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1.
Int J Cardiovasc Imaging ; 35(11): 2019-2028, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31273633

RESUMO

To determine the potential of a non-invasive acoustic device (CADScor®System) to reclassify patients with intermediate pre-test probability (PTP) and clinically suspected stable coronary artery disease (CAD) into a low probability group thereby ruling out significant CAD. Audio recordings and clinical data from three studies were collected in a single database. In all studies, patients with a coronary CT angiography indicating CAD were referred to coronary angiography. Audio recordings of heart sounds were processed to construct a CAD-score. PTP was calculated using the updated Diamond-Forrester score and patients were classified according to the current ESC guidelines for stable CAD: low < 15%, intermediate 15-85% and high > 85% PTP. Intermediate PTP patients were re-classified to low probability if the CAD-score was ≤ 20. Of 2245 patients, 212 (9.4%) had significant CAD confirmed by coronary angiography ( ≥ 50% diameter stenosis). The average CAD-score was higher in patients with significant CAD (38.4 ± 13.9) compared to the remaining patients (25.1 ± 13.8; p < 0.001). The reclassification increased the proportion of low PTP patients from 13.6% to 41.8%, reducing the proportion of intermediate PTP patients from 83.4% to 55.2%. Before reclassification 7 (3.1%) low PTP patients had CAD, whereas post-reclassification this number increased to 28 (4.0%) (p = 0.52). The net reclassification index was 0.209. Utilization of a low-cost acoustic device in patients with intermediate PTP could potentially reduce the number of patients referred for further testing, without a significant increase in the false negative rate, and thus improve the cost-effectiveness for patients with suspected stable CAD.


Assuntos
Doença da Artéria Coronariana/diagnóstico , Estenose Coronária/diagnóstico , Ruídos Cardíacos , Fonocardiografia , Adulto , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Angiografia Coronária , Doença da Artéria Coronariana/classificação , Doença da Artéria Coronariana/economia , Doença da Artéria Coronariana/fisiopatologia , Estenose Coronária/classificação , Estenose Coronária/economia , Estenose Coronária/fisiopatologia , Redução de Custos , Análise Custo-Benefício , Técnicas de Apoio para a Decisão , Feminino , Custos de Cuidados de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Fonocardiografia/economia , Fonocardiografia/instrumentação , Valor Preditivo dos Testes , Prognóstico , Reprodutibilidade dos Testes , Estudos Retrospectivos , Índice de Gravidade de Doença , Adulto Jovem
2.
Am J Cardiol ; 123(12): 1893-1899, 2019 06 15.
Artigo em Inglês | MEDLINE | ID: mdl-31014542

RESUMO

Chronic coronary artery disease (CAD) and peripheral artery disease (PAD) are both associated with elevated risks of major adverse cardiovascular events (MACE) and major adverse limb events (MALE). The frequency of these events in patients with CAD or PAD, and their corresponding costs, are not well understood. Accordingly, we describe the incidence and cost of both MACE and MALE in patients with CAD or PAD. Using a database that included healthcare claims linked to electronic medical records, we identified patients with evidence of chronic CAD and PAD, respectively, between January 1, 2009, and September 30, 2016. We assessed the occurrence of MACE (defined as myocardial infarction, stroke, or cardiovascular-related death) and MALE (critical limb ischemia, amputation, or peripheral artery disease-related revascularization). A total of 99,730 patients met all selection criteria: 86.0% had CAD, 25.8% had PAD, and 11.8% had both. Mean (±standard deviation) age was 67.7 (±11.5) years and 59.8% were male. During follow-up (mean: 1.8 years), 13.6% experienced MACE or MALE (6.3 per 100 person-years [PYs]), predominantly MACE (9.6% [4.3 per 100 PYs]). Adjusted 1-year healthcare costs were $44,495 greater in patients who experienced MACE or MALE (mean [95% confidence interval]: $64,099 [$33,254 to $123,557] vs $19,604 [$10,175 to $37,771]; p < 0.001). In conclusion, approximately 1 in 7 patients with chronic CAD or PAD experiences additional MACE or MALE within approximately 2 years of follow-up; the relatively high risk and cost of these events highlight the need for new secondary prevention therapies that may improve outcomes in these patients.


