Cost utility of fractional flow reserve-guided percutaneous coronary intervention in multivessel coronary artery disease in Brazil.

OBJECTIVE: The fractional flow reserve (FFR) versus angiography for multivessel evaluation (FAME) study has demonstrated that FFR substantially reduces major adverse cardiac events and resource utilization in coronary artery disease (CAD) patients. We aimed to assess the cost utility of FFR in percutaneous coronary interventions (PCI) from the perspective of the Brazilian Public Health System (SUS). DESIGN: Patient-level cost-utility analysis along the FAME study. PARTICIPANTS: Multivessel coronary artery disease patients. INTERVENTION: PCI, either guided by FFR or by angiography alone. SETTING: The procedure costs were based on the mean amount of unitary resource utilization multiplied by the costs from SUS reimbursement list. The utilities were derived using Brazilian weights for time trade-off European Quality of Life-5 Dimensions. The World Health Organization recommendation based on gross domestic product per capita (international dollars [I$] 35 876/quality-adjusted life year [QALY]) was used as willingness-to-pay threshold. MAIN OUTCOME MEASURE: We determined the incremental cost-utility ratio (ICUR) in I$ per QALY gained during the 1-year time horizon. RESULTS: One-year costs were I$ 8931 for the angiography-guided PCI and I$ 8968 for the FFR-guided PCI, resulting in an incremental cost of I$ 37. Effectiveness during 1 year was 0.798 QALYs for angiography-guided PCI and 0.811 for FFR-guided PCI, resulting in an incremental effectiveness of 0.013 QALYs. The base-case ICUR of FFR versus angiography-guided PCI was 2780 I$/QALY. Cost-saving results are achieved with a FFR price reduction of at least 2.2%. CONCLUSIONS: Developing countries should give attention to strategies proven to be cost-effective in other health systems. In our analysis, FFR-guided PCI is very cost-effective in the Brazilian SUS and with a minimal price reduction of the device, FFR could be cost saving.

Cost-effectiveness of on-pump and off-pump coronary artery bypass grafting for patients with coronary artery disease: Results from the MASS III trial.

BACKGROUND: Recent trials have reported similar clinical outcomes between on-pump and off-pump coronary artery bypass graft (CABG). However, long-term cost-effectiveness of these strategies is unknown. METHODS: A prespecified economic study was performed based on the MASS III trial. Costs were estimated for all patients based on observed healthcare resource usage over a 5-year follow-up. Health state utilities were evaluated with the SF-6D questionnaire. Cost-effectiveness was assessed as cost per quality-adjusted life-year (QALY) gained using a Markov model. Probabilistic sensitivity analysis with the Monte-Carlo simulation and cost-effectiveness acceptability curve were used to address uncertainty. RESULTS: Quality of life improved significantly in both groups during follow-up compared with baseline. At 5 years, when comparing on-pump and off-pump CABG groups, no differences were found in cumulative life-years (4.851 and 4.766 years, P = .319) and QALY gained (4.150 and 4.105 QALYs, P = .332). Mean cost in US dollars per patient during the trial did not differ significantly between the on-pump and off-pump groups ($5890.29 and $5674.75, respectively, P = .409). Over a lifetime horizon, the incremental cost-effectiveness ratio of on-pump versus off-pump CABG was $12,576 per QALY gained, which is above the suggested cost-effectiveness threshold range (from $3210 to 10,122). In the sensitivity analysis, the probability that on-pump CABG is cost-effective compared to off-pump surgery for a willingness-to-pay threshold of $3212 per QALY gained was <1%. For the $10,122 per QALY threshold, the same probability was 35%. CONCLUSION: This decision-analytic model suggests that on-pump CABG is not cost-effective when compared to off-pump CABG from a public health system perspective.

Estimated costs of hospitalization due to coronary artery disease attributable to familial hypercholesterolemia in the Brazilian public health system.

