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

Active disinvestment in low‐value care in Australia will improve patient outcomes and reduce waste (Deeble Issues Brief No. 23)

This Issues Brief provides recommendations on critical steps to be taken to promote disinvestment in low-value healthcare and to encourage use of high-value care. These recommendations are essential if Australia is to continue having a world-class healthcare system; providing Australians with the best possible health outcomes sustainably into the future

An economic analysis of the benefits of sterilizing medical instruments in low-temperature systems instead of steam

Background Hydrogen peroxide–based, low-temperature sterilization has been shown to do less damage to medical instruments than steam autoclaves. However, low-temperature systems are more expensive to run. Higher costs need to be balanced against savings from reduced repair costs to determine value for money when choosing how to sterilize certain instruments, which are able to be reprocessed in either system. Methods This analysis examines the economic effects of using low-temperature sterilization systems to reprocess rigid and semi-rigid endoscopes, which are sensitive to heat and moisture, but still able to be sterilized using steam. It examines the changes to costs and frequency of repairs expected over 10 years, resulting from a choice to sterilize these instruments in a low-temperature system instead of steam. Results Overall, the results showed that increased sterilization costs are outweighed by the savings associated with less frequent repairs. Over a 10-year period, in large health care facilities, the probability of achieving an internal rate of return of at least 6% is 0.81. Conclusions Our model shows it is likely to be a good decision for large health care facilities to invest in low-temperature sterilization systems

Identifying high-value care for coronary artery disease in Australia

This project compared the cost-effectiveness of drug therapy, stents and surgery for Australian patients with heart disease, modelling their long-term treatment trajectories, costs and health outcomes. It showed that drug therapy is high-value and that the health system, and Australians, would benefit from targeted rather than routine use of stents. This research provides policy recommendations to reduce the use of low-value care and increase the use of high-value care for Australian patients with heart disease

Reducing waste in collection of quality of life data through better reporting

Calculations of time spent searching for research using QoL tools that were not mentioned in tile or abstract, or catalogued using other key word

EQ-5D utilities at various treatment time points for CAD

EQ-5D utilities at various treatment time points (CABG, OMT, PCI) for coronary artery diseas

Costs and 30-day readmission after lower limb fractures from motorcycle crashes in Queensland, Australia : A linked data analysis

BackgroundLower limb trauma is the most common injury sustained in motorcycle crashes. There are limited data describing this cohort in Australia and limited international data establishing costs due to lower limb trauma following motorcycle crashes.MethodsThis retrospective cohort study utilised administrative hospitalisation data from Queensland, Australia from 2011–2017. Eligible participants included those admitted with a principal diagnosis coded as lower extremity or pelvic fracture following a motorcycle crash (defined as the index admission). Multiply injured motorcyclists where the lower limb injury was not coded as the primary diagnosis (i.e. principal diagnosis was rather coded as head injury, internal organ injures etc.) were not included in the study. Hospitalisation data were also linked to clinical costing data. Logistic regression was used to determine risk factors for 30-day readmission. Costing data were compared between those readmitted and those who weren't, using bootstrapped t-tests and ANVOA.ResultsA total of 3342 patients met eligibility, with the most common lower limb fracture being tibia/fibula fractures (40.8%). 212 participants (6.3%) were readmitted within 30-days of discharge. The following were found to predict readmission: male sex (OR 1.84, 95% CI 1.01–1.94); chronic anaemia (OR 2.19, 95% CI 1.41–3.39); current/ex-smoker (OR 1.60, 95% CI 1.21–2.12); emergency admission (OR 2.77, 95% CI 1.35–5.70) and tibia/fibula fracture type (OR 1.46, 95% CI 1.10-1.94). The most common reasons for readmission were related to ongoing fracture care, infection or post-operative complications. The average hospitalisation cost for the index admission was AU$29,044 (95$27,235-$30,853) with significant differences seen between fracture types. The total hospitalisation cost of readmissions was almost AU$2 million over the study period, with an average cost of $10,977 (95$9,131- $13,059).ConclusionsUnplanned readmissions occur in 6.3% of lower limb fractures sustained in motorcycle crashes. Independent predictors of readmission within 30 days of discharge included male sex, chronic anaemia, smoking status, fracture type and emergency admission. Index admission and readmission hospitalisation costs are substantial and should prompt health services to invest in ways to reduce readmission

Characteristics and effectiveness of postoperative rehabilitation strategies in ankle fractures: a systematic review

Objectives: To explore the characteristics and (2) to report on the effectiveness of postoperative rehabilitation strategies for people with an ankle fracture. Data Sources: PubMed, Cochrane Library, EMBASE, Web of Science and CINAHL to identify studies published from January 2010 to November 2021.Study selection: Studies that described or evaluated postoperative rehabilitation strategies for surgically repaired ankle fractures.Data extraction: Data on postoperative rehabilitation were extracted in accordance with the Template for Intervention Description and Replication (TIDieR) guide. Quality was assessed using the National Heart, Lung and Blood Institute’s Study Quality Assessment Tools.Data synthesis: Meta-analysis was planned to look at the effectiveness of postoperative rehabilitation strategies. Forty studies described postoperative rehabilitation strategies without evaluating effectiveness while 15 studies focused on evaluating effectiveness. Due to the large variety in postoperative strategies and outcomes, narrative synthesis was deemed most suitable to answer our aims. Characteristics of postoperative rehabilitation strategies varied widely and were poorly described in a way that could not be replicated. Most of the studies (48%) utilised a late weight-bearing approach although definitions and details around weight-bearing were unclear.Conclusions: Late weight-bearing has been the most common postoperative approach reported in the past 10 years. The variety of definitions around weight-bearing and the lack of details of rehabilitation regimes limits replication and impacts current clinical practice. Authors propose to adopt consistent definitions and terminology around postoperative practices like weight-bearing to improve evidence for effectiveness and ultimately patient outcomes.Level of evidence: Level III. See Instructions for Authors for a complete description of levels of evidence

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