Research of Medical Expenditure among Inpatients with Unstable Angina Pectoris in a Single Center.

BACKGROUND: With the rising incidence as well as the medical expenditure among patients with unstable angina pectoris, the research aimed to investigate the inpatient medical expenditure through the combination of diagnosis-related groups (DRGs) among patients with unstable angina pectoris in a Grade A tertiary hospital to conduct the referential standards of medical costs for the diagnosis. METHODS: Single-factor analysis and multiple linear stepwise regression method were used to investigate 3933 cases between 2014 and 2016 in Beijing Hospital (China) whose main diagnosis was defined as unstable angina pectoris to determine the main factors influencing the inpatient medical expenditure, and decision tree method was adopted to establish the model of DRGs grouping combinations. RESULTS: The major influential factors of inpatient medical expenditure included age, operative method, therapeutic effects as well as comorbidity and complications (CCs) of the disease, and the 3933 cases were divided into ten DRGs by four factors: age, CCs, therapeutic effects, and the type of surgery with corresponding inpatient medical expenditure standards setup. Data of nonparametric test on medical costs among different groups were all significant (P < 0.001, by Kruskal-Wallis test), with R2 = 0.53 and coefficient of variation (CV) = 0.524. CONCLUSIONS: The classification of DRGs by adopting the type of surgery as the main branch node to develop cost control standards in inpatient treatment of unstable angina pectoris is conducive in standardizing the diagnosis and treatment behaviors of the hospital and reducing economic burdens among patients.

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.

High-Risk Atherosclerotic Cardiovascular Disease in a Real-World Employed Japanese Population: Prevalence, Cardiovascular Event Rates, and Costs.

AIM: To assess the prevalence of high-risk atherosclerotic cardiovascular disease (ASCVD, defined as history of acute coronary syndrome [hACS], cerebrovascular atherosclerotic disease [CeVAD], peripheral artery disease [PAD], or coronary artery disease w/diabetes [CADD]) and associated costs and cardiovascular (CV) events in Japan. METHODS: A retrospective analysis was conducted using the Japan Medical Data Center (JMDC) database (2006-2011). ASCVD prevalence was estimated on the basis of diagnoses for CeVAD, PAD, CADD, and hACS (ACS claim ＞ 30-≤ 365 days after ACS-related hospitalization) during 1/1/ 2008-12/31/2009. Population denominators used in the prevalence estimations were provided by JMDC. A subcohort with an insurance coverage for ≥ 12 months before and ≥ 24 months after first/index ASCVD claim during 1/1/2008-12/31/2009 were analyzed on the basis of costs (in 2012 US dollars) and events. RESULTS: ASCVD prevalence was 1,869/100,000 population. In total, 8,112 patients met inclusion criteria for the cost and CV event analyses. Among these patients, 4.0% experienced any event (myocardial infarction, stroke, coronary revascularization, hospitalization for unstable angina) in the year after ASCVD diagnosis, which decreased to 2.2% in year 2. First-year event rates were highest (22%) in patients with hACS. Mean [SD] all-cause costs per patient in year 1 were $7,031 [$14,359] for all patients with ASCVD combined. Extrapolated to the entire employed population, total first-year costs were estimated at $8.2 billion. CONCLUSIONS: ASCVD is not rare in Japan, even within a relatively young population of employed persons. Further, the total direct first-year cost burden of ASCVD in the employed Japanese population is high. These data may inform future economic assessments of new ASCVD treatments.

Economic evaluation of clopidogrel in acute coronary syndrome patients without ST-segment elevation in Greece: a cost-utility analysis.

