Economic consequences of routine coronary angiography in low- and intermediate-risk patients with unstable angina pectoris

被引:2
作者
Desai, AS
Solomon, DH
Stone, PH
Avorn, J
机构
[1] Harvard Univ, Div Pharmacoepidemiol & Pharmacoecon, Dept Med, Brigham & Womens Hosp,Sch Med, Boston, MA 02120 USA
[2] Harvard Univ, Div Cardiovasc Med, Dept Med, Brigham & Womens Hosp,Sch Med, Boston, MA 02120 USA
关键词
D O I
10.1016/S0002-9149(03)00650-7
中图分类号
R5 [内科学];
学科分类号
1002 ; 100201 ;
摘要
In low- and intermediate-risk patients with unstable angina pectoris (UAP) and non-ST-elevation acute myocardial infarction (NSTEAMI), routine early invasive management with coronary angiography does not decrease the risk of death or AMI. The economic consequences of this strategy in low- and intermediate-risk patients are unknown. We applied a risk prediction rule to a multi-hospital practice database and to the population of the Thrombolysis In Myocardial Ischemia trial, phase IIIB (TIMI 3B), which compared early invasive with conservative therapy for UAP and NSTEAMI. We then analyzed the effect of an early invasive strategy with regard to the composite end point of death, AMI, or rehospitalization for ischemia at rest. A logistic regression model was used to compare outcomes in patients with high versus low or intermediate risk scores. The costs and benefits of early invasive management in low- or intermediate-risk patients were assessed. In the practice database, 56% of patients with UAP and NSTEAMI who had low or intermediate risk scores underwent early cardiac catheterization, although early invasive management of these lower risk patients has not been associated with a reduction in the rate of death or MI. In TIMI 3B, when rehospitalization for ischemia at rest was added to the composite end point, invasive management was superior to conservative management at 42 days (p = 0.005) and at 1 year (p = 0.03). If all low- or intermediate-risk patients randomized to conservative therapy in that trial had been treated instead with an early invasive strategy, an estimated 5.4% of rehospitalizations would have been, avoided. Within TIMI 3B, such a routine invasive strategy would have resulted in an additional cost of $2,695,700 with no effect on death or AMI, but it would have led to 34 fewer rehospitalizations. This expenditure of $79,285 per hospitalization prevented far exceeds the monetary cost of rehospitalization ($14,000). Although common in clinical practice, routine early invasive management of low- or intermediate-risk patients with UAP generates substantial health-care costs without a mortality benefit or decrease in the risk of AMI. Unless the incremental benefit in quality of life from prevented rehospitalizations for UAP is judged to be worth the large incremental cost ($79,285 per hospitalization prevented), such a strategy is unlikely to be cost effective. (C)2003 by Excerpta Medica, Inc.
引用
收藏
页码:363 / 367
页数:5
相关论文
共 13 条
[1]   ONE-YEAR RESULTS OF THE THROMBOLYSIS IN MYOCARDIAL-INFARCTION (TIMI) IIIB CLINICAL-TRIAL - A RANDOMIZED COMPARISON OF TISSUE-TYPE PLASMINOGEN-ACTIVATOR VERSUS PLACEBO AND EARLY INVASIVE VERSUS EARLY CONSERVATIVE STRATEGIES IN UNSTABLE ANGINA AND NON-Q-WAVE MYOCARDIAL-INFARCTION [J].
ANDERSON, HV ;
CANNON, CP ;
STONE, PH ;
WILLIAMS, DO ;
MCCABE, CH ;
KNATTERUD, GL ;
THOMPSON, B ;
WILLERSON, JT ;
BRAUNWALD, E .
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, 1995, 26 (07) :1643-1650
[2]   The TIMI risk score for unstable angina/non-ST elevation MI - A method for prognostication and therapeutic decision making [J].
Antman, EM ;
Cohen, M ;
Bernink, PJLM ;
McCabe, CH ;
Horacek, T ;
Papuchis, G ;
Mautner, B ;
Corbalan, R ;
Radley, D ;
Braunwald, E .
JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, 2000, 284 (07) :835-842
[3]   Cost-effectiveness of a conservative, ischemia-guided management strategy after non-Q-wave myocardial infarction - Results of a randomized trial [J].
Barnett, PG ;
Chen, S ;
Boden, WE ;
Chow, B ;
Every, NR ;
Lavori, PW ;
Hlatky, MA .
CIRCULATION, 2002, 105 (06) :680-684
[4]  
BRAUNWALD E, 1994, CIRCULATION, V89, P1545
[5]   Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban. [J].
Cannon, CP ;
Weintraub, WS ;
Demopoulos, LA ;
Vicari, R ;
Frey, MJ ;
Lakkis, N ;
Neumann, FJ ;
Robertson, DH ;
DeLucca, PT ;
DiBattiste, PM ;
Gibson, CM ;
Braunwald, E .
NEW ENGLAND JOURNAL OF MEDICINE, 2001, 344 (25) :1879-1887
[6]   The electrocardiogram predicts one-year outcome of patients with unstable angina and non-Q wave myocardial infarction: Results of the TIMI III registry ECG ancillary study [J].
Cannon, CP ;
McCabe, CH ;
Stone, PH ;
Rogers, WJ ;
Schactman, M ;
Thompson, BW ;
Pearce, DJ ;
Diver, DJ ;
Kells, C ;
Feldman, T ;
Williams, M ;
Gibson, RS ;
Kronenberg, MW ;
Ganz, LI ;
Anderson, HV ;
Braunwald, E .
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, 1997, 30 (01) :133-140
[7]   Benefit of abciximab in patients with refractory unstable angina in relation to serum troponin T levels [J].
Hamm, CW ;
Heeschen, C ;
Goldmann, B ;
Vahanian, A ;
Adgey, J ;
Miguel, CM ;
Rutsch, W ;
Berger, J ;
Kootstra, J ;
Simoons, ML .
NEW ENGLAND JOURNAL OF MEDICINE, 1999, 340 (21) :1623-1629
[8]   Troponin concentrations for stratification of patients with acute coronary syndromes in relation to therapeutic efficacy of tirofiban [J].
Heeschen, C ;
Hamm, CW ;
Goldmann, B ;
Deu, A ;
Langenbrink, L ;
White, HD .
LANCET, 1999, 354 (9192) :1757-1762
[9]   Cost-effectiveness of an invasive strategy in unstable coronary artery disease -: Results from the FRISC II invasive trial [J].
Janzon, M ;
Levin, LÅ ;
Swahn, E .
EUROPEAN HEART JOURNAL, 2002, 23 (01) :31-40
[10]   Cost and cost-effectiveness of an early invasive vs conservative strategy for the treatment of unstable angina and non-ST-segment elevation myocardial infarction [J].
Mahoney, EM ;
Jurkovitz, CT ;
Chu, HT ;
Becker, ER ;
Culler, S ;
Kosinski, AS ;
Robertson, DH ;
Alexander, C ;
Nag, S ;
Cook, JR ;
Demopoulos, LA ;
DiBattiste, PM ;
Cannon, CP ;
Weintraub, WS .
JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, 2002, 288 (15) :1851-1858