RESUMEN
BACKGROUND: In the literature, obesity has been correlated with coronary artery diseases (CADs) and high health costs. This study aimed to investigate the relationships between obesity parameters and the health costs among patients with CADs undergoing cardiac catheterization. METHOD: A secondary data analysis was done for an original study. The original study was conducted among 220 hospitalized patients undergoing cardiac catheterization from two main hospitals located in the Middle and Northern regions of Jordan. Bivariate Pearson's correlation and forward linear regression analysis were calculated in this study. RESULTS: The average health cost for the participants was 1,344 JOD (1,895.63 USD). A significant positive moderate correlation (r = 0.4) was found between hip circumference (HC) and health cost. There were significant positive weak correlations between low-density lipoprotein (LDL), triglycerides, high-sensitivity C-reactive protein (HS-CRP), hemoglobin A1c (HbA1c), and depression, and the health cost (correlation coefficient 0.17, 0.3, 0.29, 0.22 and 0.17, respectively. HC, waist circumference (WC), waist-height ratio (WHtR), waist-hip ratio (WHR), and body adiposity index (BAI) were significantly associated with health costs among male participants. In contrast, among females, none of the obesity parameters was significantly associated with health costs. The forward regression analysis illustrated that an increase of HC by 3.9 cm (ß (0.292) * SD (13.4)) will increase the health cost by 1 JOD (0.71 USD). The same analysis revealed that HS-CRP increased by 0.4 mg/dl (ß (0.258)*SD (1.43)), or triglycerides increased by 8.3 mg/dl (ß (0.241)* SD (34.3)), or depression score increased by 0.32 score (ß (0.137)* SD (2.3)), or total cholesterol increased by 4 mg/dl (ß (0.163)* SD (24.7)), the health cost will increase by one JOD (0.71 USD). CONCLUSION: Healthcare providers, including nurses, should significantly consider these factors to reduce the health costs for those at-risk patients by providing the appropriate healthcare on time.
Asunto(s)
Cateterismo Cardíaco , Enfermedad de la Arteria Coronaria , Obesidad , Humanos , Masculino , Femenino , Enfermedad de la Arteria Coronaria/economía , Cateterismo Cardíaco/economía , Persona de Mediana Edad , Jordania , Anciano , Costos de la Atención en Salud/estadística & datos numéricos , AdultoRESUMEN
BACKGROUND: Transcatheter mitral valve replacement (TMVR) has garnered interest as a viable alternative to the traditional surgical mitral valve replacement (SMVR) for high-risk patients requiring redo operations. This study aims to evaluate the association of TMVR with selected clinical and financial outcomes. METHODS: Adults undergoing isolated redo mitral valve replacement were identified in the 2016-2020 Nationwide Readmissions Database and categorized into TMVR or SMVR cohorts. Various regression models were developed to assess the association between TMVR and in-hospital mortality, as well as additional secondary outcomes. Transseptal and transapical catheter-based approaches were also compared in relation to study endpoints. RESULTS: Of an estimated 7,725 patients, 2,941 (38.1%) underwent TMVR. During the study period, the proportion of TMVR for redo operations increased from 17.8% to 46.7% (nptrend<0.001). Following adjustment, TMVR was associated with similar odds of in-hospital mortality (AOR 0.82, p = 0.48), but lower odds of stroke (AOR 0.44, p = 0.001), prolonged ventilation (AOR 0.43, p<0.001), acute kidney injury (AOR 0.61, p<0.001), and reoperation (AOR 0.29, p = 0.02). TMVR was additionally correlated with shorter postoperative length of stay (pLOS; ß -0.98, p<0.001) and reduced costs (ß -$10,100, p = 0.002). Additional analysis demonstrated that the transseptal approach had lower adjusted mortality (AOR 0.44, p = 0.02), shorter adjusted pLOS (ß -0.43, p<0.001), but higher overall costs (ß $5,200, p = 0.04), compared to transapical. CONCLUSIONS: In this retrospective cohort study, we noted TMVR to yield similar odds of in-hospital mortality as SMVR, but fewer complications and reduced healthcare expenditures. Moreover, transseptal approaches were associated with lower adjusted mortality, shorter pLOS, but higher cost, relative to the transapical. Our findings suggest that TMVR represent a cost-effective and safe treatment modality for patients requiring redo mitral valve procedures. Nevertheless, future studies examining long-term outcomes associated with SMVR and TMVR in redo mitral valve operations, are needed.
Asunto(s)
Implantación de Prótesis de Válvulas Cardíacas , Mortalidad Hospitalaria , Válvula Mitral , Humanos , Masculino , Femenino , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Implantación de Prótesis de Válvulas Cardíacas/métodos , Implantación de Prótesis de Válvulas Cardíacas/economía , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Anciano , Válvula Mitral/cirugía , Persona de Mediana Edad , Reoperación/estadística & datos numéricos , Cateterismo Cardíaco/métodos , Cateterismo Cardíaco/economía , Cateterismo Cardíaco/efectos adversos , Cateterismo Cardíaco/mortalidad , Estudios Retrospectivos , Tiempo de Internación , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/etiología , Anciano de 80 o más Años , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Coronary functional testing to formally diagnose coronary microvascular dysfunction (CMD) reduces cardiovascular events and alleviates angina. This study aims to investigate the extensive and complex journey that patients with CMD undergo, from the onset of chest pain to eventual diagnosis. METHODS: Data from the Coronary Microvascular Disease Registry (CMDR) were analyzed, including information on the date of first documentation of chest pain, number of non-invasive and invasive tests the patient underwent, emergency department visits, and hospitalizations. In addition, we estimated the total cost per patient. A total of 61 patients with CMD diagnosis were included in this analysis. RESULTS: Most patients in our cohort were older than 50 years of age. The median time from initial chest pain symptoms to diagnosis was 0.62 (interquartile range [IQR]: 0.06-2.96) years. During this period, patients visited the emergency department a median of 1.0 (IQR: 0.0-2.0) times. Diagnostic tests included 3.0 (IQR: 2.0-6.0) electrocardiograms, 3.0 (IQR: 0.0-6.0) high-sensitivity troponin tests, and 1.0 (IQR: 1.0-2.0) echocardiograms. Prior to diagnosis of CMD, 13 (21.3 %) patients had left heart catheterization without coronary functional testing. Non-invasive testing for ischemia was conducted in 43 (70.5 %) patients. Alternative non-cardiac diagnoses were given to 11 (18.0 %) patients during the diagnostic process, with referrals made to gastroenterology for 16 (26.2 %) and pulmonology for 10 (16.4 %) patients. The cost was almost $2000/patient. CONCLUSION: Timely identification of CMD offers promising opportunities for prompt symptom alleviation, accompanied by reduced visits to the emergency department, cardiovascular testing, invasive medical procedures, and consequently reduced healthcare expenses.