BACKGROUND: Current guidelines recommend treatment with antiplatelet and anticoagulant therapy for the secondary prevention of atherothrombotic events among patients with non-ST-segment elevation myocardial infarction (NSTEMI) or unstable angina (UA). The CURE (Clopidogrel in Unstable angina to prevent Recurrent Events) trial has shown that clopidogrel alone or in combination with aspirin is more effective in reducing the risk of atherothrombotic events than aspirin alone in NSTEMI or UA patients. However, in the current climate of financial constraints, the effectiveness of a treatment should be considered in conjunction with its long-term economic costs to determine the best possible care. OBJECTIVE: To evaluate the cost effectiveness of 1 year of treatment with clopidogrel in addition to aspirin in NSTEMI or UA patients from the third-party-payer perspective in Greece. METHODS: An existing Markov model consisting of six states (NSTEMI/UA/no event, first year with stroke, history of stroke, first year with myocardial infarction [MI], history of MI and death) was adapted and extended to the Greek healthcare setting for year 2012. Utility values obtained from a Greek national study were assigned to each health state in order to estimate the quality-adjusted life-years (QALYs). Costs assigned to each health state included antiplatelet treatment cost, cost for the management of adverse events and the costs for concomitant medication, hospitalization, outpatient visits, rehabilitation and nursing. Cost effectiveness and cost utility was expressed as the cost per life-year (LY) gained and QALY gained, respectively. A probabilistic sensitivity analysis was conducted. RESULTS: The Markov analysis predicts a discounted survival of 8.27 years in the aspirin treatment group and 8.41 years in the aspirin plus clopidogrel treatment group. The corresponding discounted QALYs were 6.88 and 7.00, respectively. The cumulated lifetime costs per patient were € 18 779 and € 19 191, for the aspirin and aspirin plus clopidogrel treatment arms, respectively. The incremental cost-effectiveness ratio (ICER) with the addition of clopidogrel was &U20AC;2951 for each LY saved and &U20AC;3541 for each QALY saved. Finally, clopidogrel plus aspirin was found to be cost effective in more than 95% of simulated samples at a threshold of &U20AC;7000 per discounted QALY gained. CONCLUSION: One-year treatment with clopidogrel in addition to aspirin is a cost-effective treatment option for secondary prevention in patients with acute coronary syndrome without ST-segment elevation in Greece.

Ambulatory discharge after transradial coronary intervention: Preliminary US single-center experience (Same-day TransRadial Intervention and Discharge Evaluation, the STRIDE Study).

BACKGROUND: Although the safety and cost-effectiveness of same-day discharge after uncomplicated transradial percutaneous coronary intervention (TR-PCI) is well established in Europe and Asia, such data are not available for US patients. METHODS: All patients who underwent TR-PCI at our high-volume US medical center between 2004 and 2007 were included in this study. The primary end point was in-hospital adverse clinical outcomes between 6 and 24 hours postprocedure. RESULTS: A total of 450 patients were included in this study (aged 59 +/- 11 years). Of these, 13% were female, 27% were diabetic, 6% had peripheral vascular disease, and 5% had chronic kidney disease. Procedural indications included stable angina (49%), unstable angina (31%), non-ST elevation myocardial infarction (NSTEMI) (17%), and ST elevation myocardial infarction (STEMI) (3%). All patients received an intra-arterial cocktail of heparin, verapamil, and nitroglycerin, and 13% of patients received glycoprotein IIb/IIIa inhibitors. Seven percent of patients had 3-vessel disease, 3% had bypass grafts stenoses, and 20% had class B(2)/C lesions. Procedural success rate was 96%. A total of 24 (5.3%) postprocedural complications were observed; however, none occurred between hours 6 to 24, the time differential between same-day and next-day discharge. Thirteen patients (2.9%) experienced significant complications within the first 6 hours (MI, urgent repeat revascularization, and ventricular tachycardia). Eleven (2.4%) spontaneously resolved minor access complications developed. There were 12 same-day discharges according to the operators' discretion; none required readmission. CONCLUSIONS: Although a low incidence of complications did occur, none would have been impacted by same-day discharge. Those observed before 6 hours would have prevented early discharge, and those occurring after 24 hours would have been unaffected by routine next-day discharge. This observational study demonstrated the safety and feasibility for a prospective evaluation of ambulatory TR-PCI in an American practice setting.

Pharmacoeconomics of anticoagulants in acute coronary syndrome and percutaneous coronary intervention.

