Kang Jaskaran S, Bennell Maria C, Qiu Feng, Knudtson Merril L, Austin Peter C, Ko Dennis T, Wijeysundera Harindra C
Division of Cardiology (Kang, Bennell, Ko, Wijeysundera), Sunnybrook Health Sciences Centre, Schulich Heart Centre, University of Toronto; Institute for Clinical Evaluative Sciences (Qiu, Austin, Ko, Wijeysundera), Toronto, Ont.; Libin Cardiovascular Institute of Alberta (Knudtson), University of Calgary, Calgary, Alta.; Institute of Health Policy, Management and Evaluation (Austin, Ko, Wijeysundera), University of Toronto, Toronto, Ont.
CMAJ Open. 2016 Aug 8;4(3):E409-E416. doi: 10.9778/cmajo.20150138. eCollection 2016 Jul-Sep.
Cardiovascular disease is costly, and annual expenditures are projected to increase. Our objective was to examine the variation in patient-level costs and identify drivers of cost in patients with stable coronary artery disease.
In this retrospective cohort study using administrative databases in Ontario, Canada, we identified all patients with stable coronary artery disease after index angiography between Oct. 1, 2008, and Sept. 30, 2011. We excluded patients with a myocardial infarction within 90 days before the index, with normal coronaries, or with mild coronary disease. We categorized hospitals into low, medium or high revascularization ratio centres. The primary outcome was cumulative 1-year health care costs. A hierarchical generalized linear model identified patient, physician and hospital characteristics associated with patient costs, with 2 main covariates of interest: treatment allocation (medical v. percutaneous coronary intervention v. coronary artery bypass grafting) and hospital revascularization ratio.
A total of 183 630 angiography procedures were performed in Ontario during the study period. The final cohort included 39 126 patients with stable coronary artery disease, of which 15 138 received medical treatment and 23 988 received revascularization. The mean 1-year cost was $24 026 (interquartile range $8235-$30 511). The mean costs for medical management and revascularization were $18 069 and $27 786, respectively. The strongest predictor of costs was revascularization (percutaneous coronary intervention: cost ratio 1.27, 95% CI [confidence interval] 1.24-1.31; coronary artery bypass grafting: cost ratio 2.62, 95% CI 2.53-2.71). Hospital revascularization ratio did not significantly affect costs. There was no significant interaction between treatment and revascularization ratio.
Most health care costs were due to acute care hospital admissions, and costs were higher for patients undergoing revascularization than medical therapy. This study suggests that treatment decision has a substantial impact on health care resources.
心血管疾病成本高昂，预计年度支出还会增加。我们的目标是研究患者层面成本的差异，并确定稳定型冠状动脉疾病患者的成本驱动因素。
在这项使用加拿大安大略省行政数据库的回顾性队列研究中，我们确定了2008年10月1日至2011年9月30日期间首次血管造影术后所有稳定型冠状动脉疾病患者。我们排除了在首次血管造影前90天内发生心肌梗死、冠状动脉正常或患有轻度冠状动脉疾病的患者。我们将医院分为低、中、高血运重建率中心。主要结局是1年累计医疗保健成本。分层广义线性模型确定了与患者成本相关的患者、医生和医院特征，有两个主要感兴趣的协变量：治疗分配（药物治疗与经皮冠状动脉介入治疗与冠状动脉旁路移植术）和医院血运重建率。
在研究期间，安大略省共进行了183630例血管造影手术。最终队列包括39126例稳定型冠状动脉疾病患者，其中15138例接受药物治疗，23988例接受血运重建。平均1年成本为24026美元（四分位间距8235 - 30511美元）。药物治疗和血运重建的平均成本分别为18069美元和27786美元。成本的最强预测因素是血运重建（经皮冠状动脉介入治疗：成本比1.27，95%置信区间[1.24 - 1.31]；冠状动脉旁路移植术：成本比为2.62，95%置信区间2.53 - 2.71）。医院血运重建率对成本没有显著影响。治疗与血运重建率之间没有显著交互作用。
大多数医疗保健成本是由于急性护理医院住院，接受血运重建的患者成本高于药物治疗。这项研究表明治疗决策对医疗保健资源有重大影响。