Assuntos
Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/epidemiologia , Extremidades/cirurgia , Custos de Cuidados de Saúde , Doença Arterial Periférica/complicações , Doença Arterial Periférica/epidemiologia , Idoso , Doença Crônica , Doença da Artéria Coronariana/economia , Extremidades/irrigação sanguínea , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/economia , Estudos Retrospectivos , Fatores de Risco
3.
Vasc Med ; 24(4): 341-348, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-30915913

RESUMO

Venous thromboembolism (VTE) and coronary artery disease are major health issues that cause substantial morbidity and mortality. New data have emerged suggesting that these two conditions could have a close relationship. Thus, we sought to determine the trends in annual rate of VTE occurrence in patients with ST-segment elevation myocardial infarction (STEMI) and measure its impact on in-hospital mortality, bleeding complications, and cost and length of hospitalization. We queried the 2003-2013 Nationwide Inpatient Sample databases to identify adults with primary diagnosis of STEMI. VTE events were then allocated. Inpatient outcomes of patients with VTE were compared to those without VTE. Out of 2,495,757 hospitalizations for STEMI, VTE was diagnosed in 25,149 (1%) hospitalizations. Patients who experienced VTE were older (mean age: 67.5 vs 64.8, p < 0.01) and had a higher proportion of black patients (10.1% vs 7.7%, p < 0.001) and females (40.1% vs 35%, p < 0.001) compared to patients without VTE. There was an increasing trend in the rate of VTE during the study period (2003: 0.8% vs 2013: 1.0%, p < 0.001). Patients with VTE had a prolonged hospitalization (median: 9 vs 3 days, p < 0.001), increased cost, higher risk of gastrointestinal bleeding (OR: 2.13, p < 0.001), intracranial hemorrhage (OR: 2.14, p < 0.001), blood transfusions (OR: 1.94, p < 0.001), and mortality (OR: 1.39, p < 0.001). The rate of VTE occurrence in patients with STEMI in our study was 10 per 1000 admissions. VTE was associated with more bleeding complications, longer hospital stays, higher costs, and mortality. These findings suggest that a more aggressive approach for VTE prophylaxis may be warranted in this population.


Assuntos
Doença da Artéria Coronariana/terapia , Hospitalização , Pacientes Internados , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Tromboembolia Venosa/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Doença da Artéria Coronariana/economia , Doença da Artéria Coronariana/mortalidade , Bases de Dados Factuais , Feminino , Hemorragia/epidemiologia , Custos Hospitalares , Mortalidade Hospitalar , Hospitalização/economia , Hospitalização/tendências , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Infarto do Miocárdio com Supradesnível do Segmento ST/economia , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , Tromboembolia Venosa/economia , Tromboembolia Venosa/mortalidade , Tromboembolia Venosa/terapia
4.
PET Clin ; 14(2): 211-221, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30826019

RESUMO

PET-based cardiac nuclear imaging plays a large role in the management of ischemic heart disease. Compared with conventional single-photon emission CT myocardial perfusion imaging, PET provides superior accuracy in diagnosis of coronary artery disease and, with the incorporation of myocardial blood flow and coronary flow reserve, adds value in assessing prognosis for established coronary and microvascular disease. This review describes these and other uses of PET in ischemic heart disease, including assessing myocardial viability in ischemic cardiomyopathy. Developments in novel PET flow tracers and molecular imaging tools to assess atherosclerotic plaque vulnerability, vascular calcification, and vascular remodeling also are described.


Assuntos
Isquemia Miocárdica/diagnóstico por imagem , Tomografia por Emissão de Pósitrons/métodos , Angiografia por Tomografia Computadorizada/economia , Angiografia por Tomografia Computadorizada/métodos , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/economia , Circulação Coronária/fisiologia , Análise Custo-Benefício , Reserva Fracionada de Fluxo Miocárdico/fisiologia , Humanos , Imagem Multimodal/economia , Imagem Multimodal/métodos , Isquemia Miocárdica/economia , Isquemia Miocárdica/fisiopatologia , Imagem de Perfusão do Miocárdio/economia , Imagem de Perfusão do Miocárdio/métodos , Prognóstico , Compostos Radiofarmacêuticos , Sensibilidade e Especificidade , Tomografia Computadorizada de Emissão de Fóton Único/economia , Tomografia Computadorizada de Emissão de Fóton Único/métodos
5.
Arterioscler Thromb Vasc Biol ; 39(4): 569-582, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30760017

RESUMO

Atherosclerosis is the leading cause of cardiovascular morbidity and mortality. Over the past 2 decades, increasing research attention is converging on the early detection and monitoring of atherosclerotic plaque. Among several invasive and noninvasive imaging modalities, magnetic resonance imaging (MRI) is emerging as a promising option. Advantages include its versatility, excellent soft tissue contrast for plaque characterization and lack of ionizing radiation. In this review, we will explore the recent advances in multicontrast and multiparametric imaging sequences that are bringing the aspiration of simultaneous arterial lumen, vessel wall, and plaque characterization closer to clinical feasibility. We also discuss the latest advances in molecular magnetic resonance and multimodal atherosclerosis imaging.


