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Cost-Effectiveness Analysis and Echocardiography Ali R. Rahimi, MD MPH October 10, 2007
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Background Expenditures in healthcare are increasing Resources – people, time, facilities, equipment, and knowledge – are scarce Choices need to be made daily regarding their deployment
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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.
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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.
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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.
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Review of the Literature Hand-Held Cardiac Ultrasound Stress Echo versus SPECT Imaging
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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
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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
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OptiGo Portable Device (Phillips) 2.5 MHz phased array transducer 2D, color-flow doppler, and calipers
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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
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Hand-Carried Cardiac Ultrasound
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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%)
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Hand-Carried Cardiac Ultrasound
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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
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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
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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
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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
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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
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Inpatient HCU Prediction of Normal ScanPrediction of Normal LV function Prediction with Specific Request for LV function
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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
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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
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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
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Review of the Literature Hand-Held Cardiac Ultrasound Stress Echo versus SPECT Imaging
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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
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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
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Exercise Echo vs. SPECT
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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
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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
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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
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Other Areas of CEA Analysis
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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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