Economic evaluation plays an important role during almost all stages of pharmaceutical design and use. This paper reviews the recent pharmacoeconomic literature on the use of anticoagulants for acute coronary syndromes (ACS) and percutaneous coronary intervention (PCI). Both ACS and PCI are common reasons for hospitalization and contribute significantly to costs of care. ACS and PCI practice standards are still evolving. For ACS enoxaparin does appear to be more cost-effective around the globe than unfractionated heparin (UFH) when clopidrogel and glycoprotein IIb/IIIa (GP IIb/IIIa) inhibitors are not used. With the high prevalence of clopidrogel and GP IIb/IIIa use, the question may be moot. Since the cost of UFH therapy, including the cost of anticoagulant monitoring, is less expensive than enoxaparin therapy, UFH is probably the more cost-effective strategy. For PCI, as ischemic complications were reduced during the mid'90's, bleeding complications have become the most common problem and a major cost driver. Other complications that can drive costs include the occurrence of MI and revascularization procedures (repeat PCI or CABG). Results suggest that bivalirudin plus a provisional GP IIb/IIIa inhibitor is the most cost-effective strategy for patients undergoing elective PCI. There is no clear evidence regarding its use in urgent PCI. ACS and PCI practice standards are still evolving. It would be useful to embed economic studies within new clinical trials. Full economic analysis of groups at high risk for bleeding while undergoing PCI is needed.

The cost-effectiveness of an early interventional strategy in non-ST-elevation acute coronary syndrome based on the RITA 3 trial.

BACKGROUND: Evidence suggests that an early interventional strategy for patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) can improve health outcomes but also increase costs when compared with a conservative strategy. OBJECTIVE: The aim of this study was to assess the cost-effectiveness of an early interventional strategy in different risk groups from a UK health-service perspective. DESIGN: Decision-analytic model based on randomised clinical trial data. MAIN OUTCOME MEASURES: Costs in UK Sterling at 2003/2004 prices and quality-adjusted life years (QALYs) combined into an incremental cost-effectiveness ratio. METHODS: Data from the third Randomised Intervention Trial of unstable Angina (RITA 3) was employed to estimate rates of cardiovascular death and myocardial infarction, costs and health-related quality of life. Cost-effectiveness was estimated over patients' lifetimes within the decision-analytic model. RESULTS: The mean incremental cost per QALY gained for an early interventional strategy was approximately 55,000 pounds sterling, 22,000 pounds sterling and 12,000 pounds sterling for patients at low, intermediate and high risk, respectively. The early interventional strategy is approximately 1%, 35% and 95% likely to be cost-effective for patients at low, intermediate and high risk, respectively, at a threshold of 20,000 pounds sterling per QALY. The cost-effectiveness of early intervention in low-risk patients is sensitive to assumptions about the duration of the treatment effect. CONCLUSION: An early interventional strategy in patients presenting with NSTE-ACS is likely to be considered cost-effective for patients at high and intermediate risk, but this is less likely to be the case for patients at low risk.

Cost-effectiveness of clopidogrel in acute coronary syndromes in Canada: a long-term analysis based on the CURE trial.

BACKGROUND: Cardiovascular diseases account for nearly 20% of all hospitalizations in Canada and consume 12% of the total cost of all illnesses. With increasing trends of cardiovascular disease and increasing costs of care, development of cost-effective strategies is vital. The Clopidogrel in Unstable angina to prevent Recurrent Events (CURE) trial demonstrated the effectiveness of clopidogrel plus acetylsalicylic acid (ASA) compared with ASA alone in reducing cardiovascular events in patients with acute coronary syndromes and, in addition, patients undergoing percutaneous coronary intervention in the Percutaneous Coronary Intervention in CURE (PCI-CURE) trial. OBJECTIVE: To assess the cost-effectiveness of clopidogrel in the Canadian health care system. METHODS: Estimates of hospitalization costs were based on the 2003 cost schedules released by the Health Funding and Costing Branch of the Alberta Health and Wellness, as well as on the Case Mix Group classification system. Life expectancy beyond the trial was estimated from the Saskatchewan Health Database. Cost-effectiveness was expressed as the incremental cost-effectiveness ratio, and bootstrap methods were used to estimate the joint distribution of costs and effectiveness. RESULTS: Clopidogrel was shown to be cost-effective, with incremental cost-effectiveness ratios less than $10,000 per event prevented and less than $4,000 per life-year gained. The probability of clopidogrel resulting in cost per life-year gained of less than $20,000 was 0.975 for CURE patients and 0.904 for PCI-CURE patients. CONCLUSIONS: The economic analysis demonstrated that clopidogrel combination therapy is not only cost-effective as antiplatelet therapy compared with ASA alone, but it is also cost-effective compared with other commonly used and openly reimbursed cardiovascular therapies in the Canadian health care system.

