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1.
Minerva Gastroenterol Dietol ; 65(2): 91-94, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30293414

RESUMO

BACKGROUND: More than 70 million Americans (23% of the USA population) have non-cardiac chest pain at least once in their lifetime with gastroesophageal reflux disease being the leading cause (37-66%). Current guidelines support the use of a proton pump inhibitor (PPI) prior to invasive or noninvasive testing as a diagnostic, therapeutic and cost-effective method as a part of High Value Care recommendations. METHODS: We performed a chart review of 126 patients admitted to the hospital under observation status who underwent upper gastrointestinal endoscopies in the hospital at 3 different urban community hospitals. This was compared with 260 patients admitted who did not have this procedure done. We calculated the healthcare burden including length of stay, reimbursement and complications from the procedures/extra stay in the hospital. RESULTS: The direct cost per case was almost two times in the group that underwent the procedure as compared to the group that did not. The mean length of stay was higher in the group that underwent the endoscopies. There were no complications and there was no difference in mortality. CONCLUSIONS: Upper gastrointestinal endoscopy in patients with atypical chest pain of gastrointestinal origin as an initial step is a significant healthcare burden and contradicts the currently recommended High Value Care recommendations. Our study delineates this large negative financial impact when performing upper endoscopies under observation status. Such patients should be started on an empirical trial of PPI, and endoscopy should be reserved for patients whose symptoms are unresponsive to PPIs or have alarm features.


Assuntos
Dor no Peito/diagnóstico , Endoscopia Gastrointestinal , Dor no Peito/economia , Dor no Peito/etiologia , Unidades de Observação Clínica , Endoscopia Gastrointestinal/economia , Feminino , Custos de Cuidados de Saúde , Humanos , Masculino , Pessoa de Meia-Idade
2.
BMJ Open ; 8(10): e025339, 2018 10 02.
Artigo em Inglês | MEDLINE | ID: mdl-30282688

RESUMO

INTRODUCTION: Observational data suggest a single high-sensitivity troponin blood test taken at emergency department (ED) presentation could be used to rule out major adverse cardiac events (MACE) in 10%-60% of ED patients with chest pain. This is done using an 'undetectable' cut-off (the Limit of Detection: LoD). We combined the LoD cut-off with ECG findings to create the LoDED strategy. We aim to establish whether the LoDED strategy works under real-life conditions, when compared with existing strategies, in a way that is cost-effective and acceptable to patients. METHODS AND ANALYSIS: This is a parallel-group pragmatic randomised controlled trial across UK EDs. Adults presenting to ED with suspected cardiac chest pain will be randomised 1:1. Existing rule-out strategies in current use across study centres, using serial high-sensitivity troponin testing, will be compared with the LoDED strategy. The primary outcome is successful early discharge (discharge from hospital within 4 hours of arrival) without MACE occurring within 30 days. Secondary outcomes include initial length of hospital stay; comparative costs; patient satisfaction and acceptability to patients. To detect a 9% difference between the early discharge rates (assuming an 8% rate in the standard care group) with 90% power, 594 patients need to be recruited, assuming a 95% follow-up rate. ETHICS AND DISSEMINATION: The study has been approved by the Frenchay Research Ethics Committee (reference 18/SW/0038). Results will be published in an international peer-reviewed journal. Lay summaries will be made available to patients. TRIAL REGISTRATION NUMBER: ISRCTN86184521; Pre-results.


Assuntos
Dor no Peito/diagnóstico , Eletrocardiografia , Infarto do Miocárdio/diagnóstico , Troponina/sangue , Biomarcadores/sangue , Dor no Peito/economia , Dor no Peito/etiologia , Análise Custo-Benefício , Serviço Hospitalar de Emergência , Custos Hospitalares/estatística & dados numéricos , Humanos , Tempo de Internação/economia , Limite de Detecção , Estudos Multicêntricos como Assunto , Infarto do Miocárdio/sangue , Ensaios Clínicos Pragmáticos como Assunto , Medição de Risco/métodos , Fatores de Risco
3.
Crit Pathw Cardiol ; 16(4): 126-128, 2017 12.
Artigo em Inglês | MEDLINE | ID: mdl-29135619

RESUMO

Chest pain is a common complaint in emergency departments. Several guidelines and tools exist to help the clinician determine need for hospitalization. For low-risk patients, clinical judgment can underestimate a patient's risk of major adverse cardiac event. Implementation of an advanced diagnostic protocol with the HEART Pathway can reduce hospital cost. For our academic institution, we saw an approximate $1 million in total savings during the initial implementation year along with increased outpatient visits. In addition, an increase in outpatient visits confirmed previous estimates that implementation of the HEART Pathway results in >20% reduction of hospital costs. We also identify challenges and considerations for facilities looking to repeat our successes.