Assuntos
Artérias Carótidas/diagnóstico por imagem , Doenças das Artérias Carótidas/diagnóstico por imagem , Angiografia Coronária/métodos , Doença da Artéria Coronariana/diagnóstico por imagem , Angiografia por Ressonância Magnética/métodos , Placa Aterosclerótica/diagnóstico por imagem , Doenças das Artérias Carótidas/economia , Meios de Contraste , Doença da Artéria Coronariana/economia , Previsões , Gadolínio , Humanos , Nanopartículas Metálicas , Imagem Multimodal , Placa Aterosclerótica/química , Placa Aterosclerótica/patologia , Tomografia Computadorizada com Tomografia por Emissão de Pósitrons , Tomografia por Emissão de Pósitrons
6.
Heart Lung Circ ; 28(3): e23-e25, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-29891247

RESUMO

Myocardial perfusion scanning (MPS) is commonly used to assess patients with an intermediate to high risk of coronary artery disease. Concerns have been raised about the accuracy of this test. There is little recent data regarding the specificity of the MPS in the context of current medical therapy. The primary objective of this study is to determine the specificity of MPS in diagnosing obstructive coronary artery disease. A total of 184 patients fulfilled study criteria. The overall specificity of MPS for obstructive coronary artery disease was 54%.The only demographic variable that influenced specificity was gender: males with a specificity of 66% and females with a specificity of 29% (p-value=0.001). These results suggest that the real world specificity of MPS is lower than previously indicated, particularly in the female population. The limitations proposed by the Cardiac Services Committee Report are therefore unlikely to improve patient outcomes.


Assuntos
Doença da Artéria Coronariana/diagnóstico , Medicare/estatística & dados numéricos , Imagem de Perfusão do Miocárdio/métodos , Idoso , Angiografia Coronária , Doença da Artéria Coronariana/economia , Eletrocardiografia , Teste de Esforço , Feminino , Seguimentos , Humanos , Masculino , Imagem de Perfusão do Miocárdio/economia , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Estudos Retrospectivos , Estados Unidos
7.
Ann Thorac Surg ; 107(1): 99-105, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30273569

RESUMO

BACKGROUND: Coronary artery bypass grafting (CABG) is a common surgical treatment for ischemic heart disease. Little is known about the long-term costs of conducting the surgery on-pump or off-pump. METHODS: As part of the Randomized On/Off Bypass follow-up study, we followed 2,203 participants randomized to on-pump (n = 1,099) and off-pump (n = 1,104) CABG for 5 years using Department of Veterans Affairs and Medicare administrative data. We examined annual costs through 5 years, standardized to 2016 dollars, using multivariate regression models, controlling for site and baseline patient factors. RESULTS: In the first year, including the CABG surgery, annual average costs were $66,599 (SE, $1,946) for the on-pump group and $70,552 (SE, $1,954) for the off-pump group. In years 2 to 5, average costs ranged from $15,000 to $20,000 per year. There was no significant difference between on-pump and off-pump across the 5 years. We explored differences among high-risk subgroups (diabetes, chronic obstructive pulmonary disease, peripheral vascular disease, cerebrovascular disease, renal dysfunction, ejection fraction < 35%, over age 70 years), and found no treatment assignment by time interactions, except for a nonsignificant trend in patients with diabetes. CONCLUSIONS: At 5 years, the average costs of off-pump and on-pump CABG patients did not statistically differ. Costs do not favor one approach and the decision should be based on clinical risks, especially in subgroups. Future research is warranted to examine post-CABG costs and outcomes for diabetic patients over time.