OBJECTIVE: Cardiovascular diseases are the leading cause of death in Brazil, imposing substantial economic burden on the health care system. Familial hypercholesterolemia (FH) is known to greatly increase the risk of premature coronary artery disease (CAD). This study aimed to estimate the economic impact of hospitalizations due to CAD attributable to FH in the Brazilian Unified Health Care System (SUS). SUBJECTS AND METHODS: Retrospective, cross-sectional study of data obtained from the Hospital Information System of the SUS (SIHSUS). We selected all adults (≥ 20 years of age) hospitalized from 2012--2014 with primary diagnoses related to CAD (ICD-10 I20 to I25). Attributable risk methodology estimated the contribution of FH in the outcomes of interest, using international data for prevalence (0.4% and 0.73%) and relative risk for events (RR = 8.56). RESULTS: Assuming an international prevalence of FH of 0.4% and 0.73%, of the 245,981 CAD admissions/year in Brazil, approximately 7,249 and 12,915, respectively, would be attributable to an underlying diagnosis --of FH. The total cost due to CAD per year, considering both sexes and all adults, was R$ 985,919,064, of which R$ 29,053,500 and R$ 51,764,175, respectively, were estimated to be attributable to FH. The average cost per FH-related CAD event was R$ 4,008. CONCLUSION: Based on estimated costs of hospitalization for CAD, we estimated that 2.9-5.3% are directed to FH patients. FH can require early specific therapies to lower risk in families. It is mandatory to determine the prevalence of FH and institute appropriate treatment to minimize the clinical and economic impact of this disease in Brazil.

Estimated costs of hospitalization due to coronary artery disease attributable to familial hypercholesterolemia in the Brazilian public health system

ABSTRACT Objective: Cardiovascular diseases are the leading cause of death in Brazil, imposing substantial economic burden on the health care system. Familial hypercholesterolemia (FH) is known to greatly increase the risk of premature coronary artery disease (CAD). This study aimed to estimate the economic impact of hospitalizations due to CAD attributable to FH in the Brazilian Unified Health Care System (SUS). Subjects and methods: Retrospective, cross-sectional study of data obtained from the Hospital Information System of the SUS (SIHSUS). We selected all adults (≥ 20 years of age) hospitalized from 2012­-2014 with primary diagnoses related to CAD (ICD-10 I20 to I25). Attributable risk methodology estimated the contribution of FH in the outcomes of interest, using international data for prevalence (0.4% and 0.73%) and relative risk for events (RR = 8.56). Results: Assuming an international prevalence of FH of 0.4% and 0.73%, of the 245,981 CAD admissions/year in Brazil, approximately 7,249 and 12,915, respectively, would be attributable to an underlying diagnosis ­­of FH. The total cost due to CAD per year, considering both sexes and all adults, was R$ 985,919,064, of which R$ 29,053,500 and R$ 51,764,175, respectively, were estimated to be attributable to FH. The average cost per FH-related CAD event was R$ 4,008. Conclusion: Based on estimated costs of hospitalization for CAD, we estimated that 2.9-5.3% are directed to FH patients. FH can require early specific therapies to lower risk in families. It is mandatory to determine the prevalence of FH and institute appropriate treatment to minimize the clinical and economic impact of this disease in Brazil.

Cost-effectiveness of anatomical and functional test strategies for stable chest pain: public health perspective from a middle-income country.

OBJECTIVES: The aim of this research is to evaluate the relative cost-effectiveness of functional and anatomical strategies for diagnosing stable coronary artery disease (CAD), using exercise (Ex)-ECG, stress echocardiogram (ECHO), single-photon emission CT (SPECT), coronary CT angiography (CTA) or stress cardiacmagnetic resonance (C-MRI). SETTING: Decision-analytical model, comparing strategies of sequential tests for evaluating patients with possible stable angina in low, intermediate and high pretest probability of CAD, from the perspective of a developing nation's public healthcare system. PARTICIPANTS: Hypothetical cohort of patients with pretest probability of CAD between 20% and 70%. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome is cost per correct diagnosis of CAD. Proportion of false-positive or false-negative tests and number of unnecessary tests performed were also evaluated. RESULTS: Strategies using Ex-ECG as initial test were the least costly alternatives but generated more frequent false-positive initial tests and false-negative final diagnosis. Strategies based on CTA or ECHO as initial test were the most attractive and resulted in similar cost-effectiveness ratios (I$ 286 and I$ 305 per correct diagnosis, respectively). A strategy based on C-MRI was highly effective for diagnosing stable CAD, but its high cost resulted in unfavourable incremental cost-effectiveness (ICER) in moderate-risk and high-risk scenarios. Non-invasive strategies based on SPECT have been dominated. CONCLUSIONS: An anatomical diagnostic strategy based on CTA is a cost-effective option for CAD diagnosis. Functional strategies performed equally well when based on ECHO. C-MRI yielded acceptable ICER only at low pretest probability, and SPECT was not cost-effective in our analysis.

One-year costs of bilateral or single internal mammary grafts in the Arterial Revascularisation Trial.