Assuntos
Dor no Peito/terapia , Gerenciamento Clínico , Serviço Hospitalar de Emergência/economia , Custos Hospitalares , Dor no Peito/economia , Redução de Custos , Seguimentos , Humanos , Estudos Prospectivos
4.
BMJ Open ; 7(4): e012652, 2017 05 04.
Artigo em Inglês | MEDLINE | ID: mdl-28473507

RESUMO

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.


Assuntos
Técnicas de Imagem Cardíaca/economia , Dor no Peito/diagnóstico , Dor no Peito/economia , Doença da Artéria Coronariana/diagnóstico , Teste de Esforço/economia , Custos de Cuidados de Saúde/estatística & dados numéricos , Testes de Função Cardíaca/economia , Saúde Pública , Brasil/epidemiologia , Dor no Peito/epidemiologia , Doença da Artéria Coronariana/economia , Doença da Artéria Coronariana/epidemiologia , Análise Custo-Benefício , Técnicas de Apoio para a Decisão , Pesquisa sobre Serviços de Saúde , Humanos , Valor Preditivo dos Testes , Saúde Pública/economia , Reprodutibilidade dos Testes
6.
Clin Imaging ; 43: 97-105, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28273654

RESUMO

PURPOSE: To determine lifetime cost-effectiveness of diagnostic evaluation strategies for individuals with stable chest pain and suspected coronary artery disease (CAD). METHODS: Exercise treadmill testing (ETT), stress echocardiography (SE), myocardial perfusion scintigraphy (MPS), coronary computed tomographic angiography (CCTA), and invasive coronary angiography (ICA) were assessed alone, or in succession to each other. RESULTS: Initial ETT followed by imaging wherein ETT was equivocal or unable to be performed appeared more cost-effective than any strategy employing initial testing by imaging. CONCLUSION: As pre-test likelihood of CAD varies, different modalities including SE, CCTA, and MPS result in improved costs and enhanced effectiveness.


Assuntos
Dor no Peito , Angiografia Coronária , Doença da Artéria Coronariana , Análise Custo-Benefício , Testes de Função Cardíaca , Tomografia Computadorizada de Emissão de Fóton Único , Tomografia Computadorizada por Raios X , Artérias , Dor no Peito/diagnóstico , Dor no Peito/diagnóstico por imagem , Dor no Peito/economia , Angiografia Coronária/economia , Angiografia Coronária/métodos , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/economia , Ecocardiografia/economia , Ecocardiografia/métodos , Teste de Esforço/economia , Teste de Esforço/métodos , Testes de Função Cardíaca/economia , Testes de Função Cardíaca/métodos , Humanos , Imagem de Perfusão do Miocárdio/economia , Imagem de Perfusão do Miocárdio/métodos , Tórax , Tomografia Computadorizada de Emissão de Fóton Único/economia , Tomografia Computadorizada de Emissão de Fóton Único/métodos , Tomografia Computadorizada por Raios X/economia , Tomografia Computadorizada por Raios X/métodos
7.
Int J Cardiol ; 238: 144-150, 2017 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-28325612

RESUMO

BACKGROUND: Patients with low and intermediate risk chest pain features comprise the greatest proportion presenting to emergency services for evaluation of suspected acute coronary syndromes (ACS). The efficient and timely identification of patients with these features remains a major challenge within clinical practice. Troponin assays are increasingly being used for the determination of risk among patients presenting with chest pain potentially facilitating more appropriate care. To date, no economic evaluation comparing high-sensitivity troponin T (hs-TnT) reporting to standard troponin T (c-TnT) reporting in the routine management of suspected ACS and based on longer-term clinical outcomes has been conducted. METHODS AND RESULTS: An economic evaluation was conducted with 1937 participants randomized to either hs-TnT (n=973) or c-TnT (n=964) with 12month follow-up. The primary outcome measure was the number of cumulative combined outcomes of all-cause mortality and new or recurrent ACS avoided. Mean per participant Australian Medicare costs were higher in the hs-TnT arm compared to the c-TnT arm (by $1285/patient). Mean total adverse clinical outcomes avoided were higher in the hs-TnT arm (by 0.0120/patient) resulting in an incremental cost-effectiveness ratio (ICER) of $108,552/adverse clinical outcome avoided. An ICER of $49,030/adverse clinical outcome avoided was obtained when the analysis was restricted to patients below the threshold of normal Troponin testing (actual c-TnT levels <30ng/L). CONCLUSIONS: hs-TnT reporting leads to fewer adverse clinical events but at a high ICER. For the routine implementation of hs-TnT to be more cost-effective, substantial changes in clinical practice will be required. CLINICAL TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ACTRN12614000189628). https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=365726.


