Data collection tools gathered information on prices and quantities in 2008 (private, health insurance, SUS, and Brazilian Medical Association - AMB price lists), as well as the applicable costs. RESULTS: Overall, the total cost of the procedures involving the 'standard treatment' of AMI was R$ 12,873.69, if percutaneous coronary intervention (PCI) did not involve stent use. If the stent becomes necessary, the cost increases to R$ 23,461.87. CONCLUSION: Among the results, we emphasize the fact that the costs of the more expensive procedures did not present statistically significant variations between hospitals, regardless of their location, predominant clientele or legal nature, and the fact that hospitals that treat predominantly users of the Brazilian Unified Health System registered the lowest costs, albeit not statistically significant regarding the entire chain of procedures associated with the pathology.

Custos da cadeia de procedimentos no tratamento do infarto agudo do miocárdio em hospitais brasileiros de excelência e especializados / Costs of the chain of treatment procedures in acute myocardial infarction in Brazilian reference and specialized hospitals

OBJETIVO: Apresenta a metodologia e os resultados de uma pesquisa de campo para avaliar os custos da cadeia de procedimentos para tratamento do Infarto Agudo do Miocárdio (IAM), realizada em 11 hospitais brasileiros de excelência e especializados. MÉTODOS: A apuração do custo utilizou o sistema de custo por procedimento e o sistema por patologia. Os procedimentos associados ao tratamento do IAM foram organizados com sua sequência lógica (protocolos), dando origem a um fluxograma. Os instrumentos de coleta da pesquisa contemplavam informações relativas aos preços e as quantidades (particular, convênios, tabela SUS e Associação Médica Brasileira - AMB), praticados no ano de 2008, bem como os custos pertinentes. RESULTADOS: De forma geral, o custo total dos procedimentos que integram o "tratamento-padrão" do IAM, totalizou R$ 12.873,69 se a intervenção coronária percutânea (ICP) não envolver utilização de stent. Caso este se torne necessário, o custo se eleva para R$ 23.461,87. CONCLUSÃO: Entre os resultados obtidos destacam-se: o fato de os valores dos procedimentos mais caros não apresentarem variações estatísticas significativas entre os hospitais, independentemente de sua localização, clientela predominante ou natureza jurídica; e o fato de os hospitais, que tratam predominantemente de usuários do Sistema Único de Saúde, registrar custos menores, mas não estatisticamente significativos, para toda a cadeia de procedimentos associada à patologia.

OBJECTIVE: To present the methodology and the results of a field survey to assess the chain costs of procedures for treatment of acute myocardial infarction (AMI), carried out in 11 Brazilian reference and specialized hospitals. METHODS: The cost assessment used the cost per procedure and per pathology systems. The procedures associated with the treatment of AMI were organized and their logical sequence (protocols) was used to create a flowchart. Data collection tools gathered information on prices and quantities in 2008 (private, health insurance, SUS, and Brazilian Medical Association - AMB price lists), as well as the applicable costs. RESULTS: Overall, the total cost of the procedures involving the 'standard treatment' of AMI was R$ 12,873.69, if percutaneous coronary intervention (PCI) did not involve stent use. If the stent becomes necessary, the cost increases to R$ 23,461.87. CONCLUSION: Among the results, we emphasize the fact that the costs of the more expensive procedures did not present statistically significant variations between hospitals, regardless of their location, predominant clientele or legal nature, and the fact that hospitals that treat predominantly users of the Brazilian Unified Health System registered the lowest costs, albeit not statistically significant regarding the entire chain of procedures associated with the pathology.

Association of coronary CT angiography or stress testing with subsequent utilization and spending among Medicare beneficiaries.

CONTEXT: Coronary computed tomography angiography (CCTA) is a new noninvasive diagnostic test for coronary artery disease (CAD), but its association with subsequent clinical management has not been established. OBJECTIVE: To compare utilization and spending associated with functional (stress testing) and anatomical (CCTA) noninvasive cardiac testing in a Medicare population. DESIGN, SETTING, AND PATIENTS: Retrospective, observational cohort study using claims data from a 20% random sample of 2005-2008 Medicare fee-for-service beneficiaries 66 years or older with no claims for CAD in the preceding year, who received nonemergent, noninvasive testing for CAD (n = 282,830). MAIN OUTCOME MEASURES: Cardiac catheterization, coronary revascularization, acute myocardial infarction, all-cause mortality, and total and CAD-related Medicare spending over 180 days of follow-up. RESULTS: Compared with stress myocardial perfusion scintigraphy (MPS), CCTA was associated with an increased likelihood of subsequent cardiac catheterization (22.9% vs 12.1%; adjusted odds ratio [AOR], 2.19 [95% CI, 2.08 to 2.32]; P < .001), percutaneous coronary intervention (7.8% vs 3.4%; AOR, 2.49 [2.28 to 2.72]; P < .001), and coronary artery bypass graft surgery (3.7% vs 1.3%; AOR, 3.00 [2.63 to 3.41]; P < .001). CCTA was also associated with higher total health care spending ($4200 [$3193 to $5267]; P < .001), which was almost entirely attributable to payments for any claims for CAD ($4007 [$3256 to $4835]; P < .001). Compared with MPS, there was lower associated spending with stress echocardiography (-$4981 [-$4991 to -$4969]; P < .001) and exercise electrocardiography (-$7449 [-$7452 to -$7444]; P < .001). At 180 days, CCTA was associated with a similar likelihood of all-cause mortality (1.05% vs 1.28%; AOR, 1.11 [0.88 to 1.38]; P = .32) and a slightly lower likelihood of hospitalization for acute myocardial infarction (0.19% vs 0.43%; AOR, 0.60 [0.37 to 0.98]; P = .04). CONCLUSION: Medicare beneficiaries who underwent CCTA in a nonacute setting were more likely to undergo subsequent invasive cardiac procedures and have higher CAD-related spending than patients who underwent stress testing.