OBJECTIVE: Coronary artery bypass grafting (CABG) using bilateral internal mammary arteries (BIMA) may improve survival over CABG using single internal mammary arteries (SIMA), but may be surgically more complex (and therefore costly) and associated with impaired sternal wound healing. We report, for the first time, a detailed comparison of healthcare resource use and costs over 12 months, as part of the Arterial Revascularisation (ART) Trial. METHODS: 3102 patients in 28 hospitals in seven countries were randomised to CABG surgery using BIMA (n=1548) or SIMA (n=1554). Detailed resource use data were collected covering surgery, the initial hospital episode, and for 12 months post randomisation. Using UK unit costs, total costs were calculated and compared between trial arms and for subgroups. RESULTS: Patients randomised to BIMA spent 20 min longer in theatre (95% CI 15 to 25, p<0.001) and also required more treatment for sternal wound problems. Mean (SD) total costs per patient at 12 months were £13 839 (£10 534) for BIMA and £12 717 (£9719) for SIMA (mean cost difference £1122, 95% CI £407 to £1838, p=0.002). No tests for interaction between subgroups and treatment allocation were significant. CONCLUSIONS: At 12 months from randomisation, mean costs were approximately 9% higher in BIMA than SIMA patients, primarily due to longer time in theatre and in-hospital stay, and slightly higher costs related to sternal wound problems during follow-up. Follow-up to the primary trial endpoint of 10 years will reveal whether longer-term differences emerge in graft patency or in overall survival. TRIAL REGISTRATION NUMBER: Controlled-trials.com (ISRCTN46552265).

Custos e Desfechos Clínicos na Intervenção Coronária Percutânea no Sistema Único de Saúde / Costs and Clinical Outcomes in Percutaneous Coronary Intervention by the Brazilian National Health System

O tratamento percutâneo da doença arterial coronariana (DAC) pode apresentar desfechos adversos relacionados às características da população e questões técnicas. DAC é uma das principais fontes de gastos com internações no SUS, especificamente o tratamento das síndromes coronarianas agudas (SCA), associado, principalmente, a procedimentos intervencionistas. Objetivos: Avaliar a efetividade e custo do tratamento de revascularização miocárdica percutânea realizado pelo SUS em hospital terciário em Minas Gerais. Métodos: Realizou-se uma coorte aberta prospectiva, com indivíduos submetidos à angioplastia coronária, pelo SUS, entre setembro/14 e abril/15. Os pacientes foram classificados conforme características clínicas e angiográficas e caráter do procedimento. Realizou-se acompanhamento por seis meses e avaliou-se a efetividade do tratamento. Foram levantados os gastos do SUS com os pacientes que realizaram os procedimentos eletivamente ou de urgência. Compararam-se os custos hospitalares com os valores pagos pelo SUS. Resultados: Em 83,2% dos 101 pacientes, o procedimento foi de urgência. Foram observados em seis meses: óbito (10,9%), reestenose clínica (7,9%) e infarto não fatal (2%). Não foram verificadas diferenças, com relação aos desfechos, entre os grupos angiográficos, clínicos e caráter do procedimento. Os valores pagos pelo SUS para tratamentos eletivos foram menores que os de urgência, com diferença do gasto mediano de R$1.768,75. Comparando-se os valores pagos pelo SUS aos custos da instituição, o déficit foi de R$ 430.095,30, com diferença mediana de R$ 2.283,74. Conclusões: O tratamento de revascularização miocárdica percutânea, pelo SUS, é efetivo. Os custos são maiores na urgência, e os valores pagos pelo SUS são deficitários. (Int J Cardiovasc Sci. 2016;29(6):431-442) Palavras-chave: Intervenção Coronária Percutânea / economia; Sistema Único de Saúde (SUS) / economia; Doença da Arterial Coronariana; Avaliação de Resultado de Intervenções Terapêuticas; Custos Hospitalares

