A systematic review and critical analysis of cost-effectiveness studies for coronary artery disease treatment [version 2; referees: 2 approved]

Background: Cardiovascular disease remains the primary cause of death among Australians, despite dramatic improvements in overall cardiovascular health since the 1980s. Treating cardiovascular disease continues to place a significant economic strain on the Australian health care system, with direct healthcare costs exceeding those of any other disease. Coronary artery disease accounts for nearly one third of these costs and spending continues to rise. A range of treatments is available for coronary artery disease yet evidence of cost-effectiveness is missing, particularly for the Australian context. Cost-effectiveness evidence can signal waste and inefficiency and so is essential for an efficient allocation of healthcare resources. Methods: We used systematic review methods to search the literature across several electronic databases for economic evaluations of treatments for stable coronary artery disease.  We critically appraised the literature found in searches, both against the CHEERS statement for quality reporting of economic evaluations and in terms of its usefulness for policy and decision-makers. Results: We retrieved a total of 308 references, 229 once duplicates were removed. Of these, 26 were excluded as they were not full papers (letters, editorials etc.), 55 were review papers, 50 were not cost-effectiveness analyses and 93 related to a highly specific patient sub-group or did not consider all treatment options.  This left five papers to be reviewed in full. Conclusions: The current cost-effectiveness evidence does not support the increased use of PCI that has been seen in Australia and internationally. Due to problems with accessibility, clarity and relevance to policy and decision-makers, some otherwise very scientifically rigorous analyses have failed to generate any policy changes

Chest Pain Assessment: What is Our Endgame?

Cardiac troponin (cTn) testing is crucial in assessing patients with chest pain and other acute anginal equivalent symptoms. The Fourth Universal Definition of Myocardial infarction (4th UDMI) recommends the use of troponin in identifying patients who benefit from targeted therapies, including early revascularization (1). Developments in immunoassays for cardiac troponin (I and T) over the past two decades have resulted in highly sensitive assays with improved ability to detect and quantify troponin concentrations. This has allowed clinicians to move away from using cTn as a dichotomous variable (where the 99th percentile of healthy individuals was used to define values as normal or increased), towards more complex approaches incorporating a range of cutoffs and delta values. This ensures that maximum clinical benefit can be obtained by each new generation of assay

Change to costs and lengths of stay in the emergency department and the Brisbane protocol: an observational study

- Objective To compare health service cost and length of stay between a traditional and an accelerated diagnostic approach to assess acute coronary syndromes (ACS) among patients who presented to the emergency department (ED) of a large tertiary hospital in Australia. - Design, setting and participants This historically controlled study analysed data collected from two independent patient cohorts presenting to the ED with potential ACS. The first cohort of 938 patients was recruited in 2008–2010, and these patients were assessed using the traditional diagnostic approach detailed in the national guideline. The second cohort of 921 patients was recruited in 2011–2013 and was assessed with the accelerated diagnostic approach named the Brisbane protocol. The Brisbane protocol applied early serial troponin testing for patients at 0 and 2 h after presentation to ED, in comparison with 0 and 6 h testing in traditional assessment process. The Brisbane protocol also defined a low-risk group of patients in whom no objective testing was performed. A decision tree model was used to compare the expected cost and length of stay in hospital between two approaches. Probabilistic sensitivity analysis was used to account for model uncertainty. - Results Compared with the traditional diagnostic approach, the Brisbane protocol was associated with reduced expected cost of $1229 (95$1266 to $5122) and reduced expected length of stay of 26 h (95% CI −14 to 136 h). The Brisbane protocol allowed physicians to discharge a higher proportion of low-risk and intermediate-risk patients from ED within 4 h (72% vs 51%). Results from sensitivity analysis suggested the Brisbane protocol had a high chance of being cost-saving and time-saving. - Conclusions This study provides some evidence of cost savings from a decision to adopt the Brisbane protocol. Benefits would arise for the hospital and for patients and their families

152 Pregnancy Success Following Cardiac Transplantation

BackgroundSuccessful pregnancy is achievable in cardiac transplant recipients. Published pregnancy outcomes are limited.Case Series PresentationWe report the first Australian case series. Pregnancies were managed with joint care between a single centre for maternal cardiology and single transplant service. We describe 5 successful pregnancies in 3 cardiac transplant recipients between 2015-2018, median age: 27 yrs. (range 23-38 yrs.).All patients were temporarily managed with modified immunosuppressant regimens including Tacrolimus and Azathioprine with co-ordinated care involving both transplant and maternal medicine teams. Only one patient was on prednisolone. Tacrolimus levels and echocardiography were monitored throughout.Median time from transplantation to pregnancy was 5yrs. (range 2-14yrs.). All patients had normal left ventricular ejection fraction (LVEF ≥55%) prior to pregnancy. There was no graft rejection and no deterioration in left ventricular function during pregnancy. Gestational diabetes occurred in three pregnancies and cholestasis in one. Pre-eclampsia did not occur. All pregnancies progressed to live births with APGAR scores of 9+9. Delivery occurred at 37 weeks (range 35+4-40+5 days). Mean birth weight was 3067g (range 2236-3850g). 1 infant had jaundice requiring phototherapy. Both pregnancies in one mother were complicated by post-partum haemorrhage. Tacrolimus dose increased during all pregnancies to maintain therapeutic targets.DiscussionPregnancy in transplant recipients confers risk to the mother and foetus. Pre-conception counselling, immunosuppressant tailoring and careful ongoing monitoring are paramount to avoid rejection and complications secondary to some immunosuppressant and cardiac medications. Successful pregnancy outcomes are achievable in cardiac transplant recipients with co-ordinated specialist multidisciplinary care

