Original Article

Resource Consumption and Healthcare Costs of Acute Coronary Syndrome: A Retrospective Observational Administrative Database Analysis Alessandro Roggeri, BSc,* Roberto Gnavi, MD,† Marco Dalmasso, MSc,† Raffaella Rusciani, BSc,† Massimo Giammaria, MD,‡ Monica Anselmino, MD,§ and Daniela Paola Roggeri, MSc* Abstract: The objective of this study was to estimate resource consumption and direct healthcare costs of patients with a first hospitalization for acute coronary syndrome (ACS) in 2008 in the Piedmont Region, Italy. Subjects hospitalized with a first episode of ACS in 2008 were selected from the regional hospital discharge database. All hospitalizations, drug prescriptions, and outpatient episodes of care in the 12 months following discharge were considered to estimate resource consumption and direct healthcare costs from the Piedmont Regional Health Service perspective. The analysis was carried out separately for ST-elevation myocardial infarction (STEMI), non–ST-elevation myocardial infarction (NSTEMI), and unstable angina (UA) populations. In the accrual period, 7765 subjects (1.75‰ of the total population) were hospitalized for ACS (64.2% men). The average age was 66.5 for men and 75.4 for women. The average in-hospital mortality was 6.5% (n = 508). The total ACS population was classified as: STEMI 45.2%, NSTEMI 29.4%, and UA 25.4%. The average yearly costs per patient alive at the end of follow-up (n = 6851) were 14,160.8€ (18,678.7 USD): 83.9% for inpatient admissions [11,881.2€ (15,671.8 USD)], 9.3% for drugs [1311.6€ (1730.1 USD)], 5.0% for diagnostic and therapeutic procedures and outpatient visits [708.2€ (934.1 USD)], and 1.8% for 1-day hospital stays [259.8€ (342.7 USD)]. The average yearly direct healthcare costs by ACS event were 14,984.5€ (19,765.2 USD) for STEMI, 14,554.1€ (19,197.4 USD) for NSTEMI, and 12,481.5€ (16,463.6 USD) for UA. In each subpopulation, costs were significantly higher for men than for women. ACS imposes a significant burden in terms of morbidity and mortality and generates major public health service costs.

the CV system in Italy represented the most widely used drug class, costing over 5€ billion (6.6 USD billion), almost completely covered by the Italian National Health Service (INHS).6 In Italy, ACS costs were recently evaluated in a retrospective observational study in which patients with a first episode of ACS were stratified by type of treatment received at index event (medically treated patients vs. revascularized patients).7 However, direct healthcare costs of patients discharged from hospitals with 1 of the 3 different clinical ACS conditions [ST-elevation myocardial infarction (STEMI), non–ST-elevation myocardial infarction (NSTEMI), or unstable angina (UA)] have never been studied in an Italian real-world setting. These data, which reflect real treatment pathways and related costs, could be useful to estimate the possible economic impact of new treatments in a clinical condition with a significant economic burden. Moreover, the knowledge of healthcare costs distribution among different ACS conditions could be helpful for the government of healthcare spending, and, by emphasizing the cost of new cases of ACS, to underline the possible economic saving of each ACS case prevented, thus contributing to primary prevention of CV diseases. The purpose of this study was therefore to estimate resource consumption and direct healthcare costs of patients with a first admission for ACS in 2008 in the Piedmont Region (through the analysis of regional administrative databases) separately for STEMI, NSTEMI, and UA populations.

Key Words: acute coronary syndrome, cost of illness, epidemiology, healthcare resource use, mortality

METHODS Data Sources

(Crit Pathways in Cardiol 2013;12: 204–209)

C

ardiovascular (CV) diseases are the leading cause of morbidity and mortality all around the world1 and by far the main cause of death in Italy as reported in the “Clinical, technological and institutional appropriateness criteria for the assistance of cardiovascular patients” published by the Italian Ministry of Health in 2010.2 Acute coronary syndrome (ACS) is associated with extremely high costs for both health services and the society.3,4 In Italy, CV hospitalizations during 2010 accounted for an expenditure of more than 5€ billion (6.6 USD billion) and ACS hospitalizations (myocardial infarction [MI] and percutaneous coronary intervention [PCI] with major CV diagnostic procedures) accounted for an expenditure of about 700€ million (923.3 USD million).5 Furthermore, drugs for