Percutaneous treatment of coronary arterial disease (CAD) can present adverse outcomes related to population characteristics and technical issues. CAD is one of the main sources of expense, with admission in the Brazilian Unified Health System (SUS), more specifically with treatments for acute coronary syndromes (ACS), mainly associated to interventional procedures. Objectives: To evaluate the effectiveness and cost of percutaneous myocardial revascularization performed through SUS at a tertiary hospital in the Brazilian State of Minas Gerais. Methods: We used a prospective open cohort, with individuals who underwent coronary angioplasty, through SUS, between September 2014 and April 2015. The patients were classified according to clinical and angiographic characteristic and character of the procedure. A six-month follow up was carried out and we evaluated treatment effectiveness. We verified the health system's expenditures with patients who underwent the procedure electively or as emergency surgery. We compared hospital costs with the amounts paid by SUS. Results: Of the 101 patients, 83.2% of cases underwent the procedure as emergency surgery. In six months, we observed: death (10.9%), clinical restenosis (7.9%), and non-fatal infarction (2%). No differences were observed, regarding the outcomes, between angiographic, clinical groups and character of the procedure. Amounts paid by SUS for elective treatments were smaller than emergency ones, with a median difference in expenditure of R$ 1,768.75. When comparing the amounts paid by SUS to institution costs, the deficit was of R$ 430,095.30, with a median difference of R$ 2,283.74. Conclusions: Percutaneous myocardial revascularization treatment is effective through SUS. Costs are higher in emergency scenarios, and the amounts paid by SUS are deficient.

Budget impact of applying appropriateness criteria for myocardial perfusion scintigraphy: The perspective of a developing country.

Myocardial perfusion imaging is widely used for the risk stratification of coronary artery disease. In view of its cost, besides radiation issues, judicious evaluation of the appropriateness of its indications is essential to prevent an unnecessary economic burden on the health system. We evaluated, at a tertiary-care, public Brazilian hospital, the appropriateness of myocardial perfusion scintigraphy indications, and estimated the budget impact of applying appropriateness criteria. An observational, cross-sectional study of 190 patients with suspected or known coronary artery disease referred for myocardial perfusion imaging was conducted. The appropriateness of myocardial perfusion imaging indications was evaluated with the Appropriate Use Criteria for Cardiac Radionuclide Imaging published in 2009. Budget impact analysis was performed with a deterministic model. The prevalence of appropriate requests was 78%; of inappropriate indications, 12%; and of uncertain indications, 10%. Budget impact analysis showed that the use of appropriateness criteria, applied to the population referred to myocardial perfusion scintigraphy within 1 year, could generate savings of $ 64,252.04 dollars. The 12% inappropriate requests for myocardial perfusion scintigraphy at a tertiary-care hospital suggest that a reappraisal of MPI indications is needed. Budget impact analysis estimated resource savings of 18.6% with the establishment of appropriateness criteria for MPI.

Long-term Cost-Effectiveness of Diagnostic Tests for Assessing Stable Chest Pain: Modeled Analysis of Anatomical and Functional Strategies.

Several tests exist for diagnosing coronary artery disease, with varying accuracy and cost. We sought to provide cost-effectiveness information to aid physicians and decision-makers in selecting the most appropriate testing strategy. We used the state-transitions (Markov) model from the Brazilian public health system perspective with a lifetime horizon. Diagnostic strategies were based on exercise electrocardiography (Ex-ECG), stress echocardiography (ECHO), single-photon emission computed tomography (SPECT), computed tomography coronary angiography (CTA), or stress cardiac magnetic resonance imaging (C-MRI) as the initial test. Systematic review provided input data for test accuracy and long-term prognosis. Cost data were derived from the Brazilian public health system. Diagnostic test strategy had a small but measurable impact in quality-adjusted life-years gained. Switching from Ex-ECG to CTA-based strategies improved outcomes at an incremental cost-effectiveness ratio of 3100 international dollars per quality-adjusted life-year. ECHO-based strategies resulted in cost and effectiveness almost identical to CTA, and SPECT-based strategies were dominated because of their much higher cost. Strategies based on stress C-MRI were most effective, but the incremental cost-effectiveness ratio vs CTA was higher than the proposed willingness-to-pay threshold. Invasive strategies were dominant in the high pretest probability setting. Sensitivity analysis showed that results were sensitive to costs of CTA, ECHO, and C-MRI. Coronary CT is cost-effective for the diagnosis of coronary artery disease and should be included in the Brazilian public health system. Stress ECHO has a similar performance and is an acceptable alternative for most patients, but invasive strategies should be reserved for patients at high risk.

The cost-effectiveness of strategies in coronary artery disease.

Coronary artery disease has significant social and economic implications. Health expenditures have increased in recent decades, more than the economy itself, with significant consequences, either reducing spending in other areas or increasing the budget deficit. It is necessary to create tools to identify the most cost-effective treatments, which can assist clinicians in their therapeutic decisions so that the maximum possible benefit is reached with the lowest possible cost. Efficiency must be measured by final treatment goals in which the most effective interventions are those with the lowest costs. We analyzed the cost-effectiveness of coronary artery disease treatment strategies, medical treatment, percutaneous coronary intervention and coronary artery bypass surgery, with a focus on comparative analyses between these treatment modalities.

