Health Resource Utilization and Direct Costs Associated with Angina for Patients with Coronary Artery Disease in a US Managed Care Setting

Background

Angina is often a first symptom of coronary artery disease (CAD); however, the specific burden of illness for patients with CAD-associated angina in managed care has not been reported.

Objective

To determine the clinical and cost burden of illness for patients with CAD-associated angina in a managed care environment.

Study design

A retrospective database analysis in a nationwide commercial managed care plan.

Methods

This study included patients with International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic or procedure codes for CAD between July 1, 2004, and June 30, 2006, who had data available for the period 6 months before and 12 months after the index date. The primary analyses for patients classified as having CAD with angina were based on a 3-algorithm patient-identification model (combined positive predictive value of 89%, 95% confidence interval, 0.79–0.95). Utilization measures for the 12-month postindex period, annual CAD-related direct costs, and total all-cause costs (ie, medical plus pharmacy) were determined. A generalized linear model was used to compare CAD-related costs and overall costs.

Results

Of the 246,227 patients with CAD, the 3-algorithm model assigned 230,919 patients (93.8%) to the CAD-without-angina cohort and 15,308 (6.2%) to the CAD-with-angina cohort. Patients with angina were more likely than patients without angina to be hospitalized (41% vs 11%, respectively; P <.001), to visit the emergency department (34% vs 12%, respectively; P <.001), to have office visits (94% vs 79%, respectively; P <.001), and to have more revascularization procedures (35% vs 8%, respectively; P <.001). Average CAD-related inpatient costs were $9536 versus $2169, and pharmacy costs were $1499 versus $891, for patients with and without angina, respectively. Total average CAD-related medical and pharmacy costs for patients with angina were $14,851 versus $4449 for patients with CAD without angina, and the average all-cause per-patient cost was $28,590 versus $14,334, respectively.

Conclusion

Based on these results, US patients with CAD plus angina in a managed care setting use significantly more healthcare services and incur higher costs than patients who have CAD without angina. Revascularization procedures are a major driver of these increased costs for those with CAD and angina.Chest pain, or angina pectoris, is the primary symptom of coronary artery disease (CAD), or chronic heart disease, a leading cause of morbidity and mortality in the United States. An estimated 17.5 million Americans have CAD, 9 million have angina pectoris, and approximately 500,000 new cases of angina are diagnosed annually.1,2 Current evidence-based treatment guidelines for patients with stable ischemic heart disease recommend lifestyle changes, drug therapy, and revascularization procedures.3,4 Current treatment strategies are to identify and treat underlying conditions that may contribute to angina symptoms, modify risk factors, improve a patient''s health and survival through pharmacologic and nonpharmacologic means, and utilize revascularization procedures through evidence-based practice.5

KEY POINTS

• ▸ Approximately 17.5 million Americans have coronary artery disease (CAD) and 9 million have angina, which is often the initial symptom of CAD.
• ▸ There are limited data on healthcare resource utilization and direct costs for patients with CAD plus angina, and CAD without angina.
• ▸ This study used real-world data to compare treatment patterns and costs for patients who have CAD with and without angina in a managed care setting.
• ▸ Average CAD-related inpatient costs were $9536 for those with angina versus $2169 without angina; total average CAD-related medical and pharmacy costs for patients with angina were $14,851 versus $4449 for those without angina.
• ▸ Overall, patients with CAD plus angina used considerably more healthcare resources than those without angina, including hospitalization, emergency department visits, outpatient visits, and cardiovascular drug regimens.
• ▸ In addition, patients with CAD and angina were significantly more likely to have a revascularization procedure—a major cost driver—than patients without angina.

To date, several studies have examined resource utilization in patients with angina pectoris. These studies have examined the direct costs of chronic angina using national health statistics, as well as information in 2 large clinical trials—the COURAGE and MERLIN-TIMI 36 trials.1,6,7 However, no data exist comparing the manifestation of CAD with or without documented angina.Few US studies have examined treatment patterns, resource utilization, and the cost of care for patients with CAD plus angina. Javitz and colleagues, who conducted the only database study to investigate the annual direct medical costs of chronic angina, reported annual costs ranging from $1.9 billion to $74.8 billion, depending on the way in which angina was defined.8 The study was conducted from a societal perspective, using the National Center for Health Statistics'' public-use databases. Given the considerable burden of stable ischemic heart disease and the paucity of information about its economic impact, with particular emphasis in the public healthcare sector, the objective of the current study was to compare real-world treatment patterns and costs of CAD with angina versus CAD without angina in a large, commercially insured, managed care population.