Predictors of Cumulative Health Care Costs Associated With Transcatheter Aortic Valve Replacement in Severe Aortic Stenosis.

BACKGROUND: There is wide variation in hospitalization costs for transcatheter aortic valve replacement (TAVR), suggesting inefficiency in care delivery. Our goal was to identify drivers of health care costs in TAVR. METHODS: Demographics, procedural details, in-hospital complications, and costs for all adults undergoing first-time TAVR from 2012 to 2016 in Ontario, Canada, were obtained through linkages of clinical/administrative databases. Total costs included were from initial referral to the first of either death or 1-year post-TAVR. Phase-based costing was performed to empirically estimate the presence, duration, and cost per patient for each phase up to 1 year or death. Multivariable regression was used to identify drivers of cost accumulation per phase. RESULTS: We identified 2009 first-time TAVR patients (mean age 81.7 ± 7.6, 45.9% female and Society of Thoracic Surgeons (STS) score of 7.2 ± 5.8). Phases of cost were identified with an early high-cost period within 60 days of referral, a second phase from the procedure to 60 days, and a stable phase from 60 to 360 days postprocedure. The referral phase median cost was $4527 (interquartile range [IQR]: 1708-12,594), the procedure to 60 days phase median cost was $29,518 (IQR: 24,842-40,279), and the post 60-day stable phase median cost was $6053 (IQR: 3320-17,048). Predictors of higher cost in the referral phase were in-hospital wait location, dialysis dependence, and heart-failure status. In the second (procedural) phase, predictors were nontransfemoral access, complications of stroke, and pacemaker insertion. Predictors of higher cost in the third (stable) phase were predominantly nonmodifiable, such as frailty. CONCLUSIONS: This analysis shows that there are 3 distinct phases of cost accumulation from referral to post-TAVR with some potentially modifiable cost drivers in each phase.

Empirical Insights When Defining the Population Burden of Atrial Fibrillation and Oral Anticoagulation Utilization Using Administrative Data.

Health administrative data are routinely used to assess disease burden, quality of care, and outcomes for atrial fibrillation (AF). Governments, administrators, and researchers define cohorts differently, based on 3 key factors: the case definition algorithm to identify AF, inclusion/exclusion of transient AF, and the lookback period to identify cases. We assessed the impact of varying these key factors on estimates of the use of guideline-indicated oral anticoagulation (OAC). Hospitalization, ED, and outpatient claim databases were linked in British Columbia. AF was defined by ICD-9 or 10 codes 427.3x or I48.x. We examined a specific (1 hospital or 1 ED or 2 outpatient) vs a sensitive (1 hospital or ED or outpatient) algorithm; inclusion/exclusion of AF associated with open-heart surgery; and lookback periods of 1 to 10 years. We found the more specific AF definition increased OAC utilization by 5% (58.7% vs 53.4%); excluding AF associated with open-heart surgery increased OAC utilization by 0.7% to 2.3%; and each additional lookback year identified more prevalent cases but reduced OAC utilization by approximately 1%. In 40 scenarios, generated by varying all 3 key factors, OAC utilization ranged from 52% to 72%. Assuming a ceiling of 90%, the estimated "treatment gap" therefore varied from 18% to 38%. The 2-fold variation in the OAC treatment gap was based entirely on cohort definition. This has significant implications for health policy and quality indicators.

Longitudinal changes in visceral and subcutaneous adipose tissue and metabolic syndrome: Results from the Multicultural Community Health Assessment Trial (M-CHAT).

AIM: Few studies have examined whether longitudinal changes in visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT), independent of each other, are associated with the risk of developing metabolic syndrome (MetS). The objective of this study was to examine the longitudinal effects of VAT and SAT on MetS and metabolic risk factors in a multi-ethnic sample of Canadians followed for 5-years. MATERIALS AND METHODS: In total, 598 adults of the Multicultural Community Health Assessment Trial (M-CHAT) were included in this study. Assessments of body composition using computed tomography (CT) and metabolic risk factors were conducted at baseline, 3-, and 5-years. Mixed-effects logistic regression was used to model the longitudinal effects of VAT and SAT on MetS and metabolic risk factors. RESULTS: There were significant between-person (cross-sectional) effects such that for every 10cm2 higher VAT, the odds of MetS, high-risk fasting glucose levels and high-risk HDL-C levels significantly increased by 16% (95% CI: 9-24%), 11% (3-20%), and 7% (0-14%) respectively. Significant within-person (longitudinal) effects were also found such that for every 10cm2 increase in VAT the odds of MetS and high-risk triglyceride levels significantly increased by 23% (9-39%) and 30% (14-48%), respectively. Cross-sectional or longitudinal changes in SAT were not associated with MetS or metabolic risk factors. CONCLUSIONS: This study found a direct relationship between longitudinal change in VAT and MetS risk independent of changes in SAT. Clinical practice should focus on the reduction of VAT to improve cardiovascular health outcomes.