Investigation Route of the Coronary Patient in the Public Health System in Curitiba, São Paulo and in Incor - IMPACT Study / Itinerário de Investigação do Paciente Coronariano do SUS em Curitiba, São Paulo e Incor - Estudo IMPACT

Background: The investigation of stable coronary artery disease (CAD) and its treatment depend on risk stratification for decision-making on the need for cardiac catheterization and revascularization. Objective: To analyze the procedures used in the diagnosis and invasive treatment of patients with CAD, at the Brazilian Unified Health System (SUS) in the cities of Curitiba, São Paulo and at InCor-FMUSP. Methods: Retrospective, descriptive, observational study of the diagnostic and therapeutic itineraries of the Brazilian public health care system patient, between groups submitted or not to prior noninvasive tests to invasive cardiac catheterization. Stress testing, stress echocardiography, perfusion scintigraphy, catheterization and percutaneous or surgical revascularization treatment procedures were quantified and the economic impact of the used strategies. Results: There are significant differences in the assessment of patients with suspected or known CAD in the metropolitan region in the three scenarios. Although functional testing procedures are most often used the direct costs of these procedures differ significantly (6.1% in Curitiba, 20% in São Paulo and 27% in InCor-FMUSP). Costs related to the procedures and invasive treatments represent 59.7% of the direct costs of SUS in São Paulo and 87.2% in Curitiba. In InCor-FMUSP, only 24.3% of patients with stable CAD submitted to CABG underwent a noninvasive test before the procedure. Conclusion: Although noninvasive functional tests are the ones most often requested for the assessment of patients with suspected or known CAD most of the costs are related to invasive procedures/treatments. In most revascularized patients, the documentation of ischemic burden was not performed by SUS. .

Fundamento: A investigação da doença arterial coronariana (DAC) estável e seu tratamento dependem da estratificação de risco para a decisão sobre a necessidade de cateterismo cardíaco e revascularização. Objetivo: Analisar os procedimentos utilizados no diagnóstico e tratamento invasivo dos pacientes com DAC do Sistema Único de Saúde (SUS) nos municípios de Curitiba, São Paulo e no IIncor- FMUSP. Métodos: Estudo retrospectivo, descritivo, observacional dos itinerários diagnósticos e terapêuticos dos pacientes do SUS, entre os grupos submetidos ou não a testes não invasivos prévios ao cateterismo cardíaco invasivo. Foram quantificados os procedimentos de teste ergométrico, ecocardiograma de estresse, cintilografia de perfusão, cateterismo e tratamento com revascularização percutânea ou cirúrgica e o impacto econômico destas estratégias utilizadas. Resultados: Existem diferenças importantes na avaliação do paciente com DAC suspeita ou conhecida nos três cenários. Apesar dos testes funcionais serem os procedimentos mais frequentemente utilizados, os custos diretos referentes a esses procedimentos diferem significativamente (6,1% em Curitiba, 20% em São Paulo e 27% no Incor-FMUSP). Os custos relacionados aos procedimentos e tratamentos invasivos representam 59,7% dos custos diretos do SUS em São Paulo e 87,2% em Curitiba. No Incor-FMUSP, apenas 24,3% dos pacientes com DAC estável submetidos à revascularização foram submetidos a um teste não invasivo antes do procedimento. Conclusão: Apesar dos testes funcionais não invasivos serem os exames mais frequentemente solicitados na avaliação de pacientes com DAC suspeita ou conhecida, a maior parte dos custos está relacionada a procedimento/tratamento ...

Investigation route of the coronary patient in the public health system in Curitiba, São Paulo and in InCor--IMPACT study.