Asunto(s)
Circulación Coronaria , Servicio de Urgencia en Hospital , Microcirculación , Valor Predictivo de las Pruebas , Sistema de Registros , Humanos , Persona de Mediana Edad , Masculino , Femenino , Factores de Tiempo , Anciano , Servicio de Urgencia en Hospital/economía , Enfermedad de la Arteria Coronaria/economía , Enfermedad de la Arteria Coronaria/fisiopatología , Enfermedad de la Arteria Coronaria/diagnóstico , Enfermedad de la Arteria Coronaria/complicaciones , Enfermedad de la Arteria Coronaria/terapia , Costos de Hospital , Angina de Pecho/economía , Angina de Pecho/diagnóstico , Angina de Pecho/fisiopatología , Angina de Pecho/terapia , Análisis Costo-Beneficio , Electrocardiografía/economía , Adulto , Pruebas de Función Cardíaca/economía , Biomarcadores/sangre , Cateterismo Cardíaco/economía , Pronóstico , Costos de la Atención en Salud , Dolor en el Pecho/diagnóstico , Dolor en el Pecho/etiología , Dolor en el Pecho/economíaRESUMEN
INTRODUCTION: We conducted the first comprehensive evaluation of the therapeutic value and safety profile of transcatheter mitral edge-to-edge repair (TEER) and transcatheter mitral valve replacement (TMVR) in individuals concurrently afflicted with cancer. METHODS: Utilizing the National Inpatient Sample (NIS) dataset, we analyzed all adult hospitalizations between 2016 and 2020 (n = 148,755,036). The inclusion criteria for this retrospectively analyzed prospective cohort study were all adult hospitalizations (age 18 years and older). Regression and machine learning analyses in addition to model optimization were conducted using ML-PSr (Machine Learning-augmented Propensity Score adjusted multivariable regression) and BAyesian Machine learning-augmented Propensity Score (BAM-PS) multivariable regression. RESULTS: Of all adult hospitalizations, there were 5790 (0.004%) TMVRs and 1705 (0.001%) TEERs. Of the total TMVRs, 160 (2.76%) were done in active cancer. Of the total TEERs, 30 (1.76%) were done in active cancer. After the comparable rates of TEER/TMVR in active cancer in 2016, the prevalence of TEER/TMVR was significantly less in active cancer from 2017 to 2020 (2.61% versus 7.28% p < 0.001). From 2017 to 2020, active cancer significantly decreased the odds of receiving TEER or TMVR (OR 0.28, 95%CI 0.13-0.68, p = 0.008). In patients with active cancer who underwent TMVR/TEER, there were no significant differences in socio-economic disparities, mortality or total hospitalization costs. CONCLUSION: The presence of malignancy does not contribute to increased mortality, length of stay or procedural costs in TMVR or TEER. Whereas the prevalence of TMVR has increased in patients with active cancer, the utilization of TEER in the context of active cancer is declining despite a growing patient population.
Asunto(s)
Inteligencia Artificial , Implantación de Prótesis de Válvulas Cardíacas , Insuficiencia de la Válvula Mitral , Neoplasias , Puntaje de Propensión , Humanos , Masculino , Femenino , Neoplasias/cirugía , Neoplasias/economía , Neoplasias/mortalidad , Neoplasias/epidemiología , Anciano , Implantación de Prótesis de Válvulas Cardíacas/economía , Implantación de Prótesis de Válvulas Cardíacas/métodos , Implantación de Prótesis de Válvulas Cardíacas/tendencias , Persona de Mediana Edad , Inteligencia Artificial/economía , Inteligencia Artificial/tendencias , Prevalencia , Insuficiencia de la Válvula Mitral/cirugía , Insuficiencia de la Válvula Mitral/economía , Estados Unidos/epidemiología , Estudios Retrospectivos , Cateterismo Cardíaco/economía , Estudios Prospectivos , Adulto , Anciano de 80 o más Años , Disparidades en Atención de Salud/economía , Disparidades en Atención de Salud/tendencias , Estudios de CohortesRESUMEN
AIMS: The long-term cost-effectiveness of MitraClip in heart failure patients with secondary mitral regurgitation is still unclear. This study aimed to evaluate the long-term cost-effectiveness of MitraClip added to guideline-directed medical therapy vs. guideline-directed medical therapy alone in heart failure patients with secondary mitral regurgitation from the perspective of the healthcare systems of mainland China, the United Kingdom, Germany, and the United States. METHODS AND RESULTS: A two-stage (decision + Markov) model was built. Health utilities were defined by the New York Heart Association class, heart failure re-hospitalization, and death and were calculated based on the 5 year follow-up results of the Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation trial. Direct healthcare costs were derived from the nationally representative data. Future utilities and costs were discounted at country-specific rates. The primary outcome was the lifetime incremental cost-effectiveness ratio. The mean age of the base case in our model was 72.2 years. Over a lifetime horizon, treatment with MitraClip was associated with 829 fewer heart failure re-hospitalizations per 1000 treated patients. The MitraClip treatment was associated with incremental quality-adjusted life-year gains of 0.71, 0.76, 0.78, and 0.78, as well as incremental cost-effectiveness ratios of ¥468 462, £28 910, 26 045, and $71 199 per quality-adjusted life-year for a lifetime horizon in mainland China, the United Kingdom, Germany, and the United States, respectively. In probabilistic sensitivity analysis, 0.2%, 59.4%, 99.6%, and 84.7% of patients were cost-effective in mainland China, the United Kingdom, Germany, and the United States at the country-specific willingness-to-pay thresholds. CONCLUSIONS: MitraClip + guideline-directed medical therapy was cost-effective in heart failure patients with secondary mitral regurgitation in the United Kingdom, Germany, and the United States, but not in mainland China from the perspective of the national healthcare system.