Sex-related differences in access to care among patients with premature acute coronary syndrome.

BACKGROUND: Access to care may be implicated in disparities between men and women in death after acute coronary syndrome, especially among younger adults. We aimed to assess sex-related differences in access to care among patients with premature acute coronary syndrome and to identify clinical and gender-related determinants of access to care. METHODS: We studied 1123 patients (18-55 yr) admitted to hospital for acute coronary syndrome and enrolled in the GENESIS-PRAXY cohort study. Outcome measures were door-to-electrocardiography, door-to-needle and door-to-balloon times, as well as proportions of patients undergoing cardiac catheterization, reperfusion or nonprimary percutaneous coronary intervention. We performed univariable and multivariable logistic regression analyses to identify clinical and gender-related determinants of timely procedures and use of invasive procedures. RESULTS: Women were less likely than men to receive care within benchmark times for electrocardiography (≤ 10 min: 29% v. 38%, p = 0.02) or fibrinolysis (≤ 30 min: 32% v. 57%, p = 0.01). Women with ST-segment elevation myocardial infarction (MI) were less likely than men to undergo reperfusion therapy (primary percutaneous coronary intervention or fibrinolysis) (83% v. 91%, p = 0.01), and women with non-ST-segment elevation MI or unstable angina were less likely to undergo nonprimary percutaneous coronary intervention (48% v. 66%, p < 0.001). Clinical determinants of poorer access to care included anxiety, increased number of risk factors and absence of chest pain. Gender-related determinants included feminine traits of personality and responsibility for housework. INTERPRETATION: Among younger adults with acute coronary syndrome, women and men had different access to care. Moreover, fewer than half of men and women with ST-segment elevation MI received timely primary coronary intervention. Our results also highlight that men and women with no chest pain and those with anxiety, several traditional risk factors and feminine personality traits were at particularly increased risk of poorer access to care.

Cost comparison of ablation versus antiarrhythmic drugs as first-line therapy for atrial fibrillation: an economic evaluation of the RAAFT pilot study.

INTRODUCTION: Radiofrequency ablation (RFA) has become an accepted therapy for atrial fibrillation (AF). The objective of this study was to perform an economic evaluation of RFA versus antiarrhythmic drug therapy (AAD) as first-line treatment of symptomatic paroxysmal AF. METHODS: To estimate and compare the costs of RFA versus AAD, a decision analytic model was developed using data on AF recurrence, hospitalization rates, AAD use, and treatment crossover rates derived directly from the Randomized Trial of RFA versus AAD as First-Line Treatment of Symptomatic Atrial Fibrillation (RAAFT). Resource utilization was modeled to reflect Canadian clinical practice in AF management. Unit costs of healthcare interactions were based on available Canadian government resources and published literature. Costs were assessed based on intention-to-treat. Total expected costs were computed to include initial treatment, hospital stay, physician fees, diagnostic tests, and outpatient visits. Sensitivity analyses were performed to account for the uncertainties. The study was conducted from the third party payer's perspective and costs are reported in 2005 Canadian dollars with 3% discount rate used in the analysis. RESULTS: During the 2-month blanking period following therapy selection, total average costs for RFA and AAD were $10,465 and $2,556, respectively; at 1-year follow-up, these were $12,823 and $6,053; and total 2-year cumulative total average costs were $15,303 and $14,392. Sensitivity analyses did not alter the results, suggesting the model is robust. CONCLUSIONS: RFA as first-line treatment strategy in patients with symptomatic paroxysmal AF was cost neutral 2 years after the initial procedure compared to AAD.

The ability of heart failure specialists to accurately predict NT-proBNP levels based on clinical assessment and a previous NT-proBNP measurement.

BACKGROUND: The value of routine aminoterminal pro type B natriuretic peptide (NT-proBNP) measurements in outpatient clinics remains unknown. OBJECTIVES: We sought to determine the accuracy with which heart failure (HF) specialists can predict NT-proBNP levels in HF outpatients based on clinical assessment. METHODS: We prospectively studied 160 consecutive HF patients followed in an outpatient multidisciplinary HF clinic. During a regular office visit, HF specialists were asked to estimate a patient's current NT-proBNP level based upon their clinical assessment and all available information from their chart, including a previous NT-proBNP level (if available). NT-proBNP estimations were grouped into prognostic categories (<125, 125-1000, 1000-4998, or >/=4999 pg/mL) and comparisons made between actual and estimate values. RESULTS: Overall, HF specialists estimated 67.5% of NT-proBNP levels correctly. After adjusting for clinical characteristics, knowledge of a prior NT-proBNP measurement was the only significant predictor of estimation accuracy (p=0.01). Compared to patients with a prior NT-proBNP level <125 pg/mL, physicians were 95% less likely to get a correct estimation in patients with the highest prior NT-proBNP level (>/=4999 pg/mL). CONCLUSION: HF specialists are reasonably accurate at estimating current NT-proBNP levels based upon clinical assessment and a previous NT-proBNP level, if those levels were < 4999 pg/mL. Likely, initial but not routine NT-proBNP measurements are useful in outpatient HF clinics.