Simultaneous hybrid revascularization versus off-pump coronary artery bypass for multivessel coronary artery disease.

BACKGROUND: This study sought to compare early and midterm clinical outcomes of a simultaneous hybrid coronary revascularization procedure with those in a propensity-matched subset of patients undergoing conventional off-pump coronary artery bypass grafting. METHODS: From June 2007 through December 2009, 104 consecutive patients (mean age 61.8 ± 10.2 years) with multivessel coronary artery disease underwent elective simultaneous coronary revascularization at Fuwai Hospital. Using propensity score methodology, these patients were matched with 104 patients who had undergone off-pump coronary artery bypass grafting through median sternotomy during the same period. We compared these groups' in-hospital clinical outcomes and freedom from major adverse cardiac or cerebrovascular events at a mean follow-up of 18 ± 7.9 months. RESULTS: The hybrid procedure required longer operative time and incurred higher in-hospital costs, but had shorter median intubation time (11.6 ± 6.3 vs 13.8 ± 6.8 hours, p = 0.02), intensive care unit length of stay (34.5 ± 35.6 vs 55.3 ± 46.4 hours, p < 0.001), and postoperative in-hospital length of stay (8.2 ± 2.6 vs 9.5 ± 4.5 days, p = 0.01). The hybrid group had significantly less chest tube drainage (789 ± 389 vs 834 ± 285 mL, p = 0.005) and need for blood transfusion (28.8% vs 51.9%, p > 0.001). At a mean follow-up of 18 months, the freedom from major adverse cardiac or cerebrovascular events is in favor of the hybrid group (99.0% vs 90.4%; p = 0.03). CONCLUSIONS: Compared with conventional off-pump coronary artery bypass grafting, simultaneous hybrid coronary revascularization shortens recovery time and has superior outcomes at a mean follow-up of 18 months. Simultaneous hybrid coronary revascularization provides a safe and reproducible alternative for selected patients with multivessel coronary artery diseases.

Temporal trends in the use of percutaneous coronary intervention and coronary artery bypass surgery in New York State and Ontario.

BACKGROUND: Healthcare reform initiatives in the United States have rekindled debate about the role of government regulation in the healthcare system. Although New York State (NYS) historically has had twice as many coronary revascularizations performed as Ontario, the relative evolution of coronary revascularization patterns in both jurisdictions over time is unknown. METHODS AND RESULTS: We conducted an observational study comparing the temporal trends of cardiac invasive procedures use in NYS and Ontario using population-based data from 1997 to 2006 stratified by procedure indication. For nonacute myocardial infarction patients, the age- and sex-adjusted rate of percutaneous coronary intervention (PCI) was 2.3 times (95% confidence interval, 2.2 to 2.5) greater in NYS than in Ontario in 2004 to 2006. In contrast, population-based rates of coronary artery bypass grafting among nonacute myocardial infarction patients were not significantly different. For acute myocardial infarction patients, differences in coronary revascularization rates between NYS and Ontario narrowed substantially over time. In 2004 to 2006, the relative ratio was 1.3 times higher for PCI (95% confidence interval, 1.2 to 1.5) and 1.4 times higher (95% confidence interval, 1.1 to 1.8) for coronary artery bypass grafting in NYS relative to Ontario. However, a larger relative gap (relative ratio, 2.0; 95% confidence interval, 1.7 to 2.3) was observed among acute myocardial infarction patients undergoing emergency PCIs in NYS compared with Ontario. CONCLUSIONS: The market-oriented financing approach in NYS is associated with markedly higher rates of PCI procedures for both discretionary indications (eg, PCI in nonacute myocardial infarction patients) and emergent indications (eg, primary PCI) compared with the government-funded single-payer system in Ontario.