Impact of dyspnea on medical utilization and affiliated costs in patients with acute coronary syndrome.

BACKGROUND

Current clinical practice guidelines recommend dual antiplatelet therapy with aspirin and clopidogrel or prasugrel for patients with acute coronary syndrome (ACS). Ticagrelor, an experimental antiplatelet therapy, has been shown to be associated with significantly higher rates of dyspnea than clopidogrel in clinical trials. Patients with ACS presenting with dyspnea require additional medical attention to rule out possible heart failure or other serious diagnoses. This study used real-world data to quantify the direct medical costs of dyspnea among patients with a history of ACS.

OBJECTIVE

To determine the clinical and economic impact of a dyspnea episode for patients with a history of ACS using commercial and Medicare supplemental claims data.

METHODS

Patients with an emergency room (ER) visit with a primary diagnosis of dyspnea (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] diagnosis code, 786.0x) in 2008 or 2009 were identified using Thomson Reuters MarketScan(®) Research Databases. Patients were required to have 6 months of continuous medical enrollment prior to an ER visit and a history of ACS (ie, ≥ 1 inpatient claim, ≥ 1 ER visit, or ≥ 2 outpatient claims, with an ICD-9-CM diagnosis code for ACS [410.xx or 411.1x] in any position on the outpatient claim during either the baseline period or on the index date). An episode of dyspnea was defined as all ER and outpatient services on the day of an ER claim with a primary diagnosis of dyspnea, and any inpatient admissions occurring on the day of or day following the ER visit. Procedure utilization and expenditures were evaluated for the ER visit and associated outpatient services, as well as the proportion of ER visits that led to an inpatient stay. Costs were allowed charges (ie, provider payment plus member cost-share) adjusted to 2009 US constant dollars.

RESULTS

A total of 8433 ER visits for dyspnea were identified during 2008 to 2009 from these databases of approximately 74 million beneficiaries. The average cost per dyspnea episode was $6958, of which $1621 were outpatient costs associated with the ER visit (standard deviation, $3269). Along with physician services, assessment of dyspnea often included electrocardiogram (71.3%), chest radiograph (75.9%), and, occasionally, a B-type natriuretic peptide test (14.9%) or chest computed axial tomography scan (12.2%). More than one-fourth (25.8%) of dyspnea ER visits preceded an inpatient stay, with an average cost of $20 693 per patient.

CONCLUSIONS

Dyspnea is a significant event associated with high medical resource utilization and hospital costs. Ticagrelor, an experimental antiplatelet agent not yet available on the market, has been shown to be associated with significantly higher rates of dyspnea than clopidogrel in clinical trials. Considering that the increased risk of dyspnea for ticagrelor is well documented, these costs may be important to health plan decision-makers when evaluating costs associated with each antiplatelet therapy.