Comparison of provincial prescription drug plans and the impact on patients' annual drug expenditures.

BACKGROUND: Reimbursement for outpatient prescription drugs is not mandated by the Canada Health Act or any other federal legislation. Provincial governments independently establish reimbursement plans. We sought to describe variations in publicly funded provincial drug plans across Canada and to examine the impact of this variation on patients' annual expenditures. METHODS: We collected information, accurate to December 2006, about publicly funded prescription drug plans from all 10 Canadian provinces. Using clinical scenarios, we calculated the impact of provincial cost-sharing strategies on individual annual drug expenditures for 3 categories of patients with different levels of income and 2 levels of annual prescription burden ($260 and $1000). RESULTS: We found that eligibility criteria and cost-sharing details of the publicly funded prescription drug plans differed markedly across Canada, as did the personal financial burden due to prescription drug costs. Seniors pay 35% or less of their prescription costs in 2 provinces, but elsewhere they may pay as much as 100%. With few exceptions, nonseniors pay more than 35% of their prescription costs in every province. Most social assistance recipients pay 35% or less of their prescription costs in 5 provinces and pay no costs in the other 5. In an example of a patient with congestive heart failure, his out-of-pocket costs for a prescription burden of $1283 varied between $74 and $1332 across the provinces. INTERPRETATION: Considerable interprovincial variation in publicly funded prescription drug plans results in substantial variation in annual expenditures by Canadians with identical prescription burdens. A revised pharmaceutical strategy might reduce these major inequities.

Visceral adipose tissue, a potential risk factor for carotid atherosclerosis: results of the Multicultural Community Health Assessment Trial (M-CHAT).

BACKGROUND AND PURPOSE: The association between abdominal obesity and atherosclerosis is believed to be due to excess visceral adipose tissue (VAT), which is associated with traditional risk factors. We hypothesized that VAT is an independent risk factor for atherosclerosis. METHODS: Healthy men and women (N=794) matched for ethnicity (aboriginal, Chinese, European, and South Asian) and body mass index range (<25, 25 to 29.9, or > or =30 kg/m(2)) were assessed for VAT (by computed tomography scan), carotid atherosclerosis (by ultrasound), total body fat, cardiovascular risk factors, lifestyle, and demographics. RESULTS: VAT was associated with carotid intima-media thickness (IMT), plaque area, and total area (IMT area and plaque area combined) after adjusting for demographics, family history, smoking, and percent body fat in men and women. In men, VAT was associated with IMT and total area after adjusting for insulin, glucose, homocysteine, blood pressure, and lipids. This association remained significant with IMT after further adjustment for either waist circumference or the waist-to-hip ratio. In women, VAT was no longer associated with IMT or total area after adjusting for risk factors. CONCLUSIONS: VAT is the primary region of adiposity associated with atherosclerosis and likely represents an additional risk factor for carotid atherosclerosis in men. Most but not all of this risk can be reflected clinically by either the waist circumference or waist-hip ratio measures.

Visceral adipose tissue accumulation differs according to ethnic background: results of the Multicultural Community Health Assessment Trial (M-CHAT).

BACKGROUND: It was suggested that body fat distribution differs across ethnic groups, and this may be important when considering risk of disease. Previous studies have not adequately investigated differences in discrete regions of abdominal adiposity across ethnic groups. OBJECTIVE: We compared the relation between abdominal adipose tissue and total body fat between persons living in Canada of Aboriginal, Chinese, and South Asian origin with persons of European origin. DESIGN: Healthy Aboriginal, Chinese, European, and South Asian participants (n = 822) aged between 30 and 65 y were matched by sex, ethnicity, and body mass index (BMI; in kg/m(2)) range. Total abdominal adipose tissue (TAT), subcutaneous abdominal adipose tissue (SAT), visceral adipose tissue (VAT), total body fat mass, lifestyle, and demographics were assessed. Relations between BMI and total body fat, TAT, SAT, and VAT and between total body fat and TAT, SAT, and VAT were investigated. RESULTS: BMI significantly underestimated VAT in all non-European groups. Throughout a range of total body fat mass, VAT was not significantly different between the Aboriginals and the Europeans. With total body fat >9.1 kg, Chinese participants had increasingly greater amounts of VAT than did the Europeans (P for interaction = 0.008). South Asians had less VAT with total body fat >37.4 kg but more VAT below that amount than did Europeans (P for interaction < 0.001). CONCLUSION: Compared with Europeans, the Chinese and South Asian cohorts had a relatively greater amount of abdominal adipose tissue, and this difference was more pronounced with VAT. No significant differences were observed between the Aboriginals and the Europeans.