Incremental benefit and cost-effectiveness of high-dose statin therapy in high-risk patients with coronary artery disease.

BACKGROUND: Recent clinical trials found that high-dose statin therapy, compared with conventional-dose statin therapy, reduces the risk of cardiovascular events in patients with acute coronary syndromes (ACS) and stable coronary artery disease (CAD). However, the actual benefit and cost-effectiveness of high-dose statin therapy are unknown. METHODS AND RESULTS: We designed a Markov model to compare daily high-dose with conventional-dose statin therapy for hypothetical 60-year-old cohorts with ACS and stable CAD over patient lifetime. Pooled estimates for major clinical end points (all-cause mortality, myocardial infarction, stroke, rehospitalization, and revascularization) from relevant clinical trials were incorporated. Incremental benefit was quantified as quality-adjusted life-years (QALYs). Threshold analyses determined at what price difference high-dose statins would yield incremental cost-effective ratios below $50,000, $100,000, and $150,000 per QALY gained. In ACS patients, a high-dose versus conventional-dose statin strategy resulted in a gain of 0.35 QALYs. In threshold analyses, a high-dose statin strategy consistently yielded incremental cost-effective ratios below $30,000 per QALY even under conservative model assumptions. In stable CAD patients, a high-dose statin strategy yielded a gain of only 0.10 QALYs and was sensitive to model assumptions about statin efficacy. The daily cost difference between a high- and conventional-dose statin would need to be <$1.70, $2.65, and $3.55 to yield incremental cost-effective ratios below $50,000, $100,000, and $150,000 per QALY. CONCLUSIONS: High-dose statin therapy is potentially highly effective and cost-effective in patients with ACS. In patients with stable CAD, however, the cost-effectiveness of high-dose statin therapy is highly sensitive to model assumptions about statin efficacy and cost. Use of high-dose statins can be supported on health economic grounds in patients with ACS, but the case is less clear for patients with stable CAD.

Acute coronary syndromes in Europe: 1-year costs and outcomes.

OBJECTIVE: This study aims to estimate costs (including medications prescribed, intervention rates and hospital utilization) and health outcomes of acute coronary syndromes (ACS) during the first year following diagnosis. RESEARCH DESIGN AND METHODS: Treatment pathways for ACS patients were developed and country-specific resource use was multiplied by unit costs. Countries examined were the United Kingdom (UK), France, Germany, Italy and Spain. Patients with unstable angina and acute myocardial infarction (ST-segment elevation and non-ST-segment elevation with/without Q-wave) were considered. The study models the incidence of ACS, 1-year mortality, investigations, revascularisation, pharmaceutical use and medical management. Economic outcomes were direct healthcare costs (in 2004 Euros), including total cost, cost per patient with ACS and cost per capita. RESULTS: The estimated number of deaths in the first year following ACS diagnosis ranged from around 22 500 in Spain to over 90 000 in Germany. The largest contributors to total costs are hospital stay and revascularisation procedures. Pharmaceuticals were estimated at 14-25% of ACS total cost. The total cost of ACS in the UK is estimated around 1.9 billion Euros, compared with 1.3 billion Euros in France, 3.3 billion Euros in Germany, 3.1 billion Euros in Italy and 1.0 billion Euros in Spain. The cost per ACS patient ranges from 7009 Euros (in the UK) to 12,086 Euros (Italy). CONCLUSIONS: Countries with higher expenditure on ACS patients tended to have lower case-fatality rates, and countries with the lowest incidence of ACS also had the lowest cost per capita. The costs of ACS constitute a large proportion of total healthcare expenditure of Western European economies.