Assuntos
Dor no Peito/sangue , Dor no Peito/economia , Análise Custo-Benefício , Serviços Médicos de Emergência/economia , Troponina T/sangue , Troponina T/economia , Idoso , Austrália/epidemiologia , Biomarcadores/sangue , Dor no Peito/diagnóstico , Análise Custo-Benefício/métodos , Serviços Médicos de Emergência/tendências , Feminino , Seguimentos , Humanos , Tempo de Internação/economia , Tempo de Internação/tendências , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos
8.
Am J Emerg Med ; 35(1): 77-81, 2017 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-27765481

RESUMO

INTRODUCTION: The HEART Pathway is a diagnostic protocol designed to identify low-risk patients presenting to the emergency department with chest pain that are safe for early discharge. This protocol has been shown to significantly decrease health care resource utilization compared with usual care. However, the impact of the HEART Pathway on the cost of care has yet to be reported. METHODS AND RESULTS: We performed a cost analysis of patients enrolled in the HEART Pathway trial, which randomized participants to either usual care or the HEART Pathway protocol. For low-risk patients, the HEART Pathway recommended early discharge from the emergency department without further testing. We compared index visit cost, cost at 30 days, and cardiac-related health care cost at 30 days between the 2 treatment arms. Costs for each patient included facility and professional costs. Cost at 30 days included total inpatient and outpatient costs, including the index encounter, regardless of etiology. Cardiac-related health care cost at 30 days included the index encounter and costs adjudicated to be cardiac-related within that period. Two hundred seventy of the 282 patients enrolled in the trial had cost data available for analysis. There was a significant reduction in cost for the HEART Pathway group at 30 days (median cost savings of $216 per individual), which was most evident in low-risk (Thrombolysis In Myocardial Infarction score of 0-1) patients (median savings of $253 per patient) and driven primarily by lower cardiac diagnostic costs in the HEART Pathway group. CONCLUSIONS: Using the HEART Pathway as a decision aid for patients with undifferentiated chest pain resulted in significant cost savings.


Assuntos
Síndrome Coronariana Aguda/economia , Dor no Peito/economia , Técnicas de Apoio para a Decisão , Custos de Cuidados de Saúde , Síndrome Coronariana Aguda/complicações , Síndrome Coronariana Aguda/diagnóstico , Adulto , Fatores Etários , Idoso , Cardiologia , Dor no Peito/diagnóstico , Dor no Peito/etiologia , Protocolos Clínicos , Redução de Custos/economia , Custos e Análise de Custo , Eletrocardiografia , Serviço Hospitalar de Emergência/economia , Teste de Esforço/economia , Feminino , Humanos , Masculino , Anamnese , Pessoa de Meia-Idade , Ensaios Clínicos Controlados Aleatórios como Assunto , Encaminhamento e Consulta/economia , Medição de Risco/economia , Fatores de Risco , Troponina/sangue , Estados Unidos
9.
JAMA Intern Med ; 176(11): 1693-1702, 2016 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-27695822

RESUMO

Importance: Determining innovative approaches that better align health needs to the appropriate setting of care remains a key priority for the transformation of US health care; however, to our knowledge, no comprehensive assessment exists of alternative management strategies to hospital admission for acute medical conditions. Objective: To examine the effectiveness, safety, and cost of managing acute medical conditions in settings outside of a hospital inpatient unit. Evidence Review: MEDLINE, Scopus, CINAHL, and the Cochrane Database of Systematic Reviews (January 1995 to February 2016) were searched for English-language systematic reviews that evaluated alternative management strategies to hospital admission. Two investigators extracted data independently on trial design, eligibility criteria, clinical outcomes, patient experience, and health care costs. The quality of each review was assessed using the revised AMSTAR tool (R-AMSTAR) and the strength of evidence from primary studies was graded according to the Oxford Centre for Evidence-Based Medicine. Findings: Twenty-five systematic reviews (representing 123 primary studies) met inclusion criteria. For outpatient management strategies, several acute medical conditions had no significant difference in mortality, disease-specific outcomes, or patient satisfaction compared with inpatient admission. For quick diagnostic units, the evidence was more limited but did demonstrate low mortality rates and high patient satisfaction. For hospital-at-home, a variety of acute medical conditions had mortality rates, disease-specific outcomes, and patient and caregiver satisfaction that were either improved or no different compared with inpatient admission. For observation units, several acute medical conditions were found to have no difference in mortality, a decreased length of stay, and improved patient satisfaction compared to inpatient admission; results for some conditions were more limited. Across all alternative management strategies, cost data were heterogeneous but showed near-universal savings when assessed. Conclusions and Relevance: For low-risk patients with a range of acute medical conditions, evidence suggests that alternative management strategies to inpatient care can achieve comparable clinical outcomes and patient satisfaction at lower costs. Further study and application of such opportunities for health system redesign is warranted.


