Advertisement

Cost-Effectiveness of Posthospital Management of Acute Coronary Syndrome: A Real-World Investigation From Italy

  • Federico Rea
    Affiliations
    National Centre for Healthcare Research and Pharmacoepidemiology, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy

    Unit of Biostatistics, Epidemiology, and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
    Search for articles by this author
  • Raffaella Ronco
    Correspondence
    Correspondence: Raffaella Ronco, MSc, Unit of Biostatistics, Epidemiology, and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Via Bicocca degli Arcimboldi, 8, Edificio U7, Milan, Italy 20126.
    Affiliations
    National Centre for Healthcare Research and Pharmacoepidemiology, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy

    Unit of Biostatistics, Epidemiology, and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
    Search for articles by this author
  • Nello Martini
    Affiliations
    Research and Health Foundation (Fondazione ReS [Ricerca e Salute]), Bologna, Italy
    Search for articles by this author
  • Aldo Pietro Maggioni
    Affiliations
    ANMCO Research Center, Florence, Italy
    Search for articles by this author
  • Giovanni Corrao
    Affiliations
    National Centre for Healthcare Research and Pharmacoepidemiology, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy

    Unit of Biostatistics, Epidemiology, and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
    Search for articles by this author
Published:September 04, 2021DOI:https://doi.org/10.1016/j.jval.2021.07.015

      Highlights

      • Although randomized clinical trials and observational investigations showed that treatments and clinical controls are effective to reduce the risk of fatal and nonfatal cardiovascular events in patients discharged with a diagnosis of acute coronary syndrome (ACS), adherence to care is suboptimal in real-life practice. In addition, few data are available on the cost-effectiveness profile of the evidence-based guidelines according to the ACS diagnostic categories and general clinical profiles.
      • We performed a real-world investigation in the cohort of residents in the Lombardy Region (Italy) who were discharged with a diagnosis of ACS to assess the cost-effectiveness profile of adherence to selected recommendations (including drug therapies, outpatient controls, and rehabilitation, experienced during the first year after index discharge). Clinical outcomes (cardiovascular hospital admissions and all-cause mortality) and costs (for healthcare services) were assessed for a time horizon of 5 years.
      • Our study shows that patients who adhered to these recommendations exhibited clinical benefits compared with those who did not adhere to them. In addition, adherence to drug therapy was cost saving, displaying a better cost-effectiveness profile in patients with ST elevation myocardial infarction and non-ST elevation myocardial infarction, and in those with medium or severe clinical profiles. Adherence to outpatient controls and rehabilitation is associated with an increase in costs, especially in patients with unstable angina and in those with a severe clinical profile.

      Abstract

      Objectives

      This study aimed to assess the cost-effectiveness profile of adherence to recommendations for the community management of patients discharged with a diagnosis of acute coronary syndrome (ACS).

      Methods

      The cohort of 50 282 residents in the Lombardy Region (Italy) who were discharged with a diagnosis of ACS during 2011 to 2015 was followed up until 2018. Adherence to selected recommendations including drug therapies (DTs), outpatient controls, and rehabilitation, experienced during the first year after index discharge, was considered. Adherent and nonadherent cohort members were matched on high-dimensional propensity scores. Composite clinical outcomes (cardiovascular hospital admissions and all-cause mortality) and healthcare costs were assessed for a time horizon of 5 years. Cost-effectiveness profile of adherence to recommendations was measured through the incremental cost-effectiveness ratio, that is, the incremental cost for 1 day free from the composite clinical outcome.

      Results

      Adherence to DTs, outpatient controls, and rehabilitation, respectively, regarded 39%, 81%, and 3% of cohort members. Compared with nonadherent patients, those adherent to DTs, outpatient controls, and rehabilitation had (1) a delay in the occurrence of the composite clinical outcome of 50, 43, and 73 days, respectively, and (2) lower (on average, €199 per year for DTs) and higher costs (€292 and €1024 for outpatient controls and rehabilitation). Cost-effectiveness profiles were better for patients with myocardial infarction than those with angina and for patients with more severe clinical complexity than those with milder conditions.