Utility loss and indirect costs following cardiovascular events in hypertensive patients: the ASCOT health economic substudy.

This study assessed the loss of utility and indirect costs associated with first cardiovascular events. Data was collected (using EQ-5D) prospectively at 3, 6, and 12 months following an event in the Swedish part of the Anglo-Scandinavian cardiac outcomes trial (ASCOT), including patients with mild to moderate hypertension and additional risk factors. Sixty patients were eligible for analysis. An event was associated with a one-year utility loss of 0.075 (95% CI: 0.038-0.114). For a stroke, the reduction was 0.145 (CI: 0.059-0.249) and for acute coronary syndromes (myocardial infarction or unstable angina) the loss was 0.051 (-0.003 to 0.103). The utility at baseline was no different to the utility in a control group. The indirect cost over the first 12 months (2003 Swedish Kronor, SEK) was 90028 SEK (CI: 46027-146754), 9866 euro for patients in the workforce. These results are helpful in future economic evaluations of primary preventive measures in cardiovascular medicine.

Disparities by insurance status in quality of care for elderly patients with unstable angina.

CONTEXT: Treatment disparities for socioeconomically disadvantaged populations have been widely reported, but few studies have sought explanations for these disparities. OBJECTIVE: To compare the quality of care for patients insured by Medicare alone, Medicare plus Medicaid, or Medicare plus private insurance and investigate mediators for potential disparities. DESIGN, SETTING, AND PARTICIPANTS: Retrospective, random chart review of 3122 African American or White Medicare patients >65 years of age hospitalized for unstable angina in 22 Alabama hospitals, 1993-1999. MAIN OUTCOME MEASURES: Echocardiogram within 20 minutes of presentation; evaluation by a cardiologist; appropriate anti-platelet therapy within 24 hours of admission and at discharge, heparin for high-risk patients, beta-blockers during hospitalization, and performance of appropriate coronary angiography. RESULTS: 182 (5.8%) had Medicare only, 433 (13.9%) had Medicare plus Medicaid, and 2507 (80.3%) had Medicare plus private insurance. Medicaid patients were more frequently Black, female, >85 years old, had multiple co-morbidities, or were admitted to hospitals without cardiac catheterization facilities (P<.001). Fewer Medicaid patients were admitted to hospitals with cardiac catheterization capabilities. Even after adjustment for demographics and hospital characteristics, Medicaid patients were less likely to see a cardiologist (odds ratio [OR] .57, 95% confidence interval [CI] .44-.73), receive antiplatelet therapy within 24 hours of admission (OR .66, 95% CI .50-.87), or heparin (OR .71, 95% CI .53-.97). No differences were seen with regard to having an electrocardiogram within 20 minutes of admission. Beta-blockers were used least in the Medicare-only patients, with only 37.7% receiving them (P=.04). Suitable Medicaid patients received coronary angiography less often, even after adjustment for demographics, co-morbidity, and prior revascularization (OR .68, 95% CI .48-.97). However, when adjusted for hospital characteristics, this finding was no longer observed (OR .94, 95% CI .64-1.39). CONCLUSIONS: Elderly Medicaid patients appear to receive poorer quality of care. This finding is partially, but not completely, explained by characteristics of the facilities where they are hospitalized.

Outcomes of patients with acute coronary syndromes who are treated with bivalirudin during percutaneous coronary intervention: an analysis from the Randomized Evaluation in PCI Linking Angiomax to Reduced Clinical Events (REPLACE-2) trial.