Assuntos
Doença Aguda/economia , Instituições de Assistência Ambulatorial/economia , Custos de Cuidados de Saúde , Hospitalização/economia , Pacientes Internados , Satisfação do Paciente , Doença Aguda/terapia , Dor no Peito/economia , Medicina Baseada em Evidências , Humanos , Metanálise como Assunto , Admissão do Paciente/economia , Ensaios Clínicos Controlados Aleatórios como Assunto , Estados Unidos
10.
J Nucl Med ; 57(3): 378-84, 2016 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-26635341

RESUMO

UNLABELLED: The purpose of this study was to determine whether stress myocardial perfusion (SPECT) optimized with stress-only (SO) imaging is comparable to cardiac CT angiography (CTA) for evaluating patients with acute chest pain (ACP). METHODS: This was a prospective randomized observational study in 598 ACP patients who underwent CTA versus SPECT. The primary endpoint was length of hospital stay, and secondary endpoints were test feasibility, time to diagnosis, diagnostic accuracy, radiation exposure, and overall cost. Median follow-up was 6.5 mo, with a 3.8% cardiac event rate defined as death or an acute coronary syndrome. RESULTS: Of 2,994 patients screened, 1,703 (56.9%) were not candidates for CTA because of prior cardiac disease (41%) or imaging contraindications (16%). Time to diagnosis (8.1 ± 8.5 vs. 9.4 ± 7.4 h) and length of hospital stay (19.7 ± 27.8 vs. 23.5 ± 34.4 h) were significantly shorter with CTA than with SPECT (P = 0.002). However, time to diagnosis (7.0 ± 6.2 vs. 6.8 ± 5.9 h, P = 0.20), length of stay (15.5 ± 17.2 vs. 16.7 ± 15.3 h, P = 0.36), and hospital costs ($4,242 ± $3,871 vs. $4,364 ± 1781, P = 0.86) were comparable with CTA versus SO SPECT, respectively. SO was also superior to conventional SPECT regarding all of the above metrics and significantly reduced radiation exposure (5.5 ± 4.4 vs. 12.5 ± 2.7 mSv, P < 0.0001). CONCLUSION: Stress SPECT when optimized with SO imaging is similar to CTA in time to diagnosis, length of hospital stay, and cost, with improved prognostic accuracy and less radiation exposure. Our results emphasize the importance of SO imaging, particularly in low-intermediate-risk emergency room patients who are a population likely to have a normal test result.


Assuntos
Dor no Peito/diagnóstico por imagem , Coração/diagnóstico por imagem , Síndrome Coronariana Aguda/epidemiologia , Síndrome Coronariana Aguda/mortalidade , Idoso , Dor no Peito/economia , Morte Súbita Cardíaca/epidemiologia , Morte Súbita Cardíaca/etiologia , Teste de Esforço , Feminino , Seguimentos , Humanos , Longevidade , Angiografia por Ressonância Magnética/economia , Angiografia por Ressonância Magnética/métodos , Masculino , Pessoa de Meia-Idade , Imagem de Perfusão do Miocárdio/métodos , Estudos Prospectivos , Reprodutibilidade dos Testes , Medição de Risco , Tomografia Computadorizada de Emissão de Fóton Único/economia , Tomografia Computadorizada de Emissão de Fóton Único/métodos
11.
Am J Emerg Med ; 34(1): 16-9, 2016 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-26490388

RESUMO

INTRODUCTION: We examined trends in the use of observation services and the relationship between index service type (observation services, emergency department [ED] visits, inpatient stays) and both clinical outcomes and Medicare payments. METHODS: We created a yearly cohort panel of Medicare beneficiaries with chest pain. We evaluate the relationships between index service type and 30-day clinical outcomes using a multinomial logit model and between index service type and Medicare payments using generalized linear models. RESULTS: In 2009, 24% of patients with chest pain received observation services; this rose to 29% in 2011. Conversely, 20% were treated as hospital inpatients in 2009; this fell to 16% in 2011. In the adjusted analysis, the risk of 30-day return to the hospital was 7% less (95% confidence interval, 5%-8%) for those receiving observation services as compared with inpatients. Average Medicare payments ranged from $3032 for beneficiaries initially treated in the ED to $3885 for those initially treated in observation to $6545 for those initially treated as inpatients. DISCUSSION: Patients treated in observation are less likely than those treated in the ED or as inpatients to have an adverse event within 30 days. Adjusted Medicare payments, including the index stay and the subsequent 30 days, were substantially less for those treated in observation as compared with those treated as inpatients, but more than for those treated and released from the ED. Higher rates of observation service use do not appear to be negatively affecting patient outcomes and may lower costs relative to inpatient treatment.


Assuntos
Dor no Peito/economia , Serviço Hospitalar de Emergência/economia , Hospitalização/economia , Medicare/economia , Conduta Expectante/economia , Conduta Expectante/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Feminino , Custos Hospitalares , Humanos , Masculino , Estudos Retrospectivos , Estados Unidos
12.
BMC Fam Pract ; 16: 88, 2015 Jul 23.
Artigo em Inglês | MEDLINE | ID: mdl-26202799