Assuntos
Ponte de Artéria Coronária sem Circulação Extracorpórea/economia , Doença da Artéria Coronariana/economia , Doença da Artéria Coronariana/cirurgia , Custos de Cuidados de Saúde , Complicações Pós-Operatórias/economia , Idoso , Ponte de Artéria Coronária sem Circulação Extracorpórea/efeitos adversos , Doença da Artéria Coronariana/complicações , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Fatores de Tempo
9.
Acta Biomed ; 89(3): 378-381, 2018 10 08.
Artigo em Inglês | MEDLINE | ID: mdl-30333462

RESUMO

BACKGROUND AND AIM: Applying fractional flow reserve (FFR) recently helped to assess borderline coronary defects and also facilitates assessment of these lesions. The present study aimed to assess cost-effectiveness of FFR in detection of these borderline lesions. METHODS: This cross-sectional study was conducted on140 consecutive patients with 219 diseased arteries who underwent coronary angiography and suffered intermediate coronary lesions. RESULTS: Of 18 patients who candidate for CABG before FFR, only one patient underwent CABG after determining FFR (P-value<0.05), while 15 patients were scheduled for PCI and 2 patients for medical treatment. Of 122 patients who candidate for PCI, 59 were programmed to underwent PCI after FFR determination(P-value<0.05), while the strategy in 63 patients (47 with one-vessel disease, 15 with two vessel diseases, and 1 with three vessel diseases) was modified to medical treatment. Considering strategy modifying from PCI to medical treatment, 101 stents were saved (P-value<0.05). Also, in change of strategy from CABG to PCI, spending has decreased as much as 77.3% (P-value<0.05). Furthermore, the change of treatment approach from PCI on much number of coronary vessels to PCI on less number of coronary lesions led to saving of 52.2% of costs(P-value<0.05). CONCLUSIONS: In patients with an intermediate coronary lesion, measuring FFR to guide the decision to determine treatment strategy may lead to significant cost savings.


Assuntos
Doença da Artéria Coronariana/fisiopatologia , Reserva Fracionada de Fluxo Miocárdico , Adulto , Idoso de 80 Anos ou mais , Fármacos Cardiovasculares/uso terapêutico , Tomada de Decisão Clínica , Ponte de Artéria Coronária , Doença da Artéria Coronariana/economia , Doença da Artéria Coronariana/epidemiologia , Doença da Artéria Coronariana/terapia , Redução de Custos , Análise Custo-Benefício , Estudos Transversais , Dislipidemias/epidemiologia , Feminino , Humanos , Hipertensão/epidemiologia , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea , Projetos Piloto , Índice de Gravidade de Doença , Fumar/epidemiologia
10.
Int J Cardiol ; 273: 63-68, 2018 Dec 15.
Artigo em Inglês | MEDLINE | ID: mdl-30158068

RESUMO

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.


Assuntos
Ponte de Artéria Coronária sem Circulação Extracorpórea/economia , Ponte de Artéria Coronária/economia , Doença da Artéria Coronariana/economia , Doença da Artéria Coronariana/cirurgia , Análise Custo-Benefício/métodos , Brasil/epidemiologia , Ponte de Artéria Coronária/tendências , Ponte de Artéria Coronária sem Circulação Extracorpórea/tendências , Doença da Artéria Coronariana/epidemiologia , Análise Custo-Benefício/tendências , Feminino , Seguimentos , Humanos , Masculino , Cadeias de Markov
11.
Semin Thorac Cardiovasc Surg ; 30(4): 398-405, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29949738

RESUMO

There is strong retrospective data demonstrating that bilateral internal mammary artery (BIMA) grafting leads to better long-term survival as compared to left internal mammary artery grafting. However, this survival advantage was not corroborated by the interim results of the Arterial Revascularization Trial. Today, there are barriers to widespread adoption of BIMA grafting. One of the main disadvantages of the use of BIMA grafts is the higher risk of deep sternal wound infection. Deep sternal wound infections can be minimized by skeletonized harvesting of the internal mammary artery grafts, which preserve blood flow to the sternum. Also, utilizing the BIMA graft as a "Y" graft may lead to more complete revascularization compared to its in situ use. BIMA grafting on average takes 25 minutes longer operating time with a higher in-hospital costs. We eagerly await the 10-year results of the Arterial Revascularization Trial to determine the truly unbiased randomized long-term effectiveness of BIMA grafting.