BACKGROUND: The REPLACE-2 trial demonstrated that bivalirudin with provisional glycoprotein IIb/IIIa (GPIIb/IIIa) inhibition is not inferior to heparin plus GPIIb/IIIa inhibition in patients undergoing percutaneous coronary intervention. The extent to which this applies to patients with acute coronary syndromes (ACS) is unclear. Therefore, we sought to determine if bivalirudin has similar efficacy in ACS patients as compared with "stable" patients in the REPLACE-2 trial. METHODS: We analyzed the outcomes of ACS patients compared with stable patients and the outcomes of ACS patients according to whether or not they had received bivalirudin, including the economic costs. The trial enrolled 1351 ACS patients (myocardial infarction within 7 days or unstable angina within 48 hours, but not on ongoing GPIIb/IIIa or heparin therapy) and 4554 stable patients. RESULTS: Patients with ACS had a similar rate of death or myocardial infarction at 30 days compared to stable patients (7.2% vs 6.7%, P = .51) and death at 1 year (1.6% vs 2.2%, P = .169), but a higher rate of urgent coronary artery bypass graft at 30 days (1.0% vs 0.3%, P = .002). Patients with ACS treated with bivalirudin had a similar rate of 30-day death, myocardial infarction, or urgent revascularization compared with ACS patients treated with heparin and GPIIb/IIIa inhibitors (8.7% vs 8.0%, P = .616) and death at 1 year (1.5% vs 1.8%, P = .701), but a higher rate of revascularization at 6 months (12% vs 8.4%, P = .04). Patients with ACS treated with bivalirudin had less major bleeding than ACS patients treated with heparin and GPIIb/IIIa inhibitors, although this was not statistically significant (2.7% vs 4.5%, P = .07). Mean 30-day costs for patients with ACS were dollar 12415 for those treated with bivalirudin and dollar 12806 for those treated with heparin plus GPIIb/IIIa inhibitors (P = .022). CONCLUSION: Bivalirudin with provisional GPIIb/IIIa inhibitor use in low-risk ACS patients (not receiving preprocedural GPIIb/IIIa blockade) appears to provide similar protection against death and myocardial infarction as the combination of heparin and GPIIb/IIIa inhibitors, although we observed a higher rate of revascularization at 6 months.

Cost-effectiveness of cholesterol-lowering therapy with pravastatin in patients with previous acute coronary syndromes aged 65 to 74 years compared with younger patients: results from the LIPID study.

BACKGROUND: We compared cost-effectiveness of pravastatin in a placebo-controlled trial in 5500 younger (31-64 years) and 3514 older patients (65-74 years) with previous acute coronary syndromes. METHODS: Hospitalizations and long-term medication within the 6 years of the trial were estimated in all patients . Drug dosage, nursing home, and ambulatory care costs were estimated from substudies. Incremental costs per life saved of pravastatin relative to placebo were estimated from treatment effects and resource use. RESULTS: Over 6 years, pravastatin reduced all-cause mortality by 4.3% in the older patients and by 2.3% in the younger patients. Older patients assigned pravastatin had marginally lower cost of pravastatin and other medication over 6 years (A dollar 4442 vs A dollar 4637), but greater cost offsets (A dollar 2061 vs A dollar 897) from lower rates of hospitalizations. The incremental cost per life saved with pravastatin was A dollar 55500 in the old and A dollar 167200 in the young. Assuming no treatment effect beyond the study period, the life expectancy to age 82 years of additional survivors was 9.1 years in the older and 17.3 years in the younger. Estimated additional life-years saved from pravastatin therapy were 0.39 years for older and 0.40 years for younger patients. Incremental costs per life-year saved were A dollar 7581 in the older and A dollar 14944 in the younger, if discounted at 5% per annum. CONCLUSIONS: Pravastatin therapy was more cost-effective among older than younger patients, because of their higher baseline risk and greater cost offsets, despite their shorter life expectancy.

Work resumption after newly diagnosed coronary heart disease: findings on the importance of paid leave.

OBJECTIVES: Studies have demonstrated the health benefits of work resumption for adults experiencing health problems, but there are important gaps in the research examining the factors that would help these individuals return to work. This study examines if working conditions predict whether women who experience angina or a myocardial infarction (MI) return to work. METHODS: A sample of 289 employed women from the Nurses' Health Study was analyzed. Bivariate chi-square and logistic regression analyses were conducted to examine the relationship between working conditions and the likelihood of returning to work after experiencing an MI or angina. RESULTS: Seventy-nine percent of women returned to work after experiencing an MI or angina. Women who had paid leave were substantially more likely to return to work after an MI or angina episode than women without this benefit (adjusted odds ratio [OR] 2.7, p = 0.04). CONCLUSIONS: Public and corporate policies to promote paid leave for female workers who experience a serious health condition are likely to help these workers return to their jobs, thereby providing important health and economic benefits for both workers and society.