RESUMO

BACKGROUND: Recurrent chest pain is common in patients with and without coronary artery disease. The prevalence and burden of these symptoms on healthcare is unknown. OBJECTIVES: To compare chest pain return visits (recidivism) in patients with unexplained chest pain (UCP) against reference group of patients with coronary artery disease (CAD) and estimate the annual cost of recurrent chest pain. METHODS: In a retrospective cohort study, a Veteran Affairs (VA) administrative and clinical database of Veterans who were deployed to or served in support of the wars in Iraq or Afghanistan was queried for first disease specific ICD-9 code to form two cohorts (UCP or CAD). Patients were followed between 09/2001-09/2010 for the first and cumulative return visits for UCP or cardiac pain (ACS or angina) to clinic, emergency department or admission; or for all-cause death. Time to return was analyzed using Cox regression and negative binomial models and adjusted for age, gender, race, marital status, and risk factors (hypertension, hyperlipidemia, diabetes, smoking and obesity). Direct total costs included inpatient, outpatient and fee basis (non-VA) costs. RESULTS: Of 749,036 patients, 20,521 had UCP and 5303 had CAD. UCP patients were young and had a lower burden of risk factors than CAD cohort (p < .01). Yet, these patients were likely to return earlier with any chest pain (adjusted Hazard Ratio [aHR] = 1.76; 95 % CI 1.65-1.88); or unexplained chest pain than CAD patients (aHR: 1.89; 95 % CI 1.77-2.01). UCP patients were also likely to return more frequently for any chest pain (aRate Ratio = 1.54; 95 % CI 1.43-1.64) or UCP than CAD patients (aRR =2.63; 95 % CI 2.43-2.87). Per 100 patients, the 1-year cumulative returns were 37 visits for reference group and 45 visits for UCP cohort. The annual costs for chest pain averaged $69,009 for CAD and $57,336 for UCP patients (log geometric mean ratio=1.25; 95 % CI 1.18-1.32). CONCLUSION: Chest pain recidivism is common and costly even in patients without known CAD. We need evidence-based guidelines for these patients to minimize returns.


Assuntos
Dor no Peito/epidemiologia , Custos de Cuidados de Saúde/estatística & dados numéricos , Saúde dos Veteranos/estatística & dados numéricos , Adulto , Dor no Peito/economia , Dor no Peito/terapia , Bases de Dados Factuais , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva , Estudos Retrospectivos , Síndrome , Estados Unidos/epidemiologia , Saúde dos Veteranos/economia
14.
J Cardiovasc Comput Tomogr ; 9(4): 329-36, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-26088380

RESUMO

OBJECTIVE: The purpose of this study is to investigate the cost and resource use due to chest pain (CP) evaluations after initial coronary CT angiography (CCTA) stratified by coronary artery disease (CAD) burden. METHODS: We examined 1518 patients referred for CCTA from January 2005 to July 2012 for downstream evaluation after CCTA during a median follow-up of 351 days. Results were stratified by CAD burden as quantified on CCTA into no CAD, nonobstructive CAD (<50% stenosis), or obstructive CAD (≥50% stenosis). The incidence of ischemic testing at the time of recurrent evaluation (defined as a composite of clinic visit, emergency department encounter, or ischemic testing after the index CCTA for CP, atypical CP, or angina defined by ICD-9 code), the testing modality used, and frequency of testing were abstracted and used to calculate the direct costs of downstream utilization. Major adverse cardiovascular events defined as all-cause mortality, nonfatal myocardial infarction, stroke, or revascularization >90 days from CCTA were abstracted using ICD-9 codes and Social Security Death Index query. RESULTS: A total of 174 patients (11.5%) underwent evaluation for CP after index CCTA with a higher rate of subsequent clinical visits among obstructive CAD patients compared to those with nonobstructive CAD and no CAD (17.8% vs 13.9% vs. 7.5%; P < .001). A significant reduction in the incidence of repeat ischemic testing was observed in patients with no CAD and nonobstructive CAD (P = .002). This resulted in a lower per-patient cost in the nonobstructive CAD and no CAD patients (median [interquartile range 25-75]: $2952 [$307-2952] and $235 [$0-2880]) when compared with patients with obstructive CAD (median [interquartile range 25-75]: $5832 [$5498-17,459]; P < .001). Major adverse cardiovascular events were not different in the 90 patients that underwent repeat testing at the time of CP evaluation when compared with the 84 patients for whom testing was deferred. CONCLUSION: Absence of CAD on initial CCTA was associated with lower costs and decreased downstream utilization compared to the presence of nonobstructive and obstructive CAD on CCTA during median follow-up of 351 days.