Asunto(s)
Cateterismo Cardíaco , Análisis Costo-Beneficio , Insuficiencia Cardíaca , Insuficiencia de la Válvula Mitral , Humanos , Insuficiencia de la Válvula Mitral/economía , Insuficiencia de la Válvula Mitral/cirugía , Insuficiencia de la Válvula Mitral/complicaciones , Insuficiencia Cardíaca/complicaciones , Insuficiencia Cardíaca/terapia , Insuficiencia Cardíaca/economía , Masculino , Anciano , Femenino , Cateterismo Cardíaco/métodos , Cateterismo Cardíaco/economía , Implantación de Prótesis de Válvulas Cardíacas/economía , Implantación de Prótesis de Válvulas Cardíacas/métodos , Válvula Mitral/cirugía , Factores de Tiempo , Estudios de Seguimiento , Reino Unido/epidemiología , Estados Unidos/epidemiología , Años de Vida Ajustados por Calidad de Vida , China/epidemiologíaRESUMEN
Importance: Differences in the organization and financing of health systems may produce more or less equitable outcomes for advantaged vs disadvantaged populations. We compared treatments and outcomes of older high- and low-income patients across 6 countries. Objective: To determine whether treatment patterns and outcomes for patients presenting with acute myocardial infarction differ for low- vs high-income individuals across 6 countries. Design, Setting, and Participants: Serial cross-sectional cohort study of all adults aged 66 years or older hospitalized with acute myocardial infarction from 2013 through 2018 in the US, Canada, England, the Netherlands, Taiwan, and Israel using population-representative administrative data. Exposures: Being in the top and bottom quintile of income within and across countries. Main Outcomes and Measures: Thirty-day and 1-year mortality; secondary outcomes included rates of cardiac catheterization and revascularization, length of stay, and readmission rates. Results: We studied 289â¯376 patients hospitalized with ST-segment elevation myocardial infarction (STEMI) and 843â¯046 hospitalized with non-STEMI (NSTEMI). Adjusted 30-day mortality generally was 1 to 3 percentage points lower for high-income patients. For instance, 30-day mortality among patients admitted with STEMI in the Netherlands was 10.2% for those with high income vs 13.1% for those with low income (difference, -2.8 percentage points [95% CI, -4.1 to -1.5]). One-year mortality differences for STEMI were even larger than 30-day mortality, with the highest difference in Israel (16.2% vs 25.3%; difference, -9.1 percentage points [95% CI, -16.7 to -1.6]). In all countries, rates of cardiac catheterization and percutaneous coronary intervention were higher among high- vs low-income populations, with absolute differences ranging from 1 to 6 percentage points (eg, 73.6% vs 67.4%; difference, 6.1 percentage points [95% CI, 1.2 to 11.0] for percutaneous intervention in England for STEMI). Rates of coronary artery bypass graft surgery for patients with STEMI in low- vs high-income strata were similar but for NSTEMI were generally 1 to 2 percentage points higher among high-income patients (eg, 12.5% vs 11.0% in the US; difference, 1.5 percentage points [95% CI, 1.3 to 1.8 ]). Thirty-day readmission rates generally also were 1 to 3 percentage points lower and hospital length of stay generally was 0.2 to 0.5 days shorter for high-income patients. Conclusions and Relevance: High-income individuals had substantially better survival and were more likely to receive lifesaving revascularization and had shorter hospital lengths of stay and fewer readmissions across almost all countries. Our results suggest that income-based disparities were present even in countries with universal health insurance and robust social safety net systems.
Asunto(s)
Infarto del Miocardio , Humanos , Puente de Arteria Coronaria/economía , Puente de Arteria Coronaria/estadística & datos numéricos , Estudios Transversales , Infarto del Miocardio/economía , Infarto del Miocardio/epidemiología , Infarto del Miocardio/mortalidad , Infarto del Miocardio/terapia , Infarto del Miocardio sin Elevación del ST/economía , Infarto del Miocardio sin Elevación del ST/epidemiología , Infarto del Miocardio sin Elevación del ST/mortalidad , Infarto del Miocardio sin Elevación del ST/terapia , Infarto del Miocardio con Elevación del ST/economía , Infarto del Miocardio con Elevación del ST/epidemiología , Infarto del Miocardio con Elevación del ST/mortalidad , Infarto del Miocardio con Elevación del ST/terapia , Resultado del Tratamiento , Factores Socioeconómicos , Pobreza/economía , Pobreza/estadística & datos numéricos , Anciano , Hospitalización/economía , Hospitalización/estadística & datos numéricos , Readmisión del Paciente/economía , Readmisión del Paciente/estadística & datos numéricos , Revascularización Miocárdica/economía , Revascularización Miocárdica/estadística & datos numéricos , Cateterismo Cardíaco/economía , Cateterismo Cardíaco/estadística & datos numéricos , Tiempo de Internación/economía , Tiempo de Internación/estadística & datos numéricos , InternacionalidadRESUMEN
OBJECTIVES: Patent foramen ovale is a hemodynamically insignificant interatrial communication that may cause ischemic stroke. Percutaneous patent foramen ovale closure reduces the risk for recurrent ischemic stroke in patients with a history of cryptogenic ischemic stroke. This study evaluated the cost-effectiveness of patent foramen ovale closure against medical therapy in patients after their first cryptogenic ischemic stroke in Japan. MATERIALS AND METHODS: The cost-effectiveness of patent foramen ovale closure compared with medical therapy was evaluated using the Markov model. The target patients started with patent foramen ovale closure or medical therapy for preventing secondary ischemic stroke under a stable state. Quality-adjusted life year was used as the outcome of effectiveness, and the analysis was conducted with a discount rate of 2% applied to both cost and effectiveness. The results of a multicenter open-label randomized controlled trial (RESPECT trial) evaluating patent foramen ovale closure using the Amplatzer™ PFO Occluder were used as clinical evidence. Cost-effectiveness was evaluated using the incremental cost-effectiveness ratio. It was evaluated as cost-effective if it was lower than 5 million JPY/ quality-adjusted life year. RESULTS: Patent foramen ovale closure was dominant over medical therapy by 2.53 quality-adjusted life years and an estimated cost reduction of 2,353,926 JPY. The probability of patent foramen ovale closure being dominant was 82.9%. CONCLUSIONS: Patent foramen ovale closure was dominant over medical therapy for preventing secondary ischemic stroke in patients with cryptogenic ischemic stroke.
