School of Pharmaceutical Science and Technology, Tianjin University, Tianjin, China.
Tianjin Chest Hospital, Tianjin, China.
Clin Ther. 2019 Mar;41(3):456-465.e2. doi: 10.1016/j.clinthera.2019.01.005. Epub 2019 Feb 13.
This study was conducted to examine the use of optimal medical therapy (OMT), consisting of an antiplatelet, a β-blocker, an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEI/ARB), and a statin combined, after hospital discharge and its relationship with direct medical costs in patients with acute coronary syndromes (ACS) in Tianjin, China.
Data were obtained from the Tianjin Urban Employee Basic Medical Insurance database (2011-2015). Data from adult patients with ≥1 hospitalization for ACS between January 2012 and December 2014 were included. Medications including antiplatelets, β-blockers, ACEIs/ARBs, and statins at discharge were recorded, with OMT defined as the use of all 4 indicated medications. Propensity-score matching was conducted to form matched OMT and non-OMT cohorts based on baseline differences. All-cause and ACS-related health care resource utilization and direct medical costs during a 12-month follow-up period were assessed and compared between cohorts. Generalized linear modeling was conducted to assess the association between OMT at discharge and direct medical costs.
A total of 22,041 patients were identified (mean age, 64.7 [10.7] years; 45.6% female), of whom 15.1% (3336) received OMT at discharge. The OMT cohort had fewer patients hospitalized for any cause during follow-up compared with the matched non-OMT cohort (38.1% vs 43.2%; P < 0.001), which was further associated with fewer hospitalizations (1.55 vs 1.64; P = 0.019) and shorter annualized length of stay (15.9 vs 17.2 d; P = 0.041). Despite higher costs of outpatient services (9958 vs 10,060 Chinese yuan [CNY] [P = 0.006]; adjusted difference, +456 CNY [P = 0.004]) (year-2014 1 USD = 6.20 CNY), the OMT cohort had significantly lower all-cause total costs (20,771 vs 22,877 CNY [P = 0.174]; adjusted difference, -2089 CNY [P = 0.006]), driven by lower costs of inpatient services (10,813 vs 12,817 CNY [P < 0.001]; adjusted difference, -2184 CNY [P = 0.001]). The difference in ACS-related total costs between the 2 cohorts was not statistically significant (8535 vs 9304 CNY [P = 0.128]; adjusted difference, -558 CNY [P = 0.214]).
Receiving OMT at discharge was associated with fewer hospitalizations and lower all-cause direct medical costs in these patients with ACS in China. Strategies are needed to improve OMT prescribing rates at discharge, which would lead to better clinical prognosis and total cost-savings among patients with ACS in China.
本研究旨在考察出院后使用最佳药物治疗（OMT），包括抗血小板、β受体阻滞剂、血管紧张素转换酶抑制剂/血管紧张素受体阻滞剂（ACEI/ARB）和他汀类药物联合治疗，并分析其与中国天津急性冠状动脉综合征（ACS）患者的直接医疗费用之间的关系。
数据来自天津市城镇职工基本医疗保险数据库（2011-2015 年）。纳入 2012 年 1 月至 2014 年 12 月期间因 ACS 至少住院 1 次的成年患者。记录出院时使用的抗血小板、β受体阻滞剂、ACEI/ARB 和他汀类药物，OMT 定义为使用全部 4 种推荐药物。根据基线差异，采用倾向评分匹配法形成匹配的 OMT 和非 OMT 队列。评估并比较两组患者在 12 个月随访期间的全因和 ACS 相关医疗资源利用情况和直接医疗费用。采用广义线性模型评估出院时 OMT 与直接医疗费用之间的关系。
共纳入 22041 例患者（平均年龄 64.7[10.7]岁；45.6%为女性），其中 15.1%（3336 例）出院时接受 OMT。与匹配的非 OMT 队列相比，OMT 队列在随访期间因任何原因住院的患者比例更低（38.1%比 43.2%；P<0.001），这与更少的住院治疗（1.55 次比 1.64 次；P=0.019）和更短的年均住院天数（15.9 天比 17.2 天；P=0.041）相关。尽管门诊服务费用更高（9958 元比 10060 元人民币[CNY]（P=0.006）；调整后差值，+456 CNY（P=0.004）]（2014 年 1 美元=6.20 CNY），但 OMT 队列的全因总费用明显更低（20771 元比 22877 元人民币（P=0.174）；调整后差值，-2089 元人民币（P=0.006）），这主要归因于住院费用降低（10813 元比 12817 元人民币（P<0.001）；调整后差值，-2184 元人民币（P=0.001））。两组 ACS 相关总费用的差异无统计学意义（8535 元比 9304 元人民币（P=0.128）；调整后差值，-558 元人民币（P=0.214））。
在中国 ACS 患者中，出院时接受 OMT 与更少的住院治疗和更低的全因直接医疗费用相关。需要制定策略提高出院时 OMT 的开具率，这将为中国 ACS 患者带来更好的临床预后和总体成本节约。