Assuntos
Dor no Peito/economia , Dor no Peito/mortalidade , Angiografia Coronária/economia , Estenose Coronária/diagnóstico por imagem , Custos de Cuidados de Saúde/estatística & dados numéricos , Tomografia Computadorizada por Raios X/economia , Comorbidade , Angiografia Coronária/estatística & dados numéricos , Estudos de Viabilidade , Feminino , Humanos , Masculino , Sobremedicalização/economia , Sobremedicalização/prevenção & controle , Sobremedicalização/estatística & dados numéricos , Pessoa de Meia-Idade , Fatores de Risco , Taxa de Sobrevida , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Estados Unidos , Revisão da Utilização de Recursos de Saúde
15.
Health Technol Assess ; 19(44): 1-234, 2015 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-26118801

RESUMO

BACKGROUND: Early diagnosis of acute myocardial infarction (AMI) can ensure quick and effective treatment but only 20% of adults with emergency admissions for chest pain have an AMI. High-sensitivity cardiac troponin (hs-cTn) assays may allow rapid rule-out of AMI and avoidance of unnecessary hospital admissions and anxiety. OBJECTIVE: To assess the clinical effectiveness and cost-effectiveness of hs-cTn assays for the early (within 4 hours of presentation) rule-out of AMI in adults with acute chest pain. METHODS: Sixteen databases, including MEDLINE and EMBASE, research registers and conference proceedings, were searched to October 2013. Study quality was assessed using QUADAS-2. The bivariate model was used to estimate summary sensitivity and specificity for meta-analyses involving four or more studies, otherwise random-effects logistic regression was used. The health-economic analysis considered the long-term costs and quality-adjusted life-years (QALYs) associated with different troponin (Tn) testing methods. The de novo model consisted of a decision tree and Markov model. A lifetime time horizon (60 years) was used. RESULTS: Eighteen studies were included in the clinical effectiveness review. The optimum strategy, based on the Roche assay, used a limit of blank (LoB) threshold in a presentation sample to rule out AMI [negative likelihood ratio (LR-) 0.10, 95% confidence interval (CI) 0.05 to 0.18]. Patients testing positive could then have a further test at 2 hours; a result above the 99th centile on either sample and a delta (Δ) of ≥ 20% has some potential for ruling in an AMI [positive likelihood ratio (LR+) 8.42, 95% CI 6.11 to 11.60], whereas a result below the 99th centile on both samples and a Δ of < 20% can be used to rule out an AMI (LR- 0.04, 95% CI 0.02 to 0.10). The optimum strategy, based on the Abbott assay, used a limit of detection (LoD) threshold in a presentation sample to rule out AMI (LR- 0.01, 95% CI 0.00 to 0.08). Patients testing positive could then have a further test at 3 hours; a result above the 99th centile on this sample has some potential for ruling in an AMI (LR+ 10.16, 95% CI 8.38 to 12.31), whereas a result below the 99th centile can be used to rule out an AMI (LR- 0.02, 95% CI 0.01 to 0.05). In the base-case analysis, standard Tn testing was both most effective and most costly. Strategies considered cost-effective depending upon incremental cost-effectiveness ratio thresholds were Abbott 99th centile (thresholds of < £6597), Beckman 99th centile (thresholds between £6597 and £30,042), Abbott optimal strategy (LoD threshold at presentation, followed by 99th centile threshold at 3 hours) (thresholds between £30,042 and £103,194) and the standard Tn test (thresholds over £103,194). The Roche 99th centile and the Roche optimal strategy [LoB threshold at presentation followed by 99th centile threshold and/or Δ20% (compared with presentation test) at 1-3 hours] were extendedly dominated in this analysis. CONCLUSIONS: There is some evidence to suggest that hs-CTn testing may provide an effective and cost-effective approach to early rule-out of AMI. Further research is needed to clarify optimal diagnostic thresholds and testing strategies. STUDY REGISTRATION: This study is registered as PROSPERO CRD42013005939. FUNDING: The National Institute for Health Research Health Technology Assessment programme.


Assuntos
Dor no Peito/diagnóstico , Infarto do Miocárdio/diagnóstico , Troponina C/sangue , Adulto , Dor no Peito/economia , Dor no Peito/etiologia , Análise Custo-Benefício , Custos Hospitalares/estatística & dados numéricos , Humanos , Infarto do Miocárdio/sangue , Infarto do Miocárdio/economia , Troponina C/economia
17.
Int J Cardiol ; 177(3): 867-73, 2014 Dec 20.
Artigo em Inglês | MEDLINE | ID: mdl-25466568

RESUMO

BACKGROUND: Coronary CT angiography (CCTA) has high sensitivity, with 3 recent randomized trials favorably comparing CCTA to standard-of-care. Comparison to exercise stress ECG (ExECG), the most available and least expensive standard-of-care worldwide, has not been systematically tested. METHODS: CT-COMPARE was a randomized, single-center trial of low-intermediate risk chest pain subjects undergoing CCTA or ExECG after the first negative troponin. From March 2010 to April 2011, 562 patients randomized to either dual-source CCTA (n=322) or ExECG (n=240). Primary endpoints were diagnostic performance for ACS, and hospital cost at 30 days. Secondary endpoints were time-to-discharge, admission rates, and downstream resource utilization. RESULTS: ACS occurred in 24 (4%) patients. ExECG had 213 negative studies and 27 (26%) positive studies for ACS with sensitivity of 83% [95% CI: 36, 99.6%], specificity of 91% [CI: 86, 94%], and ROC AUC of 0.87 [CI: 0.70, 1]. CCTA (>50% stenosis considered positive) had 288 negative studies and 18/35 (51%) positive studies with a sensitivity of 100% [CI: 81.5, 100], specificity of 94% [CI: 91.2, 96.7%], and ROC of 0.97 [CI: 0.92, 1.0; p=0.2]. Despite CCTA having higher odds of downstream testing (OR 2.0), 30 day per-patient cost was significantly lower for CCTA ($2193 vs $2704, p<0.001). Length of stay for CCTA was significantly reduced (13.5h [95% CI: 11.2-15.7], ExECG 19.7h [95% CI: 17.4-22.1], p<0.0005), which drove the reduction in cost. No patient had post-discharge cardiovascular events at 30 days. CONCLUSIONS: CCTA had improved diagnostic performance compared to ExECG, combined with 35% relative reduction in length-of-stay, and 20% reduction in hospital costs. These data lend further evidence that CCTA is useful as a first line assessment in emergency department chest pain.