From the *ProCure Solutions sas, Bergamo, Italy; †Servizio Sovrazonale di Epidemiologia, ASL TO3, Regione Piemonte, Italy; ‡Ospedale Maria Vittoria, Divisione di Cardiologia, ASL TO2, Torino, Italy; and §Ospedale Giovanni Bosco, Divisione di Cardiologia, ASL TO2, Torino, Italy. Reprints: Alessandro Roggeri, Via Camozzi 1/C 24027 Nembro, Bergamo, Italy. E-mail: [email protected]. Copyright © 2013 by Lippincott Williams & Wilkins ISSN: 1003-0117/13/1204-0204 DOI: 10.1097/HPC.0b013e3182a78c06

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In Italy, all people are cared for by a general practitioner and have access to healthcare services as part of the National Health Service; all procedures and services covered by the INHS are collected in regional databases. The data warehouse, provided by CSI-Piemonte (Consortium for Information Systems–Piedmont Region) for this analysis, contains information on all the Piedmont resident population (more than 4,400,000 inhabitants) obtained from administrative databases provided by the Local Health Units (including information regarding demographic characteristics, prescriptions of drugs reimbursed by INHS, hospital discharge records, and diagnostic and therapeutic procedures including outpatient visits).

Study Design and Selection of Population In this observational study, we evaluated retrospectively the population of patients with a first ACS episode (defined as index event) occurring during the period from January 1, 2008, to December 31, 2008, and classified as STEMI, NSTEMI, or UA. We excluded from this analysis patients with a previous CV hospitalization to select a homogeneous population in terms of resource consumption, healthcare costs, probability of CV recurrence, and treatment pathways. For each subpopulation, in-hospital mortality, resource consumption, and direct health costs were estimated during a 1-year follow-up period after the index event.

Critical Pathways in Cardiology  •  Volume 12, Number 4, December 2013

Critical Pathways in Cardiology  •  Volume 12, Number 4, December 2013

Patients hospitalized with a primary diagnosis of ACS (through International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) 2002, Italian version diagnosis code: 410.xx; 411.1) in 2008 were included. We excluded patients with a previous ACS event (identified through prescriptions of antiplatelet drugs in the previous 24 mo), patients with a previous MI (identified through the 412 ICD-9-CM code or being discharged from hospital in the previous 24 mo with a diagnosis of coronary heart disease), patients hospitalized for malignancies in the 24 months preceding the index event or in the 12 months following the index event of ACS, and patients with index hospitalization outside the region and patients living outside the Piedmont Region. The episode of hospitalization for the “index event” was defined as the concatenation of the admissions where the distance between the discharge date and the subsequent hospitalization was less than 1 day (up to a maximum of 3 hospitalizations). The sequence of admissions considered as part of the index event is interrupted, however, following “patient transfer to another public or private structure for rehabilitation.” ACS-STEMI events were identified through the following ICD-9-CM codes: 410.1, 410.2, 410.3, 410.4, 410.5, 410.6, 410.8, and 410.9; ACS-NSTEMI events were identified by the 410.7 code, whereas ACS-UA events were identified by the 411.1 code. Revascularizations and interventional procedures were identified on the basis of the ICD-9-CM reported in the discharge chart (primary or secondary intervention) and classified as coronary angiography (codes: 88.55, 88.56, and 88.57), PCI (codes: 36.01, 36.02, 36.05, and 36.06), and coronary artery bypass grafting (codes: 36.1x and 36.2). CV rehospitalizations and in-hospital CV deaths were identified with ICD-9-CM codes as: hypertensive disease (401–405); ischemic heart disease including ACS-STEMI, ACS-NSTEMI, and ACS-UA (410–414); diseases of pulmonary circulation (415–417); other forms of heart disease (420–429); cerebrovascular disease (430–438); diseases of arteries, arterioles, and capillaries (440–449); and diseases of veins and lymphatics and other diseases of the circulatory system (451–459). Comorbidities were summarized by the Charlson index8 considering the diagnosis at discharge of the ACS event. All drug prescriptions and diagnostic or therapeutic procedures reimbursed by the Regional Health Service (RHS) and all hospital admissions occurred in the 12 months following hospital discharge were correlated to the ACS population. As the perspective of this analysis was that of Piedmont RHS, the following resource consumptions were evaluated: reimbursed drugs (source: public price reimbursed by the INHS for drugs distributed by pharmacies and real price to be paid by the RHS for drugs distributed via direct distribution or distribution on behalf; reference years 2008–2009), diagnostic and therapeutic procedures and outpatient visits (source: RHS tariffs), and hospital admissions and 1-day hospital stays (source: RHS tariffs for the supply of hospital care for the year 2008 and 2009). Private healthcare services were not considered because the analysis was performed from the perspective of the Piedmont RHS. The cumulative cost for a drug was calculated by multiplying the units prescribed by the cost of each fill. The cumulative cost for hospitalizations was calculated by multiplying each hospitalization by the unit cost for each diagnosisrelated group. The cumulative costs for outpatient visits or diagnostic tests were calculated by multiplying each of them by their unit cost (according to the regional tariff regulations). Costs are expressed both in Euros and in US dollars with an exchange rate of 1.00€ = 1.31904 USD.9