      Conclusions

      Health-related and economic benefits are expected from improving adherence to international guidelines recommendations concerning outpatient treatments and monitoring of patients with ACS.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic and Personal
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Value in Health
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Maddox T.M.
        • Stanislawski M.A.
        • Grunwald G.K.
        • et al.
        Nonobstructive coronary artery disease and risk of myocardial infarction.
        JAMA. 2014; 312: 1754-1763
        • Libby P.
        Mechanisms of acute coronary syndromes and their implications for therapy.
        N Engl J Med. 2013; 368: 2004-2013
        • Krumholz H.M.
        • Wang Y.
        • Chen J.
        • et al.
        Reduction in acute myocardial infarction mortality in the United States: risk-standardized mortality rates from 1995-2006.
        JAMA. 2009; 302: 767-773
        • Kesteloot H.
        • Sans S.
        • Kromhout D.
        Dynamics of cardiovascular and all-cause mortality in Western and Eastern Europe between 1970 and 2000.
        Eur Heart J. 2006; 27: 107-113
        • Ferrario M.M.
        • Fornari C.
        • Bolognesi L.
        • et al.
        Recent time trends of myocardial infarction rates in northern Italy. Results from the MONICA and CAMUNI registries in Brianza: 1993-1994 versus 1997-1998 [in Italian].
        Ital Heart J Suppl. 2003; 4: 651-657
        • Piironen M.
        • Ukkola O.
        • Huikuri H.
        • et al.
        Trends in long-term prognosis after acute coronary syndrome.
        Eur J Prev Cardiol. 2017; 24: 274-280
        • Schwartz G.G.
        • Fayyad R.
        • Szarek M.
        • DeMicco D.
        • Olsson A.G.
        Early, intensive statin treatment reduces ‘hard’ cardiovascular outcomes after acute coronary syndrome.
        Eur J Prev Cardiol. 2017; 24: 1294-1296
        • Freemantle N.
        • Cleland J.
        • Young P.
        • Mason J.
        • Harrison J.
        Beta blockade after myocardial infarction: systematic review and meta regression analysis.
        BMJ. 1999; 318: 1730-1737
        • Yusuf S.
        • Sleight P.
        • et al.
        • Heart Outcomes Prevention Evaluation Study Investigators
        Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients [published correction appears in N Engl J Med. 2000;342(18):1376] [published correction appears in N Engl J Med. 2000;342(10):748].
        N Engl J Med. 2000; 342: 145-153
        • Cimminiello C.
        • Dondi L.
        • Pedrini A.
        • et al.
        Patterns of treatment with antiplatelet therapy after an acute coronary syndrome: data from a large database in a community setting.
        Eur J Prev Cardiol. 2019; 26: 836-846
        • Yusuf S.
        • Zhao F.
        • Mehta S.R.
        • et al.
        Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation [published correction appears in N Engl J Med. 2001;345(23):1716] [published correction appears in N Engl J Med. 2001;345(20):1506].
        N Engl J Med. 2001; 345: 494-502
        • Benowitz N.L.
        • Prochaska J.J.
        Smoking cessation after acute myocardial infarction.
        J Am Coll Cardiol. 2013; 61: 533-535
        • James P.A.
        • Oparil S.
        • Carter B.L.
        • et al.
        2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8) [published correction appears in JAMA. 2014;311(17):1809].
        JAMA. 2014; 311: 507-520
        • Grundy S.M.
        National Cholesterol Education Program (NCEP)-The National Cholesterol Guidelines in 2001, Adult Treatment Panel (ATP) III. Approach to lipoprotein management in 2001 National Cholesterol Guidelines.
        Am J Cardiol. 2002; 90: 11i-21i
      1. Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines [published correction appears in Circulation. 2014;129(25)(suppl 2):S46-S48] [published correction appears in Circulation. 2015;132(25):e396]. Circulation 2014;129(25)(suppl 2):S1-S45.

