Researchers Find More Expensive -- and More Beneficial -- Heart Treatment
Not So Costly In Long Run
ATLANTA - Acute
coronary syndromes ("small" heart attacks and worsening chest pains)
account for 1.4 million hospital admissions per year - and, after six
months, these patients' medical bills add up to approximately $30 billion
in the US alone.
"Health care systems operate
with limited resources. This enormous figure argues for careful consideration
of costs when developing treatment guidelines for this population,ęsays
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.