Asunto(s)
Cateterismo Cardíaco/economía , Foramen Oval Permeable/economía , Foramen Oval Permeable/terapia , Costos de la Atención en Salud , Accidente Cerebrovascular Isquémico/economía , Accidente Cerebrovascular Isquémico/prevención & control , Dispositivo Oclusor Septal/economía , Cateterismo Cardíaco/efectos adversos , Cateterismo Cardíaco/instrumentación , Ahorro de Costo , Análisis Costo-Beneficio , Femenino , Foramen Oval Permeable/complicaciones , Foramen Oval Permeable/diagnóstico por imagen , Humanos , Accidente Cerebrovascular Isquémico/diagnóstico por imagen , Accidente Cerebrovascular Isquémico/etiología , Japón , Masculino , Cadenas de Markov , Persona de Mediana Edad , Modelos Económicos , Calidad de Vida , Años de Vida Ajustados por Calidad de Vida , Ensayos Clínicos Controlados Aleatorios como Asunto , Resultado del TratamientoRESUMEN
INTRODUCTION: The aim of this study was to provide an economic assessment of interventional vs. surgical aortic valve replacement in the context of cost-effectiveness. Aortic stenosis represents the most common form of degenerative valvular heart diseases. As life expectancy increases, an even emerging prevalence is expected. Over decades, surgical replacement was considered as the method of choice. Up to one third of the patients were not eligible for surgery, as their estimated peri-operative risk was too high. In the early 2000s a catheter-based technique has been developed, being an alternative treatment option for patients, considered to be inoperable. EVIDENCE ACQUISITION: A systematic analysis of current literature was performed from September 2018 to December 2018. All suitable data in the field was obtained from Pubmed and Google/Google scholar. The search terms "TAVI AND costs," "TAVR and costs" and "aortic valve replacement AND costs" was entered in the search field, showing an overall amount of 317 publications. In a next step all obtained publications were screened by expert hand selection. EVIDENCE SYNTHESIS: Recently the Food and Drug Association (FDA) approved transcatheter aortic valve replacement (TAVR) in the low-risk setting. Nevertheless, concerns on the higher price remain. We performed an analysis of current literature on aortic stenosis and economic aspects. Out of 322 screened publications, 7 studies were found eligible by expert hand selection. Based on the predefined payment readiness of the analyzed healthcare system, TAVR appeared to have a slightly better cost effectiveness. Initial results within the early era seemed to be inconsistent. Recent publications showed, TAVR might be of more cost effectiveness when using the newest generation devices and a profound clinical experience is guaranteed. CONCLUSIONS: We assume, that TAVR will not only be the method of choice for the treatment of aortic stenosis in many patients. As the valves are getting cheaper, TAVR might even be superior to conventional heart surgery from an economic point of view.
Asunto(s)
Estenosis de la Válvula Aórtica/cirugía , Válvula Aórtica/cirugía , Cateterismo Cardíaco/economía , Arteria Femoral , Implantación de Prótesis de Válvulas Cardíacas/economía , Reemplazo de la Válvula Aórtica Transcatéter/economía , Cateterismo Cardíaco/métodos , Análisis Costo-Beneficio , Implantación de Prótesis de Válvulas Cardíacas/métodos , Humanos , Años de Vida Ajustados por Calidad de VidaRESUMEN
OBJECTIVES: Coronavirus 2019 (COVID-19) significantly impacted cardiac care delivery in a manner that has not been previously experienced in the United States. Attention and resources have focused on physicians, patients, and healthcare systems with little information regarding the effects on nurses and technologists in the cardiac catheterization laboratory (CCL). METHODS: A national, online survey was conducted for nurses and technologists working in the CCL in the United States. The survey was self administered, anonymous, and included 45 questions assessing baseline demographics, logistical changes to workflow and responsibilities, staff preparedness, and mental health. RESULTS: A total of 450 respondents completed the survey, including 283 nurses (63%) and 167 technologists (37%). A total of 349 (78%) were female and mean age range was 41-50 years. Responses indicated that 68% were the primary financial provider for their families, and 74% experienced >75% decrease in case volume despite a low inpatient COVID-19 census (54% of respondents with census <10%). There were high rates of direct care for COVID-19 patients (47%), relocation (45%), lay-off/furloughs of part-time or per diem staff (42%), lay-offs of full-time staff (12%), and decreased work hours (65%). A total of 95% expressed decreased morale with an increase in mental distress, including depression (36%). Predictors of depression included relocation status, staff preparedness, and work hours. CONCLUSION: Logistical changes to CCL staffing resulted in relocation, lay-offs, furloughs, and diminished work hours, with financial and emotional ramifications. Particular attention should be paid to those in large urban hospitals, those at risk for relocation, layoffs, and furloughs, and when preparedness and administrative communication is perceived as poor.
Asunto(s)
COVID-19/epidemiología , Cateterismo Cardíaco/economía , Costos de la Atención en Salud , Cardiopatías/diagnóstico , Pandemias/economía , Vigilancia de la Población/métodos , Adulto , Cateterismo Cardíaco/enfermería , Comorbilidad , Estudios Transversales , Femenino , Cardiopatías/economía , Cardiopatías/epidemiología , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , SARS-CoV-2 , Estados Unidos/epidemiologíaRESUMEN
One of the most frequent causes of cardiac embolism in cryptogenic stroke is a paradoxical embolus, which originate from systemic venous source though an unidentified patent foramen ovale (PFO). PFO is a common finding in the general population with a prevalence of 25% to 30%. Transcatheter PFO device closure is known to be feasible and safety treatment for such patients. In recent years, several randomized controlled trials (RCTs) have been conducted to address the superiority of PFO closure over medical therapy alone in the prevention of stroke recurrence in patients with PFO. In contrast to findings from early 3 RCTs, recent 4 RCTs could successfully show the benefits of PFO device closure compared with medical therapy, with less peri- and postprocedural complication. Based on these data, PFO device closure is recommended to carefully select cryptogenic stroke patients aged from 18 to 65 years, with a high probability of a causal role of the PFO in stroke events. However, it is still uncertain whether PFO closure is superior to oral anticoagulants therapy in these patients. Therefore, further prospective randomized trials are needed to address the efficacy of PFO device closure to oral anticoagulants therapy.
