Cost evaluation of cardiovascular magnetic resonance versus coronary angiography for the diagnostic work-up of coronary artery disease: Application of the European Cardiovascular Magnetic Resonance registry data to the German,United Kingdom,Swiss, and United States health care systems

Background

Cardiovascular magnetic resonance (CMR) has favorable characteristics for diagnostic evaluation and risk stratification of patients with known or suspected CAD. CMR utilization in CAD detection is growing fast. However, data on its cost-effectiveness are scarce. The goal of this study is to compare the costs of two strategies for detection of significant coronary artery stenoses in patients with suspected coronary artery disease (CAD): 1) Performing CMR first to assess myocardial ischemia and/or infarct scar before referring positive patients (defined as presence of ischemia and/or infarct scar to coronary angiography (CXA) versus 2) a hypothetical CXA performed in all patients as a single test to detect CAD.

Methods

A subgroup of the European CMR pilot registry was used including 2,717 consecutive patients who underwent stress-CMR. From these patients, 21% were positive for CAD (ischemia and/or infarct scar), 73% negative, and 6% uncertain and underwent additional testing. The diagnostic costs were evaluated using invoicing costs of each test performed. Costs analysis was performed from a health care payer perspective in German, United Kingdom, Swiss, and United States health care settings.

Results

In the public sectors of the German, United Kingdom, and Swiss health care systems, cost savings from the CMR-driven strategy were 50%, 25% and 23%, respectively, versus outpatient CXA. If CXA was carried out as an inpatient procedure, cost savings were 46%, 50% and 48%, respectively. In the United States context, cost savings were 51% when compared with inpatient CXA, but higher for CMR by 8% versus outpatient CXA.

Conclusion

This analysis suggests that from an economic perspective, the use of CMR should be encouraged as a management option for patients with suspected CAD.     

Comparative cost-effectiveness analyses of cardiovascular magnetic resonance and coronary angiography combined with fractional flow reserve for the diagnosis of coronary artery disease

Abstracts

Background

According to recent guidelines, patients with coronary artery disease (CAD) should undergo revascularization if significant myocardial ischemia is present. Both, cardiovascular magnetic resonance (CMR) and fractional flow reserve (FFR) allow for a reliable ischemia assessment and in combination with anatomical information provided by invasive coronary angiography (CXA), such a work-up sets the basis for a decision to revascularize or not. The cost-effectiveness ratio of these two strategies is compared.

Methods

Strategy 1) CMR to assess ischemia followed by CXA in ischemia-positive patients (CMR + CXA), Strategy 2) CXA followed by FFR in angiographically positive stenoses (CXA + FFR). The costs, evaluated from the third party payer perspective in Switzerland, Germany, the United Kingdom (UK), and the United States (US), included public prices of the different outpatient procedures and costs induced by procedural complications and by diagnostic errors. The effectiveness criterion was the correct identification of hemodynamically significant coronary lesion(s) (= significant CAD) complemented by full anatomical information. Test performances were derived from the published literature. Cost-effectiveness ratios for both strategies were compared for hypothetical cohorts with different pretest likelihood of significant CAD.

Results

CMR + CXA and CXA + FFR were equally cost-effective at a pretest likelihood of CAD of 62% in Switzerland, 65% in Germany, 83% in the UK, and 82% in the US with costs of CHF 5′794, € 1′517, £ 2′680, and $ 2′179 per patient correctly diagnosed. Below these thresholds, CMR + CXA showed lower costs per patient correctly diagnosed than CXA + FFR.

Conclusions

The CMR + CXA strategy is more cost-effective than CXA + FFR below a CAD prevalence of 62%, 65%, 83%, and 82% for the Swiss, the German, the UK, and the US health care systems, respectively. These findings may help to optimize resource utilization in the diagnosis of CAD.     

Home care—a safe and attractive alternative to inpatient administration of intensive chemotherapies

Objective  

The objective of this study was to evaluate feasibility, safety, perception, and costs of home care for the administration of intensive chemotherapies.     