BACKGROUND: The investigation of stable coronary artery disease (CAD) and its treatment depend on risk stratification for decision-making on the need for cardiac catheterization and revascularization. OBJECTIVE: To analyze the procedures used in the diagnosis and invasive treatment of patients with CAD, at the Brazilian Unified Health System (SUS) in the cities of Curitiba, São Paulo and at InCor-FMUSP. METHODS: Retrospective, descriptive, observational study of the diagnostic and therapeutic itineraries of the Brazilian public health care system patient, between groups submitted or not to prior noninvasive tests to invasive cardiac catheterization. Stress testing, stress echocardiography, perfusion scintigraphy, catheterization and percutaneous or surgical revascularization treatment procedures were quantified and the economic impact of the used strategies. RESULTS: There are significant differences in the assessment of patients with suspected or known CAD in the metropolitan region in the three scenarios. Although functional testing procedures are most often used the direct costs of these procedures differ significantly (6.1% in Curitiba, 20% in São Paulo and 27% in InCor-FMUSP). Costs related to the procedures and invasive treatments represent 59.7% of the direct costs of SUS in São Paulo and 87.2% in Curitiba. In InCor-FMUSP, only 24.3% of patients with stable CAD submitted to CABG underwent a noninvasive test before the procedure. CONCLUSION: Although noninvasive functional tests are the ones most often requested for the assessment of patients with suspected or known CAD most of the costs are related to invasive procedures/treatments. In most revascularized patients, the documentation of ischemic burden was not performed by SUS.

Cost-effectiveness of different diagnostic strategies in suspected stable coronary artery disease in Portugal.

BACKGROUND: Cost-effectiveness is an increasingly important factor in the choice of a test or therapy. OBJECTIVE: To assess the cost-effectiveness of various methods routinely used for the diagnosis of stable coronary disease in Portugal. METHODS: Seven diagnostic strategies were assessed. The cost-effectiveness of each strategy was defined as the cost per correct diagnosis (inclusion or exclusion of obstructive coronary artery disease) in a symptomatic patient. The cost and effectiveness of each method were assessed using Bayesian inference and decision-making tree analyses, with the pretest likelihood of disease ranging from 10% to 90%. RESULTS: The cost-effectiveness of diagnostic strategies was strongly dependent on the pretest likelihood of disease. In patients with a pretest likelihood of disease of ≤50%, the diagnostic algorithms, which include cardiac computed tomography angiography, were the most cost-effective. In these patients, depending on the pretest likelihood of disease and the willingness to pay for an additional correct diagnosis, computed tomography angiography may be used as a frontline test or reserved for patients with positive/inconclusive ergometric test results or a calcium score of >0. In patients with a pretest likelihood of disease of ≥ 60%, up-front invasive coronary angiography appears to be the most cost-effective strategy. CONCLUSIONS: Diagnostic algorithms that include cardiac computed tomography angiography are the most cost-effective in symptomatic patients with suspected stable coronary artery disease and a pretest likelihood of disease of ≤50%. In high-risk patients (pretest likelihood of disease ≥ 60%), up-front invasive coronary angiography appears to be the most cost-effective strategy. In all pretest likelihoods of disease, strategies based on ischemia appear to be more expensive and less effective compared with those based on anatomical tests.

Custo-Efetividade de Diferentes Estratégias Diagnósticas de Doença Coronária Estável em Portugal / Cost-Effectiveness of Different Diagnostic Strategies in Suspected Stable Coronary Artery Disease in Portugal

Fundamento: O custo-efetividade é um fator de crescente importância na escolha de um exame ou terapêutica. Objetivo: Avaliar o custo-efetividade de vários métodos habitualmente empregados no diagnóstico de doença coronária estável em Portugal. Métodos: Foram avaliadas sete estratégias diagnósticas. O custo-efetividade de cada estratégia foi definido como o custo por cada diagnóstico correto (inclusão ou exclusão de doença arterial coronária obstrutiva) num doente sintomático. Os custos e a eficácia de cada método foram avaliados por meio de inferência bayesiana e análise de árvores de decisão, fazendo variar a probabilidade pré-teste entre 10 e 90%. Resultados: O custo-efetividade das várias estratégias diagnósticas é fortemente dependente da probabilidade pré-teste. Em doentes com probabilidade pré-teste ≤ 50%, os algoritmos diagnósticos, que incluem a angiotomografia computadorizada cardíaca são os mais custo-efetivos. Nesses doentes, dependendo da probabilidade pré-teste e da disponibilidade para pagar por diagnóstico correto adicional, a angiotomografia computadorizada pode ser usada como teste de primeira linha ou ser reservada a doentes com teste ergométrico positivo/inconclusivo ou escore de cálcio > 0. Em doentes com probabilidade pré-teste ≥ 60%, o envio direto para angiografia coronária invasiva parece ser a estratégia mais custo-efetiva. Conclusão: Os algoritmos diagnósticos, que incluem a angiotomografia computadorizada cardíaca, são os mais custo-efetivos em doentes sintomáticos com suspeita de doença arterial coronária estável e probabilidade pré-teste ≤ 50%. Em doentes de risco mais elevado (probabilidade pré-teste ≥ 60%), o envio ...

