"Health care systems operate with limited resources. This enormous figure argues for careful consideration of costs when developing treatment guidelines for this population," says Elizabeth Mahoney, Ph.D., assistant professor of medicine at the Emory University School of Medicine. "Now we have evidence that early, aggressive -- and initially more expensive -- treatment of these patients is actually very cost effective over time. This is good news for these patients and their physicians because aggressive treatment offers the best prognosis."
Dr. Mahoney is one of the principal investigators in a new study conducted by Emory and Brigham and Women's Hospital researchers, published this week in the Journal of the American Medical Association (JAMA), that reaches this conclusion based on an examination of the economic costs of conservative and aggressive therapies for acute coronary syndromes over six months.
Past studies have shown that early, aggressive treatment with cardiac catheterization and, if indicated, angioplasty or bypass surgery produces better patient outcomes when compared to a conservative approach using catheterization and angioplasty or bypass surgery only in patients who fail to respond well to medical therapy (including "clot buster" drugs). However, the aggressive treatment is initially more expensive than the conservative approach -- and physicians have questioned whether additional benefits from the therapy are worth the significant additional expense.
Dr. Mahoney, Emory cardiologist William S. Weintraub, M.D., and other colleagues found that the initial higher expense for the aggressive approach diminishes over six months as patients treated with the conservative approach incur more medical and other expenses.
The Emory researchers, working in conjunction with Christopher P. Cannon, MD, of Brigham and Women's Hospital in Boston, used economic data from the landmark TACTICS-TIMI 18 (Treatment Angina with Aggrastat and Determine Cost of Therapy with an Invasive or Conservative Strategy) study, the clinical results of which were published in 2001. They examined the initial hospitalization and six month follow-up costs (including expenses associated with all re-hospitalizations and emergency room visits, cardiac-related outpatient visits and procedures, visiting nurse visits, nursing home and rehabilitation stays, and cardiac-related medications), as well as costs associated with lost productivity (missed time from work and decreased work effectiveness) due to heart problems, of 1,722 patients enrolled at U.S., non-federal hospitals who participated in the TACTICS-TIMI 18 study.
Although the average initial hospitalization costs were $1,667 higher for patients treated with the invasive strategy, more than half of this early difference was offset by significantly lower six-month follow-up costs, yielding a difference of less than $600 at 6 months. During the follow-up period, patients treated with the conservative strategy were more likely to suffer another non-fatal heart attack, resulting in higher medical costs.
While this difference in costs seems small relative to the total six month costs (which are over $21,000 for both strategies), health economic decisions are made by considering the additional costs in the context of the additional health benefits gained. Ideally, an index such as additional cost per year of life gained is used, as this allows estimates from a wide spectrum of interventions to be compared, or benchmarked, against each other. The research team also factored in estimates from epidemiological studies of life expectancy for patients with similar medical histories.
"Over all, we found the cost-effectiveness of the invasive strategy ranging from $8,371 to $25,538 per year of life gained, estimates that are favorable compared to other treatments used in current medical practice," concludes Dr. Mahoney. "These results suggest that the benefit of the early invasive strategy, in terms of reducing major cardiac events, is achieved with a small increase in cost overall, yielding favorable cost-effectiveness ratios when the impact of the lower nonfatal heart attack rate is projected over the long term. Such results reinforce the support provided by the clinical results of TACTICS-TIMI 18 for the broader use of the early invasive strategy in the management of this patient population."
The Emory Heart Center is comprised of all cardiology services and research at Emory University Hospital (EUH), Emory Crawford Long Hospital (ECLH) Carlyle Fraser Heart Center, the Andreas Gruentzig Cardiovascular Center of Emory University and the Emory Clinic. Ranked in the top ten of U.S. News & World Report's annual survey of the nation's best Heart Centers, the Emory Heart Center has a rich history of excellence in all areas of cardiology - including education, research and patient care. It is also internationally recognized as one of the birthplaces of modern interventional cardiology.
Journal
JAMA