Sex Differences in Coronary Artery Anatomy in Chest Pain Patients Investigated With Coronary Angiography

Background: Acute coronary syndrome (ACS) can present differently in men and women. This study aimed to assess sex differences in coronary artery anatomy in a cohort of patients presenting to the emergency department (ED) with undifferentiated chest pain and who underwent investigation with coronary angiography.Methods: Data were analysed from two prospective studies conducted at an Australian tertiary hospital between 2007 and 2014. Patients eligible for inclusion were those at least 18 years of age and presenting to the ED with > 5 minutes of chest pain. Outcomes measured included 30-day ACS, and rates of coronary angiography. Of those patients investigated with angiography, coronary anatomy findings were compared, including rates of normal arteries, disease severity, and single vs multivessel significant disease. Results: A total of 2,349 (60% men) patients were included in the analysis, with 153 men and 41 women diagnosed with ACS. A total of 255 (18%) men and 106 (11.4%) women were investigated with coronary angiography, yet 45.8% of these women had normal coronary arteries compared to 18.8% of the men (a difference of 27%, 95% CI 15.9–38.2). Of those with coronary artery disease present, 55.6% of men had severe disease compared to 32.3% of women (a difference of 23.3%, 95% CI 11.9–34.6). Rates of single and multivessel disease were similar. Conclusion: These findings confirm that sex differences in the manifestations of ACS exist and that not all women may benefit from invasive coronary angiography. Different strategies for investigation of possible cardiac chest pain in men and women may be indicated

Reducing waste in collection of quality-of-life data through better reporting: a case study

PurposeThis study describes the reporting of the preference-based health-related quality-of-life (HRQOL) instrument, the EQ-5D, and proposes strategies to improve reporting and reduce research waste. The EQ-5D is a validated instrument widely used for health economic evaluation and is useful for informing health policy.MethodsAs part of a systematic review of papers reporting EQ-5D utility weights in patients with coronary artery disease, we noted the reasons data from some papers could not be reused in a meta-analysis, including whether health utility weights and sufficient statistical details were reported. Research waste was quantified using: (1) the percentage of papers and sample size excluded, and (2) researcher time and cost reviewing poorly reported papers.ResultsOur search strategy found 5942 papers. At title and abstract screening 93% were excluded. Of the 379 full text papers screened, 130 papers reported using EQ-5D. Only 46% (60/130) of those studies reported utility weights and/or statistical properties enabling meta-analysis. Only 67% of included papers had reported EQ-5D in the title or abstract. A total sample size of 133,298 was excluded because of poor reporting. The cost of researcher time wasted estimated to be between $3816 and$13,279 for our review.ConclusionsPoor reporting of EQ-5D data creates research waste where potentially useful data are excluded from meta-analyses and economic evaluations. Poor reporting of HRQOL instruments also creates waste due to additional time spent reviewing papers for systematic reviews that are subsequently excluded.RecommendationsStudies using the EQ-5D should report utility weights with appropriate summary statistics to enable reuse in meta-analysis and more robust evidence for health policy. We recommend authors report the HRQOL instrument in the title or abstract in line with current reporting guidelines (CONSORT-PRO and SPIRIT-PRO Extensions) to make it easier for other researchers to find. Validated instruments should also be listed in the Medical Subject Headings (MeSH) to improve cataloguing and retrieval of previous research

Long-Term Trajectories, Costs and Health Outcomes of Privately Insured Patients Treated for Stable Coronary Artery Disease in Australia: An Observational Study

Introduction: Clinical trial results have driven significant shifts in coronary revascularisation in recent decades; however, long-term costs and health outcomes of patients remain unclear.Aim: To assess long-term trajectories, costs and quality of life of patients treated for stable coronary artery disease.Methods: Real-world Australian private admissions data were used to assess long-term trajectories and costs of treating stable coronary artery disease (n = 3,275). Diagnosis, procedure and prostheses codes were used to identify patients with coronary disease, and time to event analysis used to determine long-term trajectories. Private health claims data were used to calculate costs of relevant admissions. Responses to the EQ-5D questionnaire in the Victorian Cardiac Outcomes Registry were used to generate health utility weights between 1 (full health) and 0 (death) (n = 15,109).Results: On average, 24% of patients undergoing percutaneous intervention will undergo repeat revascularisation, and 55% will have a coronary disease-related readmission within 5 years. In comparison, 3% of bypass graft surgery patients will undergo repeat revascularisation and 32% have coronary disease-related readmissions in that time. Average costs for private procedures were $21,825 for percutaneous intervention and$48,440 for bypass graft surgery. Health utility at 30 days was 0.91 for percutaneous intervention and 0.80 for surgical patients.Discussion: The results align with clinical trials, where rates of readmission are higher in those undergoing percutaneous intervention than surgery. However, percutaneous intervention is less costly and provides higher 30-day utility. These results will inform an economic model providing important insights for promoting value-based care