True versus reported waiting times for valvular aortic stenosis surgery.

OBJECTIVES: To produce a universally accepted waiting time definition for cardiovascular surgery, present the rationale for this definition, and compare data on current waiting times in British Columbia based on this definition versus the current definition in patients waiting for aortic stenosis surgery. STUDY DESIGN: The present study is a retrospective data analysis. SETTING: The fixed-dollar, single-payer health care delivery system in British Columbia. PATIENTS: All residents of British Columbia who were at least 22 years of age and who were placed on a waiting list for aortic valve surgery with the diagnosis of aortic stenosis between January 1, 1991, and December 31, 2000, were eligible for the present study. INTERVENTIONS: Dates of physician visits, procedures and surgery were obtained from the British Columbia Cardiac Registries and Medical Services Plan databases. True waiting times from physician visits to procedures and surgery were calculated. RESULTS: Of the 2516 patients booked for aortic valve surgery with a primary diagnosis of aortic stenosis, 2237 subjects (88.9%) were eligible for analysis after exclusions. The eligible patients ranged in age from 22 to 95 years, and 36.8% were female. The true median waiting time was 243 days (148 days [25th percentile], 397 days [75th percentile]), which was 3.2 times the interval currently reported as the waiting time (75 days [42, 127]). Thirty-nine patients died while waiting for surgery. Patients used more resources while waiting for surgery than after surgery. CONCLUSIONS: True waiting times for surgery for aortic stenosis in British Columbia are significantly longer than reported waiting times. The authors propose that the wait list time for cardiovascular surgery be redefined as "the time interval between the patient's first contact with a medical care provider with symptoms or signs which ultimately lead to cardiovascular surgery and the date of that surgery".

Study design of the Multicultural Community Health Assessment Trial (M-CHAT): a comparison of body fat distribution in four distinct populations.

OBJECTIVE: To outline the study design of the Multicultural Community Health Assessment Trial (M-CHAT). The purpose of the study is to compare the relationship between visceral adipose tissue (VAT) and total body fat in men and women of Aboriginal, Chinese, and South Asian origin with a similar group of men and women of European origin. DESIGN: A total of 200 apparently healthy men and women between the ages of 30 and 65 will be recruited from each of the local Aboriginal, Chinese, and South Asian and European communities. Within each sex/ethnic group, an equal representation of participants will have a body mass index between 18.5 to 24.9, 25 to 29.9 and >30. Each participant will undergo an assessment for VAT, total body fat, metabolic risk factors, physical activity, diet, quality of life, and sociodemographics. MAIN OUTCOME MEASURES: The primary outcome of this study is the relationship between VAT and total body fat in each of the Aboriginal, Chinese, and South Asian cohorts; this relationship will be compared to the European cohort after adjustment for age, sex, socioeconomic status, smoking status, physical activity, diet, and body mass index. CONCLUSIONS: This study will be the first to identify differences in body fat distribution in these populations. We anticipate that in populations of Aboriginal, Chinese, and South Asian origin, a greater proportion of total body fat will be deposited as VAT compared to those of European origin.

Cross-provincial use of cardiac services: the importance of data-sharing for clinical registries and outcomes research.

BACKGROUND: The structure of the Canadian health care system lends itself to health services and health outcomes research. It is possible to track hospital admissions and discharges, physician billings and prescriptions using administrative databases. In addition, several provinces have developed registries that provide detailed clinical and procedural information. Using the unique personal health numbers assigned to all Canadian residents, linkage between administrative databases and population-based clinical registries provides important information regarding the use of health services and health outcomes. OBJECTIVE: To determine the extent of cross-border (British Columbia-Alberta border) use of cardiac services by British Columbia residents. METHODS: Population rates of cardiac procedures were calculated using two prospective clinical registries (British Columbia Cardiac Registries and Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease [APPROACH]), as well as administrative databases (the British Columbia Ministry of Health's hospitalization and Medical Services Plan databases). RESULTS: Analyses using only British Columbia data suggest low cardiac procedure rates for patients living in eastern British Columbia. By accessing APPROACH data, it was determined that more than 80% of British Columbia cardiac patients living along the British Columbia-Alberta border access procedural services in Alberta. CONCLUSIONS: While residents of eastern British Columbia appear to have reduced access to cardiac services when data from British Columbia are analyzed in isolation, they are actually accessing care in Alberta. Analyses based solely on single province data sources will underestimate cardiac procedures rates.