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Cost-Effectiveness Analysis and Echocardiography Ali R. Rahimi, MD MPH October 10, 2007.

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Presentation on theme: "Cost-Effectiveness Analysis and Echocardiography Ali R. Rahimi, MD MPH October 10, 2007."— Presentation transcript:

1 Cost-Effectiveness Analysis and Echocardiography Ali R. Rahimi, MD MPH October 10, 2007

2 Background Expenditures in healthcare are increasing Resources – people, time, facilities, equipment, and knowledge – are scarce Choices need to be made daily regarding their deployment

3 Economic Evaluation in Medicine Systematic analysis to identify relevant alternatives  Screening/Diagnosis, Treatment, or Rehab Understand different viewpoints  Patient, Institution, State, Federal, etc… Measurement to avoid uncertainty  Real Costs and Opportunity Costs Drummond, MF et al. Methods for the Evaluation of Health Care Programs. 1997 Oxford Medical Publications.

4 Economic Evaluation in Medicine Definition: “The comparative analysis of courses of action in terms of both their costs and consequences.”  Linkage of Costs and Consequences  Comparative to allow decision making among choices even efficacious diagnostic or therapeutic approaches Drummond, MF et al. Methods for the Evaluation of Health Care Programs. 1997 Oxford Medical Publications.

5 Cost-Effectiveness Analysis Definition:  “incremental cost of a program from a particular viewpoint is compared to the incremental health effects of the program” Health effects via natural units  BP or LDL improvement  Cases found or averted (e.g., HCM, Thrombus)  Lives saved or life-years gained Cost per unit of effect Drummond, MF et al. Methods for the Evaluation of Health Care Programs. 1997 Oxford Medical Publications.

6 Review of the Literature Hand-Held Cardiac Ultrasound Stress Echo versus SPECT Imaging

7 Premise:  Standard Echo (SE) when physical exam is inconclusive for diagnosis or severity of disease  Complete SE is an expensive test, requiring skilled personnel and done days after initial outpatient visit  Hand-carried cardiac ultrasound (HCU) device can provide reliable and timely information while providing potential health and cost benefit

8 Methods:  Prospective Study  222 patients, 9/15/04 to 12/15/04, outpatient cardiology practice in Rome, Italy  8 cardiologists  4 level II and 4 level III by ASE requirements  History/Physical  HCU when SE indicated for specific clinical “?” Cardiologist reassessed to “confirm” or “cancel” initial SE request SE done by an independent sonographer and read by a cardiologist blinded to the HCU result Findings of each study were then compared Hand-Carried Cardiac Ultrasound

9 OptiGo Portable Device (Phillips) 2.5 MHz phased array transducer 2D, color-flow doppler, and calipers

10 Hand-Carried Cardiac Ultrasound HCU Protocol: “Flexible” Exam in less than 2 minutes  Linear measurements if visually abnormal  For LVH, “IVS” and “posterior” wall were noted  LVEF > 50% - normal in absence of segmental WMA  RV evaluated for both dimension and function  Valve regurgitation qualitatively estimated using color degree on four steps and noted if more than mild  Valve stenosis both 2D and color doppler were described  Pericardial effusion detected as echo free space between pericardium SE Protocol:  Per ASE recommendations with second harmonic images analyzed per department of cardiology protocol

11 Hand-Carried Cardiac Ultrasound

12 Main reason for confirming SE was due to lack of spectral doppler modality for determining LV diastolic dysfunction HCU  cancellation of 34/108 SE requests (31%)

13 Hand-Carried Cardiac Ultrasound


15 Cost-Evaluation:  SE € 62 and HCU € 6.94  Cancellation of 34 SE  € 1872 saved  Avoidance of 2 nd office visit  € 442 saved  Total Cost Savings = € 2142 per 100 patients referred for echocardiography

16 Hand-Carried Cardiac Ultrasound Limitation:  HCU device used had limited color doppler function, preventing a comprehensive echo exam  Agreement between HCU and SE was only 73% HCU missed 9 LV hypertrophies, 1 mild pericardial effusion HCU had false-positive diagnosis in 12 patients (10 were considered to have mild LVH and 2 with RV dilatation) SE diagnosed 8 patients with PAH not detected by HCU