Asunto(s)
Cateterismo Cardíaco/instrumentación , Foramen Oval Permeable/complicaciones , Foramen Oval Permeable/cirugía , Accidente Cerebrovascular Isquémico/etiología , Dispositivo Oclusor Septal , Cateterismo Cardíaco/efectos adversos , Cateterismo Cardíaco/economía , Análisis Costo-Beneficio , Foramen Oval Permeable/tratamiento farmacológico , Humanos , Accidente Cerebrovascular Isquémico/prevención & control , Inhibidores de Agregación Plaquetaria/uso terapéutico , Complicaciones Posoperatorias , Prevención SecundariaRESUMEN
BACKGROUND: Surgical aortic valve replacement (SAVR) is the conventional treatment in patients at low or intermediate surgical risk. Transcatheter aortic valve implantation (TAVI) is a less invasive procedure, originally developed as an alternative for patients at high or prohibitive surgical risk. METHODS: We conducted a health technology assessment of TAVI versus SAVR in patients with severe, symptomatic aortic valve stenosis at intermediate surgical risk, which included an evaluation of effectiveness, safety, cost-effectiveness, budget impact, and patient preferences and values. We performed a literature search to retrieve systematic reviews and selected one that was relevant to our research question. We complemented the systematic review with a literature search to identify randomized controlled trials published after the review. Applicable, previously published cost-effectiveness analyses were available, so we did not conduct a primary economic evaluation. We analyzed the net budget impact of publicly funding TAVI in people at intermediate surgical risk in Ontario. To contextualize the potential value of TAVI for people at intermediate surgical risk, we spoke with people who had aortic valve stenosis and their families. RESULTS: We identified two randomized controlled trials; they found that in patients with severe, symptomatic aortic valve stenosis, TAVI was noninferior to SAVR with respect to the composite endpoint of all-cause mortality or disabling stroke within 2 years of follow-up (GRADE: High). However, compared with SAVR, TAVI had a higher risk of some complications and a lower risk of others. Device-related costs for TAVI (approximately $23,000) are much higher than for SAVR (approximately $6,000). Based on two published cost-effectiveness analyses conducted from the perspective of the Ontario Ministry of Health, TAVI was more expensive and, on average, more effective (i.e., it produced more quality-adjusted life-years) than SAVR. The incremental cost-effectiveness ratios showed that TAVI may be cost-effective, but the probability of TAVI being cost-effective versus SAVR was less than 60% at a willingness-to-pay value of $100,000 per quality-adjusted life-year. The net budget impact of publicly funding TAVI in Ontario would be about $2 million to $3 million each year for the next 5 years. This cost may be reduced if people receiving TAVI have a shorter hospital stay (≤ 3 days). We interviewed 13 people who had lived experience with aortic valve stenosis. People who had undergone TAVI reported reduced physical and psychological effects and a shorter recovery time. Patients and caregivers living in remote or northern regions reported lower out-of-pocket costs with TAVI because the length of hospital stay was reduced. People said that TAVI increased their quality of life in the short-term immediately after the procedure. CONCLUSIONS: In people with severe, symptomatic aortic valve stenosis at intermediate surgical risk, TAVI was similar to SAVR with respect to the composite endpoint of all-cause mortality or disabling stroke. However, the two treatments had different patterns of complications. The study authors also noted that longer follow-up is needed to assess the durability of the TAVI valve. Compared with SAVR, TAVI may provide good value for money, but publicly funding TAVI in Ontario would result in additional costs over the next 5 years. People with aortic valve stenosis who had undergone TAVI appreciated its less invasive nature and reported a substantial reduction in physical and psychological effects after the procedure, improving their quality of life.
Asunto(s)
Estenosis de la Válvula Aórtica/economía , Estenosis de la Válvula Aórtica/cirugía , Cateterismo Cardíaco/economía , Reemplazo de la Válvula Aórtica Transcatéter/economía , Válvula Aórtica/cirugía , Cateterismo Cardíaco/estadística & datos numéricos , Femenino , Humanos , Masculino , Años de Vida Ajustados por Calidad de Vida , Ensayos Clínicos Controlados Aleatorios como Asunto , Índice de Severidad de la Enfermedad , Medicina Estatal/economía , Evaluación de la Tecnología Biomédica/economía , Reemplazo de la Válvula Aórtica Transcatéter/estadística & datos numéricos , Resultado del TratamientoRESUMEN
OBJECTIVES: To assess national trends of acute kidney injury (AKI) incidence, incremental costs, risk factors, and readmissions among patients undergoing coronary angiography (CAG) and/or percutaneous coronary intervention (PCI) during 2012-2017. BACKGROUND: AKI remains a serious complication for patients undergoing CAG/PCI. Evidence is lacking in contemporary AKI trends and its impact on hospital resource utilization. METHODS: Patients who underwent CAG/PCI procedures in 749 hospitals were identified from Premier Healthcare Database. AKI was defined by ICD-9/10 diagnosis codes (584.9/N17.9, 583.89/N14.1, 583.9/N05.9, E947.8/T50.8X5) during 7 days post index procedure. Multivariable regression models were used to adjust for confounders. RESULTS: Among 2,763,681 patients, AKI incidence increased from 6.0 to 8.4% or 14% per year in overall patients; from 18.0 to 28.4% in those with chronic kidney disease (CKD) and from 2.4 to 4.2% in those without CKD (all p < .001). Significant risk factors for AKI included older age, being uninsured, inpatient procedures, CKD, anemia, and diabetes (all p < .001). AKI was associated with higher 30-day in-hospital mortality (ORadjusted = 2.55; 95% CI: 2.40, 2.70) and readmission risk (ORadjusted = 1.52; 95% CI: 1.50, 1.55). The AKI-related incremental cost during index visit and 30-day readmissions were estimated to be $8,416 and $580 per inpatient procedure and $927 and $6,145 per outpatient procedure. Overall excess healthcare burden associated with AKI was $1.67 billion. CONCLUSIONS: AKI incidence increased significantly in this large, multifacility sample of patients undergoing CAG/PCI procedures and was associated with substantial increase in hospital costs, readmissions, and mortality. Efforts to reduce AKI risk in US healthcare system are warranted.
