The Cost Effectiveness of Coronary CT Angiography and the Effective Utilization of CT-Fractional Flow Reserve in the Diagnosis of Coronary Artery Disease.

Given the high global disease burden of coronary artery disease (CAD), a major problem facing healthcare economic policy is identifying the most cost-effective diagnostic strategy for patients with suspected CAD. The aim of this review is to assess the long-term cost-effectiveness of coronary computed tomography angiography (CCTA) when compared with other diagnostic modalities and to define the cost and effective diagnostic utilization of computed tomography-fractional flow reserve (CT-FFR). A search was conducted through the MEDLINE database using PubMed with 16 of 119 manuscripts fitting the inclusion and exclusion criteria for review. An analysis of the data included in this review suggests that CCTA is a cost-effective strategy for both low risk acute chest pain patients presenting to the emergency department (ED) and low-to-intermediate risk stable chest pain outpatients. For patients with intermediate-to-high risk, CT-FFR is superior to CCTA in identifying clinically significant stenosis. In low-to-intermediate risk patients, CCTA provides a cost-effective diagnostic strategy with the potential to reduce economic burden and improve long-term health outcomes. CT-FFR should be utilized in intermediate-to-high risk patients with stenosis of uncertain clinical significance. Long-term analysis of cost-effectiveness and diagnostic utility is needed to determine the optimal balance between the cost-effectiveness and diagnostic utility of CT-FFR.

Overlapping Presentations of HELLP Syndrome and COVID-19.

Introduction: Haemolysis, elevated liver enzymes and low platelet count (HELLP) syndrome is a leading cause of maternal mortality. The emergence of coronavirus disease 2019 (COVID-19) has led to challenges in diagnosing HELLP syndrome due to overlapping clinical and laboratory presentations. We report a case of HELLP syndrome complicated by COVID-19 infection. Case Description: An otherwise healthy pregnant 31-year-old woman presented with fever, myalgia and headache. She was found to be COVID-positive with laboratory signs of HELLP syndrome. Symptoms and laboratory findings trended toward normal after delivery confirming the diagnosis of HELLP syndrome. Discussion: A prompt diagnosis of HELLP syndrome is essential to avoid maternal and fetal complications. Clinicians should be aware of the similarities in presentation between HELLP syndrome and COVID-19 for timely diagnosis and treatment. LEARNING POINTS: SARS-CoV-2 preferentially binds to ACE2 which is expressed in extrapulmonary tissue including placental tissue.COVID-19, HELLP syndrome and preeclampsia may have similar characteristics including elevated blood pressures, liver dysfunction, cardiopulmonary complaints and hypercoagulability.The temporal relationship of symptomatic improvement with delivery and after delivery may better differentiate HELLP syndrome from COVID-19.

Understanding Patient Perceptions Towards Direct Primary Care: A Focus Group Study.

Direct primary care (DPC) is a growing model of care that is suggested as an alternative to traditional fee-for-service healthcare. Patient-reported experiences of DPC can provide unique insight into the impact of joining the model and inform quality improvement. The purpose of this study was to investigate patient perceptions of DPC. Thirty-one participants were initially recruited for the study and completed a survey assessing patient demographics. Of the 31 participants, 10 went on to complete the focus group interviews. Qualitative analysis of focus group transcripts identified common themes and subthemes. Focus group findings were stratified into 4 themes including quality of care, access to care, affordability, physician qualities, and reasons for choosing DPC. The top positive subthemes were good communication, joining DPC due to poor past healthcare experiences, and physician personability. The most common negative subthemes were difficulty referring to specialists outside the practice, poor communication, and poor access to medications. All findings were presented and discussed with the investigated clinic to facilitate improvements in healthcare delivery.

The Merits, Limitations, and Future Directions of Cost-Effectiveness Analysis in Cardiac MRI with a Focus on Coronary Artery Disease: A Literature Review.

Cardiac magnetic resonance (CMR) imaging has a wide range of clinical applications with a high degree of accuracy for many myocardial pathologies. Recent literature has shown great utility of CMR in diagnosing many diseases, often changing the course of treatment. Despite this, it is often underutilized possibly due to perceived costs, limiting patient factors and comfort, and longer examination periods compared to other imaging modalities. In this regard, we conducted a literature review using keywords "Cost-Effectiveness" and "Cardiac MRI" and selected articles from the PubMed MEDLINE database that met our inclusion and exclusion criteria to examine the cost-effectiveness of CMR. Our search result yielded 17 articles included in our review. We found that CMR can be cost-effective in quality-adjusted life years (QALYs) in select patient populations with various cardiac pathologies. Specifically, the use of CMR in coronary artery disease (CAD) patients with a pretest probability below a certain threshold may be more cost-effective compared to patients with a higher pretest probability, although its use can be limited based on geographic location, professional society guidelines, and differing reimbursement patterns. In addition, a stepwise combination of different imaging modalities, with conjunction of AHA/ACC guidelines can further enhance the cost-effectiveness of CMR.