17 Objective:  Assess accuracy of HCU in predicting a normal study and its cost-effectiveness in reducing SE on hospital inpatients Many patients for Echo have no cardiac pathology ID those who are normal to decrease SE referrals

18 Inpatient HCU Methods:  District General Hospital – 2000 SE’s/year  157 consecutive inpatients Mean age 68 (range: 18-97) years 61% Male  HCU (OptiGo) at bedside as part of clinical assessment  SE was subsequently performed on all patients  Main outcome measures: Accuracy of HCU in determining a normal or abnormal study Cost-Effectiveness Analysis

19 Inpatient HCU Costs  Unit cost of SE based on sonographer’s fee, transportation and device depreciation = £ 66.15  Purchase cost of device = £ 6000  Cardiologist hourly fee = £ 18.00  HCU scan (10 minutes), writing report and depreciation = £ 4.00/scan

20 Inpatient HCU Prediction of Normal ScanPrediction of Normal LV function Prediction with Specific Request for LV function

21 Inpatient HCU HCU predicted normal valvular function  84% sensitivity, 86% specificity, 93% PPV and 71% NPV (82% agreement, k = 0.61, 95% CI 0.49-0.74) HCU missed 4 patients with abnormalities  1 moderate LVH  1 severe Aortic Stenosis  1 moderate mitral regurgitation  1 mild LV dilatation 3 of the 4 findings were in studies requested with no specific reason Studies with no specific reason had 33% sensitivity, 87% specificity, 77% PPV and 87% NPV

22 Inpatient HCU Cost-Evaluation:  Yearly Cost for 2000 SE = £ 132, 300  Yearly Cost for 2000 POC HCU = £ 8,000  POC HCU  29% completely normal studies Potential Cost Saving = £ 30,367 29% reduction in workload for department  POC HCU for LV Function requests (64%)  22% normal Potential Cost Saving = £ 23,986 22% reduction in workload for department

23 Inpatient HCU Limitations:  Generalizability and External Validity  Cardiology Fellows as sonographer  Missed findings with resulting cost-risk Thus, individuals with a higher pre-test probability for an abnormal study (i.e., known LV dysfunction or valvular disease) should undergo first-line SE

24 Review of the Literature Hand-Held Cardiac Ultrasound Stress Echo versus SPECT Imaging

25 Purpose:  compare prognostic accuracy and incremental cost-effectiveness [(CE ratios <$50,000 per life year saved (LYS)] of exercise echo and SPECT imaging in symptomatic, intermediate risk patients

26 Exercise Echo vs. SPECT Methods:  Enrolled 9521 Intermediate risk patients with stable angina (Canadian Class I or II) 4884 referred for exercise echo 4637 referred for SPECT imaging  Referral centers included: Cleveland Clinic Foundation, University of Indiana, Asheville Cardiology Associates, Hartford Hospital, Cedars-Sinai Medical Center, and St. Louis University Health Sciences Center Pre-Test clinical risk defined by an estimated predicted rate of cardiac death or MI derived from a Cox proportional hazards model  Intermediate Risk  1% to ≤ 3% per year

27 Exercise Echo vs. SPECT

28 Cost-Effectiveness Analysis:  Echo vs. SPECT in patients with Intermediate Duke Treadmill Score = $39,506/LYS  SPECT vs. Echo in patients with prior history of CAD = $32,381/LYS Lead to greater use of anti-ischemic drugs and revascularization therapy  additional 1.4 LYS

29 Exercise Echo vs. SPECT Cost-Effectiveness Sub-Analysis:  Echo vs. SPECT with risk of cardiac event < 2%/year  $20,565/LYS In this population, if achieve 100% utilization of exercise echo  60% cost savings or $2564/patient over 3 years compared to 100% utilization of SPECT  Stress induced WMA resulted in earlier referral for catheterization and subsequent improved life expectancy

30 Exercise Echo vs. SPECT Cost-Effectiveness Sub-Analysis:  SPECT vs. Echo in individuals with known CAD  $32,381/LYS and a gain in life expectancy of 1.1 years Secondary to greater frequency and reduced time to revascularization

31 Other Areas of CEA Analysis

32 Comments/Discussion Study of 59 Indications for TTE/TEE ---------------------------------------------------------------------- Developing Teaching Tools and Provider Education Use of 3-D Echo – may cut costs? Future Studies – Ideas?

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