Assuntos
Doença da Artéria Coronariana/cirurgia , Anastomose de Artéria Torácica Interna-Coronária/métodos , Doença da Artéria Coronariana/economia , Doença da Artéria Coronariana/mortalidade , Custos Hospitalares , Humanos , Anastomose de Artéria Torácica Interna-Coronária/efeitos adversos , Anastomose de Artéria Torácica Interna-Coronária/economia , Anastomose de Artéria Torácica Interna-Coronária/mortalidade , Duração da Cirurgia , Complicações Pós-Operatórias/etiologia , Fatores de Risco , Resultado do Tratamento
12.
Cardiovasc Revasc Med ; 19(6S): 7-11, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-29937383

RESUMO

BACKGROUND AND PURPOSE: Transradial percutaneous coronary intervention (TR-PCI) has been increasingly popular over the last decade in the US. Previous studies have shown that same-day (SD) discharge after elective PCI is as safe as overnight (ON) observation. Our study was performed to assess the clinical and financial impact of early discharge in patients undergoing TR-PCI. METHODS: This is a single center registry of patients undergoing elective TR-PCI. Timing of discharge was determined by the treating physician. (Groups: Same Day Discharge -SD-; Overnight Stay -ON-). Demographic data, procedural characteristics and adverse outcomes were recorded. Outcomes included 30 day-MACE and procedure- related complications, as well as total operative costs in patients from both groups. Propensity score matching for patient demographics, coronary symptoms and procedure indicators was used to compare both groups. RESULTS: The entire cohort included 852 patients (429 in SD group and 423 in ON group) and the propensity score matched groups of 245 patients in the SD group and 245 patients in the ON group. The two groups had no significant baseline clinical differences, and had similar clinical outcomes. Specifically, no significant difference was noted in procedural complications (3.7% vs 2.5%, p = 0.43), re-hospitalization (4.1% vs 4.1%, p = 0.92), re-intervention (2.5% vs 2.1%, p = 0.77), myocardial infarction (0% vs 0.08%, p = 0.15), stroke (0% vs 0%, p = 1.0) and all-cause mortality (0% vs 0%, p = 1.0). SD Group patients had a significant lower procedure-related cost compared to overnight stay patients ($3,346.45 vs $4,681.99, p < 0.0001) and lower 30-day post procedure-associated cumulative costs/total operating costs ($4,493.22 vs $7,112.21, p < 0.0001). CONCLUSION: In elective patients undergoing low risk TR-PCI, same-day discharge seems to be a safe and feasible clinical practice, with significant potential savings to the US healthcare system.


Assuntos
Cateterismo Cardíaco/métodos , Cateterismo Periférico/métodos , Doença da Artéria Coronariana/cirurgia , Tempo de Internação , Alta do Paciente , Intervenção Coronária Percutânea/métodos , Artéria Radial , Idoso , Cateterismo Cardíaco/efeitos adversos , Cateterismo Cardíaco/economia , Cateterismo Periférico/efeitos adversos , Cateterismo Periférico/economia , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/economia , Redução de Custos , Análise Custo-Benefício , Estudos de Viabilidade , Feminino , Custos Hospitalares , Humanos , Tempo de Internação/economia , Masculino , Pessoa de Meia-Idade , Alta do Paciente/economia , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/economia , Pontuação de Propensão , Punções , Sistema de Registros , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
13.
Cardiovasc Ther ; 36(5): e12442, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-29873191

RESUMO

AIM: Compared with second-generation durable polymer drug-eluting stents (DP-DES), the cost-effectiveness of biodegradable polymer drug-eluting stents (BP-DES) remains unclear in the real-world setting. We assessed the cost-effectiveness of BP-DES in patients with coronary artery disease undergoing percutaneous coronary intervention (PCI). METHODS: We developed a decision-analytic model to compare the cost-effectiveness of BP-DES to DP-DES over 1 year and 5 years from healthcare payer perspective. Relative treatment effects during the first year post-PCI were obtained from a real-world population analysis while clinical event risks in the subsequent 4 years were derived from a meta-analysis of published studies. RESULTS: At 1 year, based on the clinical data analysis of 497 propensity-score matched pairs of patients, BP-DES were associated with an incremental cost-effectiveness ratio (ICER) of USD20 503 per quality-adjusted life-year (QALY) gained. At 5 years, BP-DES yielded an ICER of USD4062 per QALY gained. At the willingness-to-pay threshold of USD50 400 (one gross domestic product per capita in Singapore in 2015), BP-DES were cost-effective. Sensitivity analysis showed that the cost of stents had a significant impact on the cost-effectiveness of BP-DES. Threshold analysis demonstrated that if the cost difference between BP-DES and DP-DES exceeded USD493, BP-DES would not be cost-effective in patients with 1 year of follow-up. CONCLUSIONS: Biodegradable polymer drug-eluting stents were cost-effective compared with DP-DES in patients with coronary artery disease at 1 year and 5 years after PCI. It is worth noting that the cost of stents had a significant impact on the findings.