Assuntos
Síndrome Coronariana Aguda/diagnóstico por imagem , Dor no Peito/diagnóstico por imagem , Angiografia Coronária/normas , Serviço Hospitalar de Emergência/normas , Custos Hospitalares , Tomografia Computadorizada por Raios X/normas , Síndrome Coronariana Aguda/economia , Adulto , Dor no Peito/economia , Angiografia Coronária/economia , Serviço Hospitalar de Emergência/economia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Tomografia Computadorizada por Raios X/economia
18.
J Cardiovasc Comput Tomogr ; 8(5): 375-83, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-25301043

RESUMO

BACKGROUND: Coronary CT angiography (CTA) is a powerful tool for the evaluation of chest pain in the emergency department (ED). Some debate persists regarding its cost-effectiveness in a low-to-intermediate risk population. OBJECTIVE: This study sought to evaluate the safety and cost-effectiveness of coronary CTA for low-to-intermediate risk patients presenting to the ED with chest pain in a closed-loop referral system. METHODS: Chest pain patients were evaluated in the ED via a local rapid coronary CTA protocol and tracked prospectively for ED throughput, disposition, chest pain recidivism, and cost utilization as compared with an age-matched cohort evaluated for chest pain treated with usual care. RESULTS: One hundred eighty-three patients underwent the rapid coronary CTA protocol compared with an age-matched cohort of 184 patients treated with usual care. The median follow-up period for major adverse cardiovascular events in the coronary CTA group was 9.0 months (range, 1.8-14.5 months) and 11.1 months (range, 0-14.0 months) for the age-matched cohort. The median ED length of stay (LOS) was 5.8 hours (range, 2.6-12.3 hours) for the rapid coronary CTA cohort and 12.2 hours (range, 1.7-40.3 hours) for the age-matched cohort (P < .001). The median time to performance of coronary CTA was 2.5 hours (range, 0.4-8.7 hours) with a median time from coronary CTA performance to disposition of 2.9 hours (range, 0.8-8.6 hours). Total median hospital LOS was 5.9 hours (range, 2.7-124 hours) in the rapid coronary CTA cohort compared with 25.0 hours (range, 1.2-208 hours) in the age-matched cohort (P < .001). Hospital admission was more common in the age-matched cohort (98.9% vs 9.3%; P < .001). There was a significant reduction in total payer cost in coronary CTA group when compared to usual care ($182,064.55 vs $685,190.77; P < .001). CONCLUSIONS: Coronary CTA for ED risk stratification and disposition within a closed referral system resulted in the shortest ED LOS published to date while being safe and cost-effective.


Assuntos
Dor no Peito/diagnóstico por imagem , Dor no Peito/economia , Angiografia Coronária/economia , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/economia , Tempo de Internação/economia , Tomografia Computadorizada por Raios X/economia , Causalidade , Dor no Peito/mortalidade , Estudos de Coortes , Comorbidade , Angiografia Coronária/mortalidade , Angiografia Coronária/estatística & dados numéricos , Doença da Artéria Coronariana/mortalidade , Feminino , Custos de Cuidados de Saúde/estatística & dados numéricos , Mortalidade Hospitalar , Humanos , Incidência , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Medição de Risco , Fatores de Risco , Sensibilidade e Especificidade , Taxa de Sobrevida , Texas/epidemiologia , Tomografia Computadorizada por Raios X/mortalidade , Tomografia Computadorizada por Raios X/estatística & dados numéricos
19.
Circulation ; 130(8): 668-75, 2014 Aug 19.
Artigo em Inglês | MEDLINE | ID: mdl-25015342