Asunto(s)
Lesión Renal Aguda/epidemiología , Cateterismo Cardíaco/tendencias , Angiografía Coronaria/tendencias , Costos de la Atención en Salud/tendencias , Intervención Coronaria Percutánea/tendencias , Lesión Renal Aguda/economía , Lesión Renal Aguda/terapia , Anciano , Anciano de 80 o más Años , Cateterismo Cardíaco/efectos adversos , Cateterismo Cardíaco/economía , Angiografía Coronaria/efectos adversos , Angiografía Coronaria/economía , Bases de Datos Factuales , Femenino , Costos de Hospital/tendencias , Humanos , Incidencia , Tiempo de Internación/economía , Tiempo de Internación/tendencias , Masculino , Persona de Mediana Edad , Readmisión del Paciente/economía , Readmisión del Paciente/tendencias , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/economía , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
Transesophageal echocardiography (TEE) under general anesthesia (GA) or intracardiac echocardiography (ICE) under sedation is usually used for echocardiographic guidance during transcatheter atrial septal defect (ASD) closure. However, appropriate selection of guidance has not been fully established. Our study aimed to evaluate whether selection of guidance depending on anatomic ASD features and TEE tolerability under sedation contributes to procedure success. On the basis of anatomic ASD characteristics and TEE tolerability under sedation during the pre-procedural TEE, we selected either TEE, ICE, or combined TEE and ICE under moderate-to-deep sedation or TEE under GA for guidance. Anatomic characteristics of the defect, medical costs, complications, and primary outcomes for these four different types of guidance were analyzed. A total of 154 patients were classified into four guidance groups depending on the results of diagnostic TEE under sedation; 11 patients were scheduled for the procedure under GA in advance. Procedures were successfully completed in all but two patients in whom closure guided by TEE under sedation was attempted for an extremely large defect or extensive superior rim deficiency. Two patients who underwent TEE or combined TEE and ICE guidance under sedation were converted to ICE-only guidance due to desaturation or excessive body movement. Device dislodgement was not observed during the procedure or during median follow-up of 1188 days [interquartile range 577-1831]. Appropriate selection of guidance might contribute to successful transcatheter ASD closure.
Asunto(s)
Cateterismo Cardíaco , Ecocardiografía Transesofágica , Defectos del Tabique Interatrial/terapia , Adolescente , Adulto , Anciano , Anestesia General , Cateterismo Cardíaco/efectos adversos , Cateterismo Cardíaco/economía , Cateterismo Cardíaco/instrumentación , Niño , Preescolar , Toma de Decisiones Clínicas , Sedación Consciente , Sedación Profunda , Ecocardiografía Transesofágica/economía , Femenino , Defectos del Tabique Interatrial/diagnóstico por imagen , Defectos del Tabique Interatrial/economía , Defectos del Tabique Interatrial/fisiopatología , Costos de Hospital , Humanos , Masculino , Persona de Mediana Edad , Selección de Paciente , Valor Predictivo de las Pruebas , Dispositivo Oclusor Septal , Resultado del Tratamiento , Adulto JovenRESUMEN
OBJECTIVES: The aim of this study was to compare optical coherence tomographic (OCT) guidance and fractional flow reserve (FFR) guidance in patients with angiographically intermediate coronary lesions (AICLs) in a single-center, prospective, 1:1 randomized trial. BACKGROUND: FFR and OCT imaging may help both in the assessment of AICLs and in percutaneous coronary intervention optimization. METHODS: Patients with AICLs were randomized to FFR or OCT imaging. In the FFR arm, PCI was performed if FFR was ≤0.80. In the OCT imaging arm, PCI was performed if area stenosis was ≥75% or 50% to 75% with minimal luminal area <2.5 mm2 or plaque rupture. Angina (evaluated using the Seattle Angina Questionnaire), major adverse cardiac events, and cost were assessed at the end of follow-up. The pre-defined primary endpoint was the composite of major adverse cardiac events or significant angina (defined as Seattle Angina Questionnaire frequency scale score <90) at 13 months. RESULTS: A total of 350 patients (with 446 AICLs) were enrolled (176 randomized to FFR and 174 to OCT imaging). The primary endpoint of major adverse cardiac events or significant angina at 13 months occurred in 14.8% of patients in the FFR arm and in 8.0% in the OCT imaging arm (p = 0.048). This result was driven by a statistically nonsignificant lower occurrence of all primary endpoint components. Up to 13 months, the rate of medically managed patients was significantly higher (p < 0.001) and total cost significantly lower (p < 0.001) with FFR in comparison with OCT imaging. CONCLUSIONS: In patients with AICLs, OCT guidance is associated with lower occurrence of the composite of major adverse cardiac events or significant angina. FFR guidance is associated with a higher rate of medical management and lower costs. FFR or OCT Guidance to Revascularize Intermediate Coronary Stenosis Using Angioplasty [FORZA]; NCT01824030).