Assuntos
Implantes Absorvíveis/economia , Doença da Artéria Coronariana/economia , Doença da Artéria Coronariana/terapia , Stents Farmacológicos/economia , Custos de Cuidados de Saúde , Intervenção Coronária Percutânea/economia , Polímeros/economia , Tomada de Decisão Clínica , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/mortalidade , Análise Custo-Benefício , Técnicas de Apoio para a Decisão , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Econômicos , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/instrumentação , Intervenção Coronária Percutânea/mortalidade , Desenho de Prótese , Anos de Vida Ajustados por Qualidade de Vida , Fatores de Tempo , Resultado do Tratamento
14.
Arch Endocrinol Metab ; 62(3): 303-308, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29791657

RESUMO

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.


Assuntos
Doença da Artéria Coronariana/economia , Custos de Cuidados de Saúde/estatística & dados numéricos , Hospitalização/economia , Hipercolesterolemia/economia , Saúde Pública/economia , Adulto , Idoso , Brasil , Doença da Artéria Coronariana/etiologia , Doença da Artéria Coronariana/terapia , Estudos Transversais , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Hipercolesterolemia/complicações , Hipercolesterolemia/terapia , Masculino , Pessoa de Meia-Idade , Saúde Pública/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco
16.
J Am Heart Assoc ; 7(4)2018 02 15.
Artigo em Inglês | MEDLINE | ID: mdl-29449273

RESUMO

BACKGROUND: Same-day discharge (SDD) after elective percutaneous coronary intervention is safe, less costly, and preferred by patients, but it is usually performed in low-risk patients, if at all. To increase the appropriate use of SDD in more complex patients, we implemented a "patient-centered" protocol based on risk of complications at Barnes-Jewish Hospital. METHODS AND RESULTS: Our objectives were as follows: (1) to evaluate time trends in SDD; (2) to compare (a) mortality, bleeding, and acute kidney injury, (b) patient satisfaction, and (c) hospital costs by SDD versus no SDD (NSDD); and (3) to compare SDD eligibility by our patient-centered approach versus Society for Cardiovascular Angiography and Interventions guidelines. Our patient-centered approach was based on prospectively identifying personalized bleeding, mortality, and acute kidney injury risks, with a personalized safe contrast limit and mitigating those risks. We analyzed Barnes-Jewish Hospital's National Cardiovascular Data Registry CathPCI Registry data from July 1, 2009 to September 30, 2015 (N=1752). SDD increased rapidly from 0% to 77% (P<0.001), independent of radial access. Although SDD patients were comparable to NSDD patients, SDD was not associated with adverse outcomes (0% mortality, 0% bleeds, and 0.4% acute kidney injury). Patient satisfaction was high with SDD. Propensity score-adjusted costs were $7331 lower/SDD patient (P<0.001), saving an estimated $1.8 million annually. Only 16 patients (6.95%) met the eligibility for SDD by Society for Cardiovascular Angiography and Interventions guidelines, implying our patient-centered approach markedly increased SDD eligibility. CONCLUSIONS: With a patient-centered approach, SDD rapidly increased and was safe in 75% of patients undergoing elective percutaneous coronary intervention, despite patient complexity. Patient satisfaction was high, and hospital costs were lower. Patient-centered decision making to facilitate SDD is an important opportunity to improve the value of percutaneous coronary intervention.


Assuntos
Doença da Artéria Coronariana/terapia , Tempo de Internação/tendências , Alta do Paciente/tendências , Assistência Centrada no Paciente/tendências , Intervenção Coronária Percutânea/tendências , Lesão Renal Aguda/etiologia , Idoso , Tomada de Decisão Clínica , Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/economia , Doença da Artéria Coronariana/mortalidade , Redução de Custos , Análise Custo-Benefício , Feminino , Hemorragia/etiologia , Custos Hospitalares , Humanos , Tempo de Internação/economia , Masculino , Pessoa de Meia-Idade , Missouri , Alta do Paciente/economia , Satisfação do Paciente , Seleção de Pacientes , Assistência Centrada no Paciente/economia , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/economia , Intervenção Coronária Percutânea/mortalidade , Sistema de Registros , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
17.
Cardiovasc Revasc Med ; 19(5 Pt B): 607-612, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29358042