Background: Cost-effectiveness is an increasingly important factor in the choice of a test or therapy. Objective: To assess the cost-effectiveness of various methods routinely used for the diagnosis of stable coronary disease in Portugal. Methods: Seven diagnostic strategies were assessed. The cost-effectiveness of each strategy was defined as the cost per correct diagnosis (inclusion or exclusion of obstructive coronary artery disease) in a symptomatic patient. The cost and effectiveness of each method were assessed using Bayesian inference and decision-making tree analyses, with the pretest likelihood of disease ranging from 10% to 90%. Results: The cost-effectiveness of diagnostic strategies was strongly dependent on the pretest likelihood of disease. In patients with a pretest likelihood of disease of ≤50%, the diagnostic algorithms, which include cardiac computed tomography angiography, were the most cost-effective. In these patients, depending on the pretest likelihood of disease and the willingness to pay for an additional correct diagnosis, computed tomography angiography may be used as a frontline test or reserved for patients with positive/inconclusive ergometric test results or a calcium score of >0. In patients with a pretest likelihood of disease of ≥ 60%, up-front invasive coronary angiography appears to be the most cost-effective strategy. Conclusions: Diagnostic algorithms that include cardiac computed tomography angiography are the most cost-effective in symptomatic patients with suspected stable coronary artery disease and a pretest likelihood of disease of ≤50%. In high-risk patients (pretest likelihood of disease ≥ 60%), up-front invasive coronary angiography appears to be the most cost-effective strategy. In all pretest likelihoods of disease, strategies based on ischemia appear to be more expensive and less effective compared with those based on anatomical tests. .

Comparison of cost-effectiveness of oral rapamycin plus bare-metal stents versus first generation of drug-eluting stents (from the Randomized Oral Rapamycin in Argentina [ORAR] 3 trial).

The aim of this study was to compare 5-year cost-effectiveness and clinical outcomes of patients with oral rapamycin (OR) plus bare-metal stent versus the drug-eluting stent (DES) strategy. During 2006 to 2007, a total of 200 patients were randomized to OR (n = 100) and DES (n = 100). Primary end point was to compare costs of initial procedure and cost-effectiveness of both revascularization strategies. Safety was evaluated by the composite of death, myocardial infarction, and cerebrovascular accident. Efficacy was assessed by target vessel and target lesion revascularizations. The 2 groups had similar baseline demographic, clinical, and angiographic characteristics. In the DES group, paclitaxel-, zotarolimus-, and sirolimus-eluting stents were used. Five-year clinical follow-up was accomplished in 99% patients. The DES group had significantly higher procedural (p <0.001), discharge to first-year (p = 0.02), and 1- to 5-year costs (p <0.001) compared with the OR group. At 5 years, the composite end point of death, myocardial infarction, and cerebrovascular accident (12% in the OR group vs 25% in the DES group, p = 0.01) was significantly less in the OR group. Target vessel revascularization (14.5% in the OR group vs 21% in the DES group, p = 0.16) and target lesion revascularization (10% in the OR group vs 17.6% in the DES group, p = 0.05) were not significantly different. In conclusion, a strategy of OR plus bare-metal stent was cost saving than a first-generation DES.

Angiotomografia de coronárias na avaliação da dor torácica aguda na sala de emergência / Coronary computed tomography angiography in the assessment of acute chest pain in the emergency room

A angiotomografia de coronárias emergiu recentemente como uma ferramenta diagnóstica acurada na avaliação da doença arterial coronariana, fornecendo dados diagnósticos e prognósticos que se correlacionam diretamente com os dados fornecidos pela cineangiocoronariografia. Com a evolução tecnológica, permitindo melhora na resolução temporal, espacial, melhor cobertura do volume cardíaco com redução significativa da dose de radiação, somada à necessidade de protocolos de estratificação de risco mais efetivos para pacientes com dor torácica no pronto-socorro, sua aplicação passou a ser testada no cenário da dor torácica aguda, já que cerca de dois terços das angiografias coronarianas invasivas não demonstram doença coronariana obstrutiva significativa. Na prática diária, sem o uso de tecnologias mais eficientes, como a angiotomografia de coronárias, permanece um desafio ao médico do setor de emergência a estratificação segura e eficiente do paciente com dor torácica aguda. Recentemente, vários estudos, incluindo três randomizados, mostraram resultados favoráveis ao uso dessa tecnologia no pronto-socorro para pacientes com baixa a intermediária probabilidade de doença arterial coronariana. Nesta revisão, apresentamos os dados do uso da angiotomografia de coronárias na estratificação de risco de pacientes com dor torácica na sala de emergência, o seu valor diagnóstico, prognóstico e custo-efetividade e uma análise crítica dos recentes estudos multicêntricos publicados.