Outcomes of patients with stable low-risk coronary artery disease receiving medical- and PCI-preceding therapies in Japan: J-SAP study 1-1.

BACKGROUND: Stable coronary artery disease (CAD) is classified into 2 types: high-risk (ie, 3-vessel disease, left main trunk lesions, or ostial lesions of the left anterior descending (LAD)) and low-risk (1- or 2-vessel disease other than ostial lesions of the LAD), which comprise the majority of CAD patients. According to ACC/AHA/ACP-ASIM guidelines for low-risk CAD, anti-anginal agents should be initially administered to control attacks, then coronary intervention should be considered when medical therapy is not effective (medical-preceding therapy: M). In Japan, however, the initial treatment is generally percutaneous coronary intervention (PCI) combined with medical therapy (PCI-preceding therapy: P). METHODS AND RESULTS: In the present study the long-term outcomes of 190 M patients and 192 matched P patients at 34 nationwide hospitals were surveyed over 3 years (mean: 3.4 years) starting in 2000. Age, gender, initial severity of anginal symptoms, number of lesion vessels, risk factors and prescriptions were similar between the 2 groups. During the 3.4-year follow-up, additional PCI or coronary artery bypass grafting was required in 9.4% of the M group and in 33.2% of the P group. The rates of cardiac death were similar (1.6% in M and 2.6% in P). The overall rate of cardiac death and acute coronary syndrome was 2.1% in M and 4.7% in P, but the difference was not significant. The grade of anginal symptoms 12 months later was well improved in both M (1.6+/-1.4 to 0.6+/-0.9) and P (1.7+/-1.4 to 0.3+/-0.7) and there was no significant difference. Averaged annual medical cost was lower in M than in P (4.4-fold lower in the first year and 3.1-fold by the next year). CONCLUSIONS: The present study suggests that M and P for Japanese low-risk CAD may have a similar effect on long-term prognosis, but M is cheaper.

The role of risk stratification in the decision to provide upstream versus selective glycoprotein IIb/IIIa inhibitors for acute coronary syndromes: a cost-effectiveness analysis.

OBJECTIVES: We endeavored to determine under what conditions a strategy of upstream use of small molecule platelet glycoprotein (GP) IIb/IIIa inhibitors for all acute coronary syndromes (ACS) patients is cost effective compared to that of selective use of abciximab in only those patients requiring percutaneous coronary intervention (PCI). BACKGROUND: Small molecule GP IIb/IIIa inhibitors have shown benefit in ACS, but abciximab, the more expensive GP IIb/IIIa inhibitor, may be more effective during PCI. However, abciximab does not have proven efficacy in medical management. No prior study has attempted to balance these competing benefits. METHODS: A decision analysis was performed to examine two strategies: 1) treat all ACS patients upstream with a small molecule GP IIb/IIIa inhibitor and continue through medical management and PCI, if performed; or 2) wait, and selectively use abciximab only in patients who ultimately undergo PCI. Applicable randomized controlled trial data were used for the principal analysis. RESULTS: The strategy of upstream use of a small molecule GP IIb/IIIa inhibitor was superior to selective use, and economically acceptable, with a cost-effectiveness ratio of 18,000 dollars per year of life gained. The superiority of the upstream use strategy persisted over the majority of sensitivity analyses. When stratified by risk according to Thrombolysis in Myocardial Infarction risk score, a strategy of upstream use was only cost effective in those patients with moderate or high risk. CONCLUSIONS: Upstream use of small molecule GP IIb/IIIa inhibition in ACS patients with moderate or high risk for cardiovascular events is a cost-effective approach that should be considered in this subset of patients.