Asunto(s)
Cateterismo Cardíaco , Fármacos Cardiovasculares/uso terapéutico , Estenosis Coronaria/diagnóstico por imagen , Estenosis Coronaria/terapia , Reserva del Flujo Fraccional Miocárdico/efectos de los fármacos , Intervención Coronaria Percutánea , Tomografía de Coherencia Óptica , Anciano , Cateterismo Cardíaco/economía , Fármacos Cardiovasculares/efectos adversos , Fármacos Cardiovasculares/economía , Toma de Decisiones Clínicas , Estenosis Coronaria/economía , Estenosis Coronaria/fisiopatología , Ahorro de Costo , Análisis Costo-Beneficio , Femenino , Costos de la Atención en Salud , Humanos , Masculino , Persona de Mediana Edad , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/economía , Valor Predictivo de las Pruebas , Estudios Prospectivos , Reproducibilidad de los Resultados , Ciudad de Roma , Índice de Severidad de la Enfermedad , Factores de Tiempo , Tomografía de Coherencia Óptica/economía , Resultado del TratamientoRESUMEN
BACKGROUND: There are limited data on the use of intravascular ultrasound (IVUS), optical coherence tomography (OCT), and fractional flow reserve (FFR) during acute myocardial infarction (AMI). OBJECTIVES: To assess the temporal trends of IVUS, OCT, and FFR use in AMI. METHODS: A retrospective cohort study from the National Inpatient Sample (2004-2014) was designed to include AMI admissions that received coronary angiography. Administrative codes were used to identify percutaneous coronary intervention (PCI), IVUS, OCT, and FFR. Outcomes included temporal trends, inhospital mortality and resource utilization stratified by IVUS, OCT, or FFR use. RESULTS: In 4,419,973 AMI admissions, IVUS, OCT, and FFR were used in 2.6%, 0.1%, and 0.6%, respectively. There was a 22-fold, 118-fold, and 33-fold adjusted increase in IVUS, OCT, and FFR use, respectively, in 2014 compared to the first year of use. Non-ST-elevation AMI presentation, male sex, private insurance coverage, admission to a large urban hospital, and absence of cardiac arrest and cardiogenic shock were associated with higher IVUS, OCT, or FFR use. PCI was performed in 83.2% of the IVUS, OCT, or FFR cohort compared to 64.2% of the control group (p < .001). The cohort with IVUS/OCT/FFR use had lower inhospital mortality (adjusted odds ratio 0.53 [95% confidence interval 0.50-0.56]), more frequent discharges to home (83.7% vs. 76.8%), shorter hospital stays (4.3 ± 4.4 vs. 5.0 ± 5.5 days) and higher hospitalization costs ($90,683 ± 74,093 vs. $74,671 ± 75,841). CONCLUSIONS: In AMI, the use of IVUS, OCT, and FFR has increased during 2004-2014. Significant patient and hospital-level disparities exist in the use of these technologies.
Asunto(s)
Cateterismo Cardíaco/tendencias , Reserva del Flujo Fraccional Miocárdico , Infarto del Miocardio/diagnóstico por imagen , Infarto del Miocardio/fisiopatología , Tomografía de Coherencia Óptica/tendencias , Ultrasonografía Intervencional/tendencias , Anciano , Cateterismo Cardíaco/economía , Angiografía Coronaria/tendencias , Bases de Datos Factuales , Femenino , Disparidades en Atención de Salud/tendencias , Costos de Hospital/tendencias , Mortalidad Hospitalaria/tendencias , Humanos , Pacientes Internos , Tiempo de Internación/tendencias , Masculino , Persona de Mediana Edad , Infarto del Miocardio/mortalidad , Infarto del Miocardio/terapia , Alta del Paciente/tendencias , Intervención Coronaria Percutánea/tendencias , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Factores de Tiempo , Tomografía de Coherencia Óptica/economía , Resultado del Tratamiento , Ultrasonografía Intervencional/economía , Estados UnidosRESUMEN
This review summarizes the impact of transradial access for cardiac catheterization and percutaneous coronary intervention related to patient satisfaction, patient safety, and health care costs. In studies comparing transradial versus transfemoral approach, transradial access causes less bleeding and less vascular access site complications and provides a mortality benefit in patients with acute coronary syndromes. Transradial access improves patient satisfaction related to site tolerability by reducing pain and discomfort, and facilitating early ambulation with reduced length of stay. Taken in total, the existing randomized and observational data strongly support radial access for improved safety, patient satisfaction, and significant cost savings.
Asunto(s)
Cateterismo Cardíaco/economía , Cateterismo Cardíaco/métodos , Satisfacción del Paciente , Intervención Coronaria Percutánea/economía , Intervención Coronaria Percutánea/métodos , Arteria Radial , Cateterismo Cardíaco/efectos adversos , Hemorragia/epidemiología , Hemorragia/etiología , Humanos , Intervención Coronaria Percutánea/efectos adversos , Medición de RiesgoAsunto(s)
Estenosis de la Válvula Aórtica/cirugía , Cateterismo Cardíaco/economía , Enfermedades de las Válvulas Cardíacas/economía , Implantación de Prótesis de Válvulas Cardíacas/economía , Reemplazo de la Válvula Aórtica Transcatéter/economía , Estenosis de la Válvula Aórtica/diagnóstico , Estenosis de la Válvula Aórtica/economía , Análisis Costo-Beneficio , Enfermedades de las Válvulas Cardíacas/patología , Enfermedades de las Válvulas Cardíacas/cirugía , Implantación de Prótesis de Válvulas Cardíacas/métodos , Humanos , Factores de Riesgo , Resultado del TratamientoRESUMEN
OBJECTIVES: This study investigated whether left ventricular (LV) stimulation via a guidewire-reduced procedure duration while maintaining efficacy and safety compared with standard right ventricular (RV) stimulation. BACKGROUND: Rapid ventricular pacing is necessary to ensure cardiac standstill during transcatheter aortic valve replacement (TAVR). METHODS: This is a prospective, multicenter, single-blinded, superiority, randomized controlled trial. Patients undergoing transfemoral TAVR with a SAPIEN valve (Edwards Lifesciences, Irvine, California) were allocated to LV or RV stimulation. The primary endpoint was procedure duration. Secondary endpoints included efficacy, safety, and cost at 30 days. RESULTS: Between May 2017 and May 2018, 307 patients were randomized, but 4 were excluded because they did not receive the intended treatment: 303 patients were analyzed in the LV (n = 151) or RV (n = 152) stimulation groups. Mean procedure duration was significantly shorter in the LV stimulation group (48.4 ± 16.9 min vs. 55.6 ± 26.9 min; p = 0.0013), with a difference of -0.12 (95% confidence interval: -0.20 to -0.05) in the log-transformed procedure duration (p = 0.0012). Effective stimulation was similar in the LV and RV stimulation groups: 124 (84.9%) versus 128 (87.1%) (p = 0.60). Safety of stimulation was also similar in the LV and RV stimulation groups: procedural success occurred in 151 (100%) versus 151 (99.3%) patients (p = 0.99); 30-day MACE-TAVR (major adverse cardiovascular event-transcatheter aortic valve replacement) occurred in 21 (13.9%) versus 26 (17.1%) patients (p = 0.44); fluoroscopy time (min) was lower in the LV stimulation group (13.48 ± 5.98 vs. 14.60 ± 5.59; p = 0.02), as was cost (18,807 ± 1,318 vs. 19,437 ± 2,318; p = 0.001). CONCLUSIONS: Compared with RV stimulation, LV stimulation during TAVR was associated with significantly reduced procedure duration, fluoroscopy time, and cost, with similar efficacy and safety. (Direct Left Ventricular Rapid Pacing Via the Valve Delivery Guide-wire in TAVR [EASY TAVI]; NCT02781896).