RESUMO

BACKGROUND: Pulmonary nodules (PNs) are often detected incidentally during coronary computed tomographic (CT) angiography, which is increasingly being used to evaluate patients with chest pain symptoms. However, the efficiency of following up on incidentally detected PN is unknown. METHODS AND RESULTS: We determined demographic and clinical characteristics of stable symptomatic patients referred for coronary CT angiography in whom incidentally detected PNs warranted follow-up. A validated lung cancer simulation model was populated with data from these patients, and clinical and economic consequences of follow-up per Fleischner guidelines versus no follow-up were simulated. Of the 3665 patients referred for coronary CT angiography, 591 (16%) had PNs requiring follow-up. The mean age of patients with PNs was 59±10 years; 66% were male; 67% had ever smoked; and 21% had obstructive coronary artery disease. The projected overall lung cancer incidence was 5.8% in these patients, but the majority died of coronary artery disease (38%) and other causes (57%). Follow-up of PNs was associated with a 4.6% relative reduction in cumulative lung cancer mortality (absolute mortality: follow-up, 4.33% versus non-follow-up, 4.54%), more downstream testing (follow-up, 2.34 CTs per patient versus non-follow-up, 1.01 CTs per patient), and an average increase in quality-adjusted life of 7 days. Costs per quality-adjusted life-year gained were $154 700 to follow up the entire cohort and $129 800 per quality-adjusted life-year when only smokers were included. CONCLUSIONS: Follow-up of PNs incidentally detected in patients undergoing coronary CT angiography for chest pain evaluation is associated with a small reduction in lung cancer mortality. However, significant downstream testing contributes to limited efficiency, as demonstrated by a high cost per quality-adjusted life-year, especially in nonsmokers.


Assuntos
Técnicas de Imagem Cardíaca/economia , Angiografia Coronária/economia , Doença da Artéria Coronariana/economia , Neoplasias Pulmonares/economia , Nódulo Pulmonar Solitário/economia , Tomografia Computadorizada por Raios X/economia , Idoso , Técnicas de Imagem Cardíaca/métodos , Dor no Peito/diagnóstico por imagem , Dor no Peito/economia , Pesquisa Comparativa da Efetividade , Simulação por Computador , Angiografia Coronária/métodos , Doença da Artéria Coronariana/diagnóstico por imagem , Análise Custo-Benefício , Feminino , Seguimentos , Política de Saúde/economia , Humanos , Achados Incidentais , Neoplasias Pulmonares/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Anos de Vida Ajustados por Qualidade de Vida , Encaminhamento e Consulta/economia , Medição de Risco/economia , Nódulo Pulmonar Solitário/diagnóstico por imagem , Tomografia Computadorizada por Raios X/métodos
20.
Circ Cardiovasc Qual Outcomes ; 7(2): 292-8, 2014 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-24594550

RESUMO

BACKGROUND: High body mass index (BMI) increases the probability of indeterminate findings on diagnostic studies, length of stay, and cost of care for hospitalized patients. No study has examined the economic and operational impact of BMI in patients with chest complaints presenting to the emergency department (ED). The objective was to measure the association of BMI with the main outcomes of cost of care, length of stay (including time in the ED and time in the wards if admitted), and radiation exposure in patients presenting to the ED with chest pain and dyspnea. METHODS AND RESULTS: This was a prospective, 4-center, outcomes study. Patients were adults with dyspnea and chest pain, nondiagnostic electrocardiograms, and no obvious diagnosis. Patients were followed for the main outcomes for 90 days. Outcomes that were stratified by BMI in 5 categories, underweight, normal weight, overweight, obese, and morbidly obese, were compared using the Kruskall-Wallis rank test, and the independent predictive value of BMI was tested with multivariate regressions. Compared with medical costs for normal weight patients, costs were 22% higher for overweight patients (P=0.077), 28% higher for obese patients (P=0.020), and 41% higher for morbidly obese patients (P=0.015). Morbidly obese patients without computerized tomographic scanning stayed in the hospital 34% longer than normal weight patients (P=0.073), and morbidly obese patients with computerized tomographic scanning stayed in the hospital 44% longer than normal weight patients (P=0.083). BMI was not a significant predictor of radiation exposure. Morbidly obese patients had the highest proportion (87%) of no significant cardiopulmonary diagnosis for 90 days after computerized tomographic pulmonary angiography. CONCLUSIONS: BMI was associated with increases in cost of care and length of hospital stay for patients with chest pain and dyspnea. These results emphasize a need for specific protocols to manage morbidly obese patients presenting to the ED with chest pain and dyspnea. Clinical Trial Registration- http://www.clinicaltrials.gov. Unique identifier: NCT01059500.


Assuntos
Índice de Massa Corporal , Dor no Peito/diagnóstico , Dispneia/diagnóstico , Obesidade/diagnóstico , Adolescente , Adulto , Idoso de 80 Anos ou mais , Dor no Peito/economia , Dor no Peito/epidemiologia , Criança , Pré-Escolar , Dispneia/economia , Dispneia/epidemiologia , Serviço Hospitalar de Emergência , Exposição Ambiental/efeitos adversos , Feminino , Seguimentos , Custos de Cuidados de Saúde/estatística & dados numéricos , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Obesidade/economia , Obesidade/epidemiologia , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Radiação Ionizante , Resultado do Tratamento , Adulto Jovem
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