The coronary computed tomography angiography has recently emerged as an accurate diagnostic tool in the evaluation of coronary artery disease, providing diagnostic and prognostic data that correlate directly with the data provided by invasive coronary angiography. The association of recent technological developments has allowed improved temporal resolution and better spatial coverage of the cardiac volume with significant reduction in radiation dose, and with the crucial need for more effective protocols of risk stratification of patients with chest pain in the emergency room, recent evaluation of the computed tomography coronary angiography has been performed in the setting of acute chest pain, as about two thirds of invasive coronary angiographies show no significantly obstructive coronary artery disease. In daily practice, without the use of more efficient technologies, such as coronary angiography by computed tomography, safe and efficient stratification of patients with acute chest pain remains a challenge to the medical team in the emergency room. Recently, several studies, including three randomized trials, showed favorable results with the use of this technology in the emergency department for patients with low to intermediate likelihood of coronary artery disease. In this review, we show data resulting from coronary angiography by computed tomography in risk stratification of patients with chest pain in the emergency room, its diagnostic value, prognosis and cost-effectiveness and a critical analysis of recently published multicenter studies.

Coronary computed tomography angiography in the assessment of acute chest pain in the emergency room.

The coronary computed tomography angiography has recently emerged as an accurate diagnostic tool in the evaluation of coronary artery disease, providing diagnostic and prognostic data that correlate directly with the data provided by invasive coronary angiography. The association of recent technological developments has allowed improved temporal resolution and better spatial coverage of the cardiac volume with significant reduction in radiation dose, and with the crucial need for more effective protocols of risk stratification of patients with chest pain in the emergency room, recent evaluation of the computed tomography coronary angiography has been performed in the setting of acute chest pain, as about two thirds of invasive coronary angiographies show no significantly obstructive coronary artery disease. In daily practice, without the use of more efficient technologies, such as coronary angiography by computed tomography, safe and efficient stratification of patients with acute chest pain remains a challenge to the medical team in the emergency room. Recently, several studies, including three randomized trials, showed favorable results with the use of this technology in the emergency department for patients with low to intermediate likelihood of coronary artery disease. In this review, we show data resulting from coronary angiography by computed tomography in risk stratification of patients with chest pain in the emergency room, its diagnostic value, prognosis and cost-effectiveness and a critical analysis of recently published multicenter studies.

Randomized comparison of cost-saving and effectiveness of oral rapamycin plus bare-metal stents with drug-eluting stents: three-year outcome from the randomized oral rapamycin in Argentina (ORAR) III trial.

OBJECTIVES: The Oral Rapamycin in ARgentina (ORAR) III trial is a randomized study comparing a strategy of oral rapamycin (OR) plus bare-metal stent (BMS) versus a strategy of drug-eluting stents (DES) in patients with de novo coronary lesions. The purpose of this study was to assess the 3 years cost-effectiveness outcome of each strategy. BACKGROUND: OR after BMS has been associated with reduction of target vessel revascularization (TVR) although its value in long-term efficacy in comparison with DES is unknown. METHODS: In three hospitals in Buenos Aires, Argentina, 200 patients were randomized to OR plus BMS (n = 100) or DES (n = 100). Primary objectives were costs and effectiveness. Cost analysis included in-hospital and follow-up costs. Safety was defined as the composite of death, myocardial infarction (MI), and stroke. Efficacy was defined as TVR. RESULTS: Baseline characteristics between groups were similar. The 3-year follow-up rate was 99%. Cardiac mortality was 2% and 5% in OR group and DES group, respectively (P = 0.44). The composite of death, MI and stroke rate was 11% in OR group and 20% in DES group (P = 0.078). TVR rate was 14.5% in OR group and 17.6% in DES group (P = 0.50), respectively. Three year cumulative costs were significantly lower in the OR arm as compared to the DES arm (P = 0.0001) and DES strategy did not result cost-effective according to the non-inferiority test. CONCLUSIONS: At 3 years follow-up, there were no differences in effectiveness between the two strategies, and DES strategy was not more cost-effective as compared to OR plus BMS.