        • Amsterdam E.A.
        • Wenger N.K.
        • Brindis R.G.
        • et al.
        2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines [published correction appears in Circulation. 2014;130(25):e431-e432].
        Circulation. 2014; 130: 2354-2394
        • Ibanez B.
        • James S.
        • Agewall S.
        • et al.
        2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC).
        Eur Heart J. 2017; 39: 119-177
        • Bansilal S.
        • Castellano J.M.
        • Garrido E.
        • et al.
        Assessing the impact of medication adherence on long-term cardiovascular outcomes.
        J Am Coll Cardiol. 2016; 68: 789-801
        • Choudhry N.K.
        • Glynn R.J.
        • Avorn J.
        • et al.
        Untangling the relationship between medication adherence and post-myocardial infarction outcomes: medication adherence and clinical outcomes.
        Am Heart J. 2014; 167: 51-58.e5
        • Rasmussen J.N.
        • Chong A.
        • Alter D.A.
        Relationship between adherence to evidence-based pharmacotherapy and long-term mortality after acute myocardial infarction.
        JAMA. 2007; 297: 177-186
        • Lee J.H.
        • Yang D.H.
        • Park H.S.
        • et al.
        Suboptimal use of evidence-based medical therapy in patients with acute myocardial infarction from the Korea Acute Myocardial Infarction Registry: prescription rate, predictors, and prognostic value.
        Am Heart J. 2010; 159: 1012-1019
        • Ho P.M.
        • Spertus J.A.
        • Masoudi F.A.
        • et al.
        Impact of medication therapy discontinuation on mortality after myocardial infarction.
        Arch Intern Med. 2006; 166: 1842-1847
        • Ryder H.F.
        • McDonough C.
        • Tosteson A.N.
        • Lurie J.D.
        Decision analysis and cost-effectiveness analysis.
        Semin Spine Surg. 2009; 21: 216-222
        • Cowper P.A.
        • Knight J.D.
        • Davidson-Ray L.
        • et al.
        Acute and 1-year hospitalization costs for acute myocardial infarction treated with percutaneous coronary intervention: results from the TRANSLATE-ACS registry.
        J Am Heart Assoc. 2019; 8e011322
        • Zhao Z.
        • Winget M.
        Economic burden of illness of acute coronary syndromes: medical and productivity costs.
        BMC Health Serv Res. 2011; 11: 35
        • Forné C.
        • Subirana I.
        • Blanch J.
        • et al.
        A cost-utility analysis of increasing percutaneous coronary intervention use in elderly patients with acute coronary syndromes in 6 European countries.
        Eur J Prev Cardiol. 2021; 28: 408-417
        • Rea F.
        • Ronco R.
        • Pedretti R.F.E.
        • Merlino L.
        • Corrao G.
        Better adherence with out-of-hospital healthcare improved long-term prognosis of acute coronary syndromes: evidence from an Italian real-world investigation.
        Int J Cardiol. 2020; 318: 14-20
        • Rea F.
        • Cantarutti A.
        • Merlino L.
        • Ungar A.
        • Corrao G.
        • Mancia G.
        Antihypertensive treatment in elderly frail patients: evidence from a large Italian database.
        Hypertension. 2020; 76: 442-449
        • Corrao G.
        • Monzio Compagnoni M.
        • Cantarutti A.
        • et al.
        Balancing cardiovascular benefit and diabetogenic harm of therapy with statins: real-world evidence from Italy.
        Diabetes Res Clin Pract. 2020; 164108197
        • Trifirò G.
        • Gini R.
        • Barone-Adesi F.
        • et al.
        The role of European healthcare databases for post-marketing drug effectiveness, safety and value evaluation: where does Italy stand?.
        Drug Saf. 2019; 42: 347-363
        • Corrao G.
        • Rea F.
        • Di Martino M.
        • et al.
        Developing and validating a novel multisource comorbidity score from administrative data: a large population-based cohort study from Italy.
        BMJ Open. 2017; 7e019503
        • Goldberger J.J.
        • Bonow R.O.
        • Cuffe M.
        • et al.
        beta-Blocker use following myocardial infarction: low prevalence of evidence-based dosing.
        Am Heart J. 2010; 160: 435-442.e1
        • Andrade S.E.
        • Kahler K.H.
        • Frech F.
        • Chan K.A.
        Methods for evaluation of medical adherence and persistence using automated databases.
        Pharmacoepidemiol Drug Saf. 2006; 15: 565-577
        • Schneeweiss S.
        • Rassen J.A.
        • Glynn R.J.
        • Avorn J.
        • Mogun H.
        • Brookhart M.A.
        High-dimensional propensity score adjustment in studies of treatment effects using health care claims data [published correction appears in Epidemiology. 2018;29(6):e63-e64].
        Epidemiology. 2009; 20: 512-522
        • Austin P.C.
        A comparison of 12 algorithms for matching on the propensity score.
        Stat Med. 2014; 33: 1057-1069
        • Fine J.P.
        • Gray R.J.
        A Proportional hazards model for the subdistribution of a competing risk.
        J Am Stat Assoc. 1999; 94: 496-509