Statistical Analysis A nonparametric statistical hypothesis test (Wilcoxon-MannWhitney) was used to compare average yearly cost per patient for © 2013 Lippincott Williams & Wilkins

Resource Consumption and Healthcare Costs of ACS

men versus women in the total ACS population and in each subpopulation by type of ACS (STEMI, NSTEMI, and UA), total yearly cost per patient alive at the end of the follow-up period for the elderly population (age ≥ 80 yr) versus the weighted average yearly cost of previous age classes, and cost per patient died of a CV event during hospitalizations versus the average yearly cost of patients who survive 1 year from the index event. A nonparametric test (Kruskal-Wallis) was used to compare total yearly direct costs and hospitalization costs of the subpopulations by type of ACS (STEMI, NSTEMI, and UA).

RESULTS Patient Characteristics at Index Event In the accrual period (January 1, 2008 to December 31, 2008), out of 4,432,571 subjects (2,149,373 men and 2,283,198 women) living in the Piedmont Region,10 7765 (1.75‰ of the total population, 2.32‰ of men, and 1.22‰ of women) were hospitalized for a first ACS episode (45.2% STEMI, 29.4% NSTEMI, and 25.4% UA). Patients’ demographic characteristics, ward of admission, and presence of comorbidity at index event are reported in Table 1. In the total population with ACS, and in each subpopulation, men account for more than 60% of patients. At the ACS index event, the average age of women was about 9 years older than men in the overall population (10.9 yr older than men in STEMI, 10.1 in NSTEMI, and 4.9 in UA). As expected, patients with more severe disease (STEMI and NSTEMI) were admitted at the index event mainly in coronary care units (82.1% and 74.2%, respectively), whereas patients with less severe disease (UA) were more frequently admitted in cardiology wards (54.4%). Coronary angiography was performed in about 3 out of 4 patients in all subpopulations; PCI procedures were more frequently performed in STEMI and UA patients, whereas coronary artery bypass grafting was more frequent in UA patients than in other subgroups and, in any case, less frequent than PCI (Table 2). The in-hospital mortality rate at the index event was 6.5% (n = 508) in the total ACS population; mortality rate increased with disease severity (11% in STEMI patients vs. 1.1% in UA patients) (Table 2). In the total ACS population, in-hospital mortality rates (all cause and CV) at index event and during follow-up were higher for women than for men (Table 3). During follow-up, CV rehospitalization occurred in 2324 (33.9%) patients in the ACS population alive at the end of follow-up, 679 (9.9%) of whom had an ACS relapse.

Resources Utilization and Costs The total annual expenditure supported by the Piedmont RHS for the ACS population with a first hospitalization in 2008 was 106,719,070€ (140,766,722 USD); hospitalizations accounted for 84.9% of the total expenditure, drugs for 8.6%, diagnostic and therapeutic procedures (including outpatient visits to be paid by the RHS) for 4.8%, and 1-day hospital admissions for 1.7%. The average yearly cost per patient of the ACS population alive at the end of the follow-up period (n = 6851) in charge to RHS was 14,160.8€ ± 10,563.5€ (mean ± SD) (18,678.7 USD ± 13,933.7 USD), of which 11,881.2€ ± 9579.9€ (15,671.8 USD ± 12,636.3 USD) for hospitalizations, 1311.6€ ± 1351.2€ (1730.1 USD ± 1782.3 USD) for drugs, 708.2€ ± 3152.0€ (934.1 USD ± 4157.6 USD) for diagnostic and therapeutic procedures and outpatient visits, and 259.8€ ± 1182.4€ (342.7 USD ± 1559.6 USD) for 1-day hospital stays; the index event accounted for 60% of the total direct healthcare costs [8514.6€ (11,231.1 USD)]. The www.critpathcardio.com  |  205

Critical Pathways in Cardiology  •  Volume 12, Number 4, December 2013

Roggeri et al

Table 1.  Demographic Characteristics, Ward of Admission, and Presence of Comorbidity at Index Event Total ACS