Comparison of HIV-infected patients’ characteristics, healthcare resources use and cost between native and migrant patients

Objectives:  To assess whether patients’ characteristics and healthcare resources consumption and costs were different between native and migrant populations in Switzerland. Methods:  All adult patients followed-up in the Swiss HIV-cohort study in our institution during 2000–2003 were considered. Patients’ characteristics were retrieved from the cohort database. Hospital and outpatient resource use were extracted from individual charts and valued with 2002 tariffs. Results:  The 66 migrants were younger (29 ± 8 years versus 37 ± 11, p < 0.001), less often of male gender (38 % versus 70 %, p < 0.001), predominantly infected via heterosexual contact (87 % versus 52 %, p < 0.01), with lower mean CD4 level at enrolment (326 ± 235 versus 437 ± 305, p = 0.002) than their 200 native counterparts. Migrants had fewer hospitalizations, more frequent outpatient visits, laboratory tests, and lower total cost of care per year of follow-up (€ 2′215  ±  4′206 versus 4′155  ±  12′304, p = 0.037). Resource use and costs were significantly higher in people with < 200 CD4 cell counts in both groups. Conclusions:  Migrant population had more advanced disease, more outpatient visits but less hospitalizations, resulting in lower costs of care when compared with native population. Submitted: 14 May 2007; revised: 14 April 2008, 27 August 2008; accepted: 05 September 2008     

Can the impact of bed closure in intensive care units be reliably monitored?

Objective To assess the properties of various indicators aimed at monitoring the impact on the activity and patient outcome of a bed closure in a surgical intensive care unit (ICU).Design Comparison before and after the intervention.Setting A surgical ICU at a university hospital.Patients All patients admitted to the unit over two periods of 10 months.Intervention Closure of one bed out of 17.Measurements and results Activity and outcome indicators in the ICU and the structures upstream from it (emergency department, operative theater, recovery room) and downstream from it (intermediate care units). After the bed closure, the monthly medians of admitted patients and ICU hospital days increased from 107 (interquartile range 94–112) to 113 (106–121, P=0.07) and from 360 (325–443) to 395 (345–436, P=0.48), respectively, along with the linear trend observed in our institution. All indicators of workload, patient severity, and outcome remained stable except for SAPS II score, emergency admissions, and ICU readmissions, which increased not only transiently but also on a mid-term basis (10 months), indicating that the process of patient care delivery was no longer predictable.Conclusions Health care systems, including ICUs, are extraordinary flexible, and can adapt to multiple external constraints without altering commonly used activity and outcome indicators. It is therefore necessary to set up multiple indicators to be able to reliably monitor the impact of external interventions and intervene rapidly when the system is no longer under control.     

Citizens’ preferences for brand name drugs for treating acute and chronic conditions

Background

Generic drugs have been advocated to decrease the proportion of healthcare costs devoted to drugs, but are still underused.

Objective

To assess citizens’ preferences for brand name drugs (BNDs) compared with generic drugs for treating acute and chronic conditions.

Methods

A questionnaire with eight hypothetical scenarios describing four acute and four chronic conditions was developed, with willingness to pay (WTP) determined using a payment card system randomized to ascending (AO) or descending order (DO) of prices. The questionnaire was distributed with an explanation sheet, an informed consent form and a pre-stamped envelope over a period of 3 weeks in 19 community pharmacies in Lausanne, Switzerland. The questionnaire was distributed to every third customer who also had health insurance, understood French and was aged ≥16 years (up to a maximum of ten customers per day and 100 per pharmacy). The main outcome measure was preferences assessed by WTP for BNDs as compared with generics, and impact of participants’ characteristics on WTP.

Results

Of the 1800 questionnaires, 991 were distributed and 393 returned (pharmacy participation rate = 55%, subject participation rate = 40%, overall response rate = 22%); 51.7% were AO and 48.3% DO. Participants were predominantly women (62.6%) and of median age 62 years (range 16–90). The majority (70%) declared no WTP for BNDs as compared with generics. WTP was higher in people with an acute disease than in those with a chronic disease, did not depend on the type of chronic disease, and was higher in people from countries other than Switzerland.

Conclusions

Most citizens visiting pharmacies attribute no added value to BNDs as compared with generics, although some citizen characteristics affected WTP. These results could be of interest to several categories of decision makers within the healthcare system.