        • Pak K.
        • Uno H.
        • Kim D.H.
        • et al.
        Interpretability of cancer clinical trial results using restricted mean survival time as an alternative to the hazard ratio.
        JAMA Oncol. 2017; 3: 1692-1696
        • Bang H.
        • Tsiatis A.A.
        Estimating medical costs with censored data.
        Biometrika. 2000; 87: 329-343
        • Cohen D.J.
        • Reynolds M.R.
        Interpreting the results of cost-effectiveness studies.
        J Am Coll Cardiol. 2008; 52: 2119-2126
        • Drummond M.
        • Sculpher M.
        • Claxton K.
        • Stoddart G.L.
        • Torrance G.W.
        Methods for the Economic Evaluation of Health Care Programmes.
        4th ed. Oxford University Press, Oxford, United Kingdom2015
        • Di Tanna G.L.
        • Bychenkova A.
        • O’Neill F.
        • et al.
        Evaluating cost-effectiveness models for pharmacologic interventions in adults with heart failure: a systematic literature review.
        Pharmacoeconomics. 2019; 37: 359-389
      2. Macroeconomics and Health: investing in health for economic development: executive summary / report of the Commission on Macroeconomics and Health. World Health Organization.
        https://apps.who.int/iris/handle/10665/42463
        Date accessed: September 2, 2021
        • Lahoud R.
        • Howe M.
        • Krishnan S.M.
        • Zacharias S.
        • Jackson E.A.
        Effect of use of combination evidence-based medical therapy after acute coronary syndromes on long-term outcomes.
        Am J Cardiol. 2012; 109: 159-164
        • Wright R.S.
        • Anderson J.L.
        • Adams C.D.
        • et al.
        2011 ACCF/AHA focused update incorporated into the ACC/AHA 2007 Guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in collaboration with the American Academy of Family Physicians, Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons.
        J Am Coll Cardiol. 2011; 57: e215-e367
        • Hamood H.
        • Hamood R.
        • Green M.S.
        • Almog R.
        Determinants of adherence to evidence-based therapy after acute myocardial infarction.
        Eur J Prev Cardiol. 2016; 23: 975-985
        • Faridi K.F.
        • Peterson E.D.
        • McCoy L.A.
        • Thomas L.
        • Enriquez J.
        • Wang T.Y.
        Timing of first postdischarge follow-up and medication adherence after acute myocardial infarction.
        JAMA Cardiol. 2016; 1: 147-155
        • Roifman I.
        • Sivaswamy A.
        • Chu A.
        • et al.
        Clinical effectiveness of cardiac noninvasive diagnostic testing in outpatients evaluated for stable coronary artery disease.
        J Am Heart Assoc. 2020; 9e015724
        • Salzwedel A.
        • Jensen K.
        • Rauch B.
        • et al.
        Effectiveness of comprehensive cardiac rehabilitation in coronary artery disease patients treated according to contemporary evidence based medicine: update of the Cardiac Rehabilitation Outcome Study (CROS-II).
        Eur J Prev Cardiol. 2020; 27: 1756-1774
        • Anderson L.
        • Oldridge N.
        • Thompson D.R.
        • et al.
        Exercise-based cardiac rehabilitation for coronary heart disease: Cochrane systematic review and meta-analysis.
        J Am Coll Cardiol. 2016; 67: 1-12
        • Piepoli M.F.
        • Hoes A.W.
        • Agewall S.
        • et al.
        2016 European Guidelines on cardiovascular disease prevention in clinical practice: the Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts) developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR).
        Eur Heart J. 2016; 37: 2315-2381
        • O’Gara P.T.
        • Kushner F.G.
        • Ascheim D.D.
        • et al.
        2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines [published correction appears in Circulation. 2013;128(25):e481].
        Circulation. 2013; 127: e362-e425
        • Eijsvogels T.M.H.
        • Maessen M.F.H.
        • Bakker E.A.
        • et al.
        Association of cardiac rehabilitation with all-cause mortality among patients with cardiovascular disease in The Netherlands.
        JAMA Netw Open. 2020; 3e2011686
        • Shield K.D.
        • Parkin D.M.
        • Whiteman D.C.
        • et al.
        Population attributable and preventable fractions: cancer risk factor surveillance, and cancer policy projection.
        Curr Epidemiol Rep. 2016; 3: 201-211
        • Kotseva K.
        • Wood D.
        • De Backer G.
        • De Bacquer D.
        • EUROASPIRE III Study Group
        Use and effects of cardiac rehabilitation in patients with coronary heart disease: results from the EUROASPIRE III survey.
        Eur J Prev Cardiol. 2013; 20: 817-826
        • Garrison Jr., L.P.
        • Neumann P.J.
        • Erickson P.
        • Marshall D.
        • Mullins C.D.
        Using real-world data for coverage and payment decisions: the ISPOR Real-world Data Task Force report.
        Value Health. 2007; 10: 326-335
        • Andersohn F.
        • Willich S.N.
        The healthy adherer effect.
        Arch Intern Med. 2009; 169: 1635-1636