STEMI

n = 7765

n = 3506

n Age (mean) Gender  Women  Men Department of admission  Coronary care unit  Cardiology  Medicine  Other Charlson index  0  1

%

n

n

%

71.3 ± 12.9

68.2 ± 11.1

35.8 64.2

1210 2296

34.5 65.5

896 1390

39.2 60.8

674 1299

34.2 65.8

5274 1629 701 161

67.9 21.0 9.0 2.1

2877 261 298 70

82.1 7.4 8.5 2.0

1695 294 253 44

74.1 12.9 11.1 1.9

702 1074 150 47

35.6 54.4 7.6 2.4

1647 4347

21.2 56.0

— 2531

0.0 72.2

— 1617

0.0 70.7

1647 199

83.5 10.1

1771

22.8

975

27.8

669

29.3

127

6.4

STEMI

In-hospital mortality

n = 1973 %

2780 4985

Table 2.  Mortality Rate, Revascularizations, and Interventional Procedures Performed at Index Event Procedures

n

69.4 ± 13.6

expenditure for CV drugs (anatomic therapeutic chemical classes C01-C10 plus clopidogrel, ticlopidine, and aspirin) represented only 5.4% of the total healthcare expenditure to be paid by the RHS [842€/patient/yr (1110.6 USD)], whereas hospitalizations and 1-day hospital stays accounted for 86.6% of the total expenditure, representing the major cost driver. In the ACS population alive at the end of follow-up, men had a significantly higher average yearly cost per patient than women (14,716.9€ ± 10,744.0€ vs. 13,067.7€ ± 10,049.9€, respectively; P < 0.0001) (19,412.2 USD ± 14,171.8 USD vs. 17,236.8 USD ± 13,256.2 USD, respectively; P < 0.0001) (Fig. 1). In terms of values, all cost components but drugs were significantly higher in men than in women [diagnostics and therapeutic procedures (P = 0.0043); day hospitals (P < 0.0001); hospitalizations (P < 0.0001); drugs (P = 0.2235)], hospitalizations representing the principal driver of the difference in total costs between genders. In terms of percentages, cost composition is similar between genders; hospitalizations represent with about 84% the major cost component both in men and in women. Moreover, in each subgroup, women had a lower access to invasive procedures (Table 4). The analysis of the subpopulations by type of ACS (STEMI, NSTEMI, and UA) highlights that the total yearly direct healthcare costs significantly decreased with decreasing disease severity (14,984.5€ ± 10,961.7€, 14,554.5€ ± 10,719.5€, and 12,482.2€ ± 9540.9€, respectively; P < 0.0001) (19,765.2 USD ± 14,458.9 USD, 19,198.0 USD ± 14,139.4 USD, and 16,464.5 USD ± 12,584.8

Coronary angiography PCI CABG

UA

n = 2286 %

69.7 ± 12.8

 ≥2

NSTEMI

Table 3.  Mortality Rates

NSTEMI

UA

n

%

n

%

n

%

2662

75.9

1676

73.3

1732

87.8

2292 109

65.4 3.1

1162 135

50.8 5.9

1207 136

61.2 6.9

387

11.0

99

4.3

22

1.1

CABG indicates coronary artery bypass grafting.

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USD, respectively; P < 0.0001); in these populations, index events accounted for 62%, 61%, and 56% of the total direct healthcare costs (9286.6€, 8841.3€, and 6985.1€) (12,249.4 USD, 11,662.0 USD, and 9213.6 USD), respectively. The average annual cost composition per patient alive at the end of follow-up by ACS index event is reported in Figure 2. The major cost driver in all the subpopulations were hospitalizations, which significantly decreased according to disease severity (12,918.8€ ± 10,285.1€, 12,173.8€ ± 9499.6€, and 9982.3€ ± 8169.2€ for STEMI, NSTEMI, and UA, respectively; P < 0.0001) (17,040.4 USD ± 13,566.5 USD, 16,057.7 USD ± 12,530.4 USD, and 13,167.1 USD ± 10,775.5 USD for STEMI, NSTEMI, and UA, respectively; P < 0.0001). Moreover, as reported for the total ACS population alive at the end of follow-up, the average yearly cost per patient in each subpopulation was significantly higher for men than for women (15,363.2€ vs. 14,125.2€ in STEMI, 15,363.7€ vs. 13,220.7€ in NSTEMI, and 13,022.2€ vs. 11,440.0€ in UA; P 

Resource consumption and healthcare costs of acute coronary syndrome: a retrospective observational administrative database analysis.

The objective of this study was to estimate resource consumption and direct healthcare costs of patients with a first hospitalization for acute corona...
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