RESUMO

BACKGROUND: Percutaneous coronary interventions (PCI), especially medical devices, consume large amounts of medical resources. It is important to know which type of lesions requires high device costs among current PCI. The purpose of this study was to investigate the association between lesion characteristics and medical device costs in current PCI. METHODS: We identified 593 coronary artery lesions in our PCI database between January 1, 2015 and December 31, 2015. The total PCI cost was calculated for each lesion. The highest quartile (Q1) of total PCI costs was defined as the highest cost group, whereas the other quartiles (Q2, Q3, Q4) were defined as the low-intermediate cost group. RESULTS: The mean PCI cost in the highest cost and low-intermediate cost groups was ¥1,032,943 ±â€¯211,912 and ¥532,547 ±â€¯112,127, respectively. In a multivariate logistic regression analysis, lesion length (10 mm increase: OR 2.93, 95% CI 2.25-3.82, P < 0.001), left main lesion (OR 2.96, 95% CI 1.02-8.60, P = 0.046), moderate to severe calcification (OR 16.43, 95% CI 7.97-33.88, P < 0.001), chronic total occlusion (CTO) (OR 5.83, 95% CI 2.07-16.39, P = 0.001), and bifurcation (OR 2.01, 95% CI 1.08-3.75, P = 0.027) were significantly associated with the highest cost group. CONCLUSIONS: Lesion characteristics including CTO, diffuse long lesion, calcification, and bifurcation were significantly associated with the highest device cost. Non-CTO complex lesions including bifurcation and calcification as well as CTO lesions require higher PCI device costs than non-complex lesions.


Assuntos
Cateteres Cardíacos/economia , Doença da Artéria Coronariana/economia , Doença da Artéria Coronariana/cirurgia , Oclusão Coronária/economia , Oclusão Coronária/cirurgia , Custos Hospitalares , Intervenção Coronária Percutânea/economia , Intervenção Coronária Percutânea/instrumentação , Stents/economia , Calcificação Vascular/economia , Calcificação Vascular/cirurgia , Idoso , Idoso de 80 Anos ou mais , Doença Crônica , Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico por imagem , Oclusão Coronária/diagnóstico por imagem , Bases de Dados Factuais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Ultrassonografia de Intervenção , Calcificação Vascular/diagnóstico por imagem
18.
Circulation ; 137(5): 480-487, 2018 01 30.
Artigo em Inglês | MEDLINE | ID: mdl-29097450

RESUMO

BACKGROUND: Previous studies found that percutaneous coronary intervention (PCI) does not improve outcome compared with medical therapy (MT) in patients with stable coronary artery disease, but PCI was guided by angiography alone. FAME 2 trial (Fractional Flow Reserve Versus Angiography for Multivessel Evaluation) compared PCI guided by fractional flow reserve with best MT in patients with stable coronary artery disease to assess clinical outcomes and cost-effectiveness. METHODS: A total of 888 patients with stable single-vessel or multivessel coronary artery disease with reduced fractional flow reserve were randomly assigned to PCI plus MT (n=447) or MT alone (n=441). Major adverse cardiac events included death, myocardial infarction, and urgent revascularization. Costs were calculated on the basis of resource use and Medicare reimbursement rates. Changes in quality-adjusted life-years were assessed with utilities determined by the European Quality of Life-5 Dimensions health survey at baseline and over follow-up. RESULTS: Major adverse cardiac events at 3 years were significantly lower in the PCI group compared with the MT group (10.1% versus 22.0%; P<0.001), primarily as a result of a lower rate of urgent revascularization (4.3% versus 17.2%; P<0.001). Death and myocardial infarction were numerically lower in the PCI group (8.3% versus 10.4%; P=0.28). Angina was significantly less severe in the PCI group at all follow-up points to 3 years. Mean initial costs were higher in the PCI group ($9944 versus $4440; P<0.001) but by 3 years were similar between the 2 groups ($16 792 versus $16 737; P=0.94). The incremental cost-effectiveness ratio for PCI compared with MT was $17 300 per quality-adjusted life-year at 2 years and $1600 per quality-adjusted life-year at 3 years. The above findings were robust in sensitivity analyses. CONCLUSIONS: PCI of lesions with reduced fractional flow reserve improves long-term outcome and is economically attractive compared with MT alone in patients with stable coronary artery disease. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01132495.