Asunto(s)
Válvula Aórtica/cirugía , Cateterismo Cardíaco/instrumentación , Catéteres Cardíacos , Estimulación Cardíaca Artificial , Prótesis Valvulares Cardíacas , Marcapaso Artificial , Reemplazo de la Válvula Aórtica Transcatéter/instrumentación , Función Ventricular Izquierda , Función Ventricular Derecha , Anciano , Anciano de 80 o más Años , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/fisiopatología , Cateterismo Cardíaco/efectos adversos , Cateterismo Cardíaco/economía , Catéteres Cardíacos/economía , Estimulación Cardíaca Artificial/efectos adversos , Estimulación Cardíaca Artificial/economía , Ahorro de Costo , Análisis Costo-Beneficio , Femenino , Francia , Prótesis Valvulares Cardíacas/economía , Costos de Hospital , Humanos , Masculino , Tempo Operativo , Marcapaso Artificial/economía , Estudios Prospectivos , Dosis de Radiación , Exposición a la Radiación/prevención & control , Factores de Riesgo , Método Simple Ciego , Factores de Tiempo , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Reemplazo de la Válvula Aórtica Transcatéter/economía , Resultado del TratamientoRESUMEN
BACKGROUND: Coronary angiography with two catheters is the traditional strategy for diagnostic coronary procedures. TIG I catheter permits to cannulate both coronary arteries, avoiding exchanging catheters during coronary angiography by transradial access. OBJECTIVE: The aim of this study is to evaluate the impact of one-catheter strategy, by avoiding catheter exchange, on coronary catheterization performance and economic costs. METHODS: Transradial coronary diagnostic procedures conducted from January 2013 to June 2017 were collected. One-catheter strategy (TIG I catheter) and two-catheter strategy (left and right Judkins catheters) were compared. The volume of iodinated contrast administered was the primary endpoint. Secondary endpoints included radial spasm, procedural duration (fluoroscopy time) and exposure to ionizing radiation (dose-area product and air kerma). Direct economic costs were also evaluated. For statistical analyses, two-tailed p-values < 0.05 were considered statistically significant. RESULTS: From a total of 1,953 procedures in 1,829 patients, 252 procedures were assigned to one-catheter strategy and 1,701 procedures to two-catheter strategy. There were no differences in baseline characteristics between the groups. One-catheter strategy required less iodinated contrast [primary endpoint; (60-105)-mL vs. 92 (64-120)-mL; p < 0.001] than the two-catheter strategy. Also, the one-catheter group presented less radial spasm (5.2% vs. 9.3%, p = 0.022) and shorter fluoroscopy time [3.9 (2.2-8.0)-min vs. 4.8 (2.9-8.3)-min, p = 0.001] and saved costs [149 (140-160)-/procedure vs. 171 (160-183)-/procedure; p < 0.001]. No differences in dose-area product and air kerma were detected between the groups. CONCLUSIONS: One-catheter strategy, with TIG I catheter, improves coronary catheterization performance and reduces economic costs compared to traditional two-catheter strategy in patients referred for coronary angiography.
Asunto(s)
Catéteres Cardíacos/economía , Angiografía Coronaria/métodos , Anciano , Cateterismo Cardíaco/economía , Cateterismo Cardíaco/instrumentación , Cateterismo Cardíaco/métodos , Medios de Contraste , Angiografía Coronaria/economía , Angiografía Coronaria/instrumentación , Ahorro de Costo/economía , Femenino , Fluoroscopía , Humanos , Masculino , Persona de Mediana Edad , Isquemia Miocárdica/diagnóstico por imagen , Arteria Radial/diagnóstico por imagen , Dosis de Radiación , Radiación Ionizante , Estudios Retrospectivos , Espasmo , Factores de TiempoRESUMEN
OBJECTIVES: The aim of this study was to assess the real-world impact of transcatheter mitral valve repair (TMVR) on hospitalizations and Medicare costs pre- versus post-TMVR. BACKGROUND: TMVR is effective in degenerative mitral regurgitation (MR) and appropriately selected patients with functional MR with high surgical risk. METHODS: Patients undergoing TMVR in the Society of Thoracic Surgeons/American College of Cardiology TVT (Transcatheter Valve Therapy) Registry from 2013 to 2018 were linked to Medicare claims data. Rates of hospitalizations, hospitalized days, and Medicare costs were compared 1-year pre-TMVR to 1-year post-TMVR. RESULTS: Across 246 sites, 4,970 patients with a median age of 83 years (interquartile range: 77 to 87 years) were analyzed. The TMVR indication was degenerative MR in 77.5% and functional MR in 16.7%. From pre- to post-TMVR, heart failure (HF) hospitalization rates (479 vs. 370 hospitalizations/1,000 person-years; rate ratio [RR]: 0.77) and cardiovascular hospitalizations (838 vs. 632; RR: 0.75) decreased significantly (p < 0.001 for all). Similarly, the rates of hospitalized days decreased for HF and cardiovascular causes (p < 0.05 for all). Following TMVR, the odds of having no Medicare costs for HF hospitalizations increased (69% vs. 79%; odds ratio: 1.67; p < 0.001). However, the average total Medicare costs per day alive among patients with any HF hospitalizations after TMVR increased significantly (p < 0.001). The HF hospitalization rates decreased for patients with functional MR (683 vs. 502; RR: 0.74) and those with degenerative MR (431 vs. 337; RR: 0.78) (p < 0.001). CONCLUSIONS: TMVR is associated with a decrease in cardiovascular and HF hospitalizations and a greater likelihood of having no HF Medicare costs in the year after TMVR, regardless of MR etiology. Further work is necessary to elucidate the reasons for increased costs among patients with HF hospitalizations post-TMVR.