von Wyl Viktor, Ulyte Agne, Wei Wenjia, Radovanovic Dragana, Grübner Oliver, Brüngger Beat, Bähler Caroline, Blozik Eva, Dressel Holger, Schwenkglenks Matthias
Department of Epidemiology, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Hirschengraben 84, 8001, Zurich, Switzerland.
Institute for Implementation Science in Health Care, University of Zurich, Universitätsstrasse 84, 8006, Zurich, Switzerland.
BMC Health Serv Res. 2020 Dec 4;20(1):1125. doi: 10.1186/s12913-020-05985-x.
Using the example of secondary prophylaxis of myocardial infarction (MI), our aim was to establish a framework for assessing cost consequences of compliance with clinical guidelines; thereby taking cost trajectories and cost distributions into account.
Swiss mandatory health insurance claims from 1840 persons with hospitalization for MI in 2014 were analysed. Included persons were predominantly male (74%), had a median age of 73 years, and 71% were pre-exposed to drugs for secondary prophylaxis, prior to index hospitalization. Guideline compliance was defined as being prescribed recommended 4-class drug prophylaxis including drugs from the following four classes: beta-blockers, statins, aspirin or P2Y inhibitors, and angiotension-converting enzyme inhibitors or angiotensin receptor blockers. Health care expenditures (HCE) accrued over 1 year after index hospitalization were compared by compliance status using two-part regression, trajectory analysis, and counterfactual decomposition analysis.
Only 32% of persons received recommended 4-class prophylaxis. Compliant persons had lower HCE (- 4865 Swiss Francs [95% confidence interval - 8027; - 1703]) and were more likely to belong to the most favorable HCE trajectory (with 6245 Swiss Francs average annual HCE and comprising 78% of all studied persons). Distributional analyses showed that compliance-associated HCE reductions were more pronounced among persons with HCE above the median.
Compliance with recommended prophylaxis was robustly associated with lower HCE and more favorable cost trajectories, but mainly among persons with high health care expenditures. The analysis framework is easily transferrable to other diseases and provides more comprehensive information on HCE consequences of non-compliance than mean-based regressions alone.
以心肌梗死（MI）二级预防为例，我们的目的是建立一个评估遵循临床指南的成本后果的框架；从而将成本轨迹和成本分布考虑在内。
分析了2014年1840例因MI住院的瑞士强制性医疗保险索赔数据。纳入的人群主要为男性（74%），中位年龄为73岁，71%的人在首次住院前已接受二级预防药物治疗。指南依从性定义为开具推荐的四类药物预防，包括以下四类药物：β受体阻滞剂、他汀类药物、阿司匹林或P2Y抑制剂，以及血管紧张素转换酶抑制剂或血管紧张素受体阻滞剂。使用两部分回归、轨迹分析和反事实分解分析，比较了首次住院后1年内按依从状态累积的医疗保健支出（HCE）。
只有32%的人接受了推荐的四类预防。依从的人HCE较低（-4865瑞士法郎[95%置信区间-8027；-1703]），并且更有可能属于最有利的HCE轨迹（平均每年HCE为6245瑞士法郎，占所有研究对象的78%）。分布分析表明，在HCE高于中位数的人群中，与依从性相关的HCE降低更为明显。
遵循推荐的预防措施与较低的HCE和更有利的成本轨迹密切相关，但主要是在医疗保健支出较高的人群中。该分析框架易于应用于其他疾病，并且比仅基于均值的回归提供了关于不依从的HCE后果的更全面信息。