Assuntos
Cateterismo Cardíaco , Doença da Artéria Coronariana/cirurgia , Reserva Fracionada de Fluxo Miocárdico , Intervenção Coronária Percutânea , Cateterismo Cardíaco/economia , Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/economia , Doença da Artéria Coronariana/fisiopatologia , Análise Custo-Benefício , Europa (Continente) , Custos de Cuidados de Saúde , Humanos , América do Norte , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/economia , Valor Preditivo dos Testes , Estudos Prospectivos , Qualidade de Vida , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
19.
J Thorac Cardiovasc Surg ; 155(3): 875-882.e1, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29248284

RESUMO

OBJECTIVE: The financial implications of postoperative complications in cardiac surgery remain poorly understood. The purpose of this study was to define the cost of surgery without complications and demonstrate the incremental cost of each complication. METHODS: All patients undergoing isolated coronary artery bypass grafting (CABG) were evaluated (2006-2015) from a statewide Society of Thoracic Surgeons database collaborative (N = 36,588). Patients were stratified by presence of postoperative complications, including major morbidities as defined by the Society of Thoracic Surgeons (ie, prolonged ventilation, renal failure, reoperation, stroke, and deep sternal wound infection). Hierarchical modeling was used to identify the independent inflation-adjusted cost of each complication while controlling for hospital variation and time. RESULTS: The median age was 64 years, 74.3% were men, and average predicted risk of mortality was 1.9%. A total of 24,738 (67.7%) patients experienced no complications at an average cost of $36,580. Each complication independently increases the cost of care and resulted in an exponential increase in cost. After accounting for incidence and incremental costs, institutions in our collaborative have spent an estimated $59.1 million on prolonged ventilation, $8.3 million on renal failure, $7.6 million on reoperation, $3.3 million on stroke, and $256,000 on deep sternal wound infections over the past 10 years. CONCLUSIONS: The average cost of CABG without complication was $36,580. Each additional major complication resulted in an exponential increase in cost. Over the past 10 years, the total cost of complications after isolated CABG was $78.6 million, emphasizing the importance of quality improvement projects to contain costs.


Assuntos
Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/economia , Doença da Artéria Coronariana/economia , Doença da Artéria Coronariana/cirurgia , Custos Hospitalares , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/terapia , Idoso , Idoso de 80 Anos ou mais , Ponte de Artéria Coronária/mortalidade , Doença da Artéria Coronariana/mortalidade , Redução de Custos , Análise Custo-Benefício , Bases de Dados Factuais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Econômicos , Complicações Pós-Operatórias/mortalidade , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Virginia/epidemiologia
20.
Cardiovasc Interv Ther ; 33(4): 328-336, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-28875395

RESUMO

Compared to rotational atherectomy (RA), orbital atherectomy (OA) has been shown to decrease procedure failure and reintervention rates in the treatment of severely calcified coronary artery lesions. Our objective was to explore the cost-effectiveness of OA compared to RA in the Japanese healthcare system. A decision-analytic model calculated reintervention rates and consequent total 1-year costs. Effectiveness inputs were therapy-specific target lesion revascularization (TLR) rates and all-cause mortality, pooled from clinical studies. Index and reintervention costs were determined based on claims data analysis of n = 33,628 subjects treated in 2014-2016. We computed incremental cost-effectiveness in Japanese Yen (JPY) per life year (LY) gained based on differences in 1-year cost and projected long-term survival, assuming OA device cost between JPY 350,000 and ​JPY 550,000. OA was found to be associated with improved clinical outcomes (12-month TLR rate 5.0 vs. 15.7%) and projected survival gain (8.34 vs. 8.16 LYs (+0.17), based on 1-year mortality of 5.5 vs. 6.8%). Total 1-year costs were lower for device cost of JPY 430,000 or less, and reached a maximum ICER of JPY 753,445 per LY at the highest assumed device cost, making OA dominant or cost-effective across the tested range, at ICERs substantially below the willingness-to-pay threshold. In conclusion, orbital atherectomy for the treatment of severely calcified coronary artery lesions, compared to rotational atherectomy, is a cost-effective treatment approach in the Japanese healthcare system due to improved clinical performance.


Assuntos
Aterectomia Coronária/economia , Doença da Artéria Coronariana/cirurgia , Custos de Cuidados de Saúde/estatística & dados numéricos , Calcificação Vascular/cirurgia , Idoso , Aterectomia Coronária/métodos , Doença da Artéria Coronariana/economia , Doença da Artéria Coronariana/mortalidade , Análise Custo-Benefício , Feminino , Humanos , Japão , Masculino , Pessoa de Meia-Idade , Taxa de Sobrevida , Resultado do Tratamento , Calcificação Vascular/economia
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