IMPORTANCE: In the Empagliflozin Outcome Trial in Patients With Chronic Heart Failure With Preserved Ejection Fraction (EMPEROR-Preserved), empagliflozin significantly reduced hospitalizations for ...heart failure while improving patient-reported health status compared with placebo. The long-term cost-effectiveness of empagliflozin among patients who have heart failure with preserved ejection fraction (HFpEF) remains unclear. OBJECTIVE: To estimate the cost-effectiveness of empagliflozin in patients with HFpEF. DESIGN, SETTING, AND PARTICIPANTS: This cost-effectiveness analysis performed from October 2021 to April 2022 included a Markov model using estimates of treatment efficacy, event probabilities, and utilities from EMPEROR-Preserved and published literature. Costs were derived from national surveys and pricing data sets. Quality of life was imputed from a heart failure–specific quality-of-life measure. Two analyses were performed, with and without a treatment effect on cardiovascular mortality. Subgroup analyses were based on diabetes status, ejection fraction, and health status impairment due to heart failure. The model reproduced the event rates and risk reduction with empagliflozin observed in EMPEROR-Preserved over 26 months of follow-up; future projections extended across the lifetime of patients. EXPOSURES: Empagliflozin or standard of care. MAIN OUTCOMES AND MEASURES: Hospitalizations for heart failure, life-years, quality-adjusted life-years (QALYs), lifetime costs, and lifetime incremental cost-effectiveness ratio. RESULTS: A total of 5988 patients were included in the analysis, with a mean age of 72 years, New York Heart Association class II to IV heart failure, and left ventricular ejection fraction greater than 40%. At the Federal Supply Schedule price of $327 per month, empagliflozin yielded 0.06 additional QALYs and $26 257 incremental costs compared with standard of care, producing a cost per QALY gained of $437 442. Incremental costs consisted of total drug costs of $29 586 and savings of $3329 from reduced hospitalizations for heart failure. Cost-effectiveness was similar across subgroups. The results were most sensitive to the monthly cost, quality-of-life benefit, and mortality effect of empagliflozin. A price reduction to $153 per month, incremental utility of 0.02, or 8% reduction in cardiovascular mortality would bring empagliflozin to $180 000 per QALY gained, the threshold for intermediate value. Using Medicare Part D monthly pricing of $375 after rebates and $511 before rebates, empagliflozin would remain low value at $509 636 and $710 825 per QALY gained, respectively. Cost-effectiveness estimates were robust to variation in the frequency and disutility of heart failure hospitalizations. CONCLUSIONS AND RELEVANCE: In this economic evaluation, based on current cost-effectiveness benchmarks, empagliflozin provides low economic value compared with standard of care for HFpEF, largely due to its lack of efficacy on mortality and small benefit on quality of life.
Cardiac toxicity is one of the most concerning side effects of anti-cancer therapy. The gain in life expectancy obtained with anti-cancer therapy can be compromised by increased morbidity and ...mortality associated with its cardiac complications. While radiosensitivity of the heart was initially recognized only in the early 1970s, the heart is regarded in the current era as one of the most critical dose-limiting organs in radiotherapy. Several clinical studies have identified adverse clinical consequences of radiation-induced heart disease (RIHD) on the outcome of long-term cancer survivors. A comprehensive review of potential cardiac complications related to radiotherapy is warranted. An evidence-based review of several imaging approaches used to detect, evaluate, and monitor RIHD is discussed. Recommendations for the early identification and monitoring of cardiovascular complications of radiotherapy by cardiac imaging are also proposed.
While transthoracic echocardiography (TTE) is responsible for more Medicare spending than any other cardiovascular imaging procedure, little is known about its commercial cost footprint. The 2021 ...Hospital Price Transparency Final Rule mandated that U.S. hospitals publish their insurer-negotiated and self-pay prices for services. This study sought to characterize and assess factors contributing to variation in TTE prices.
We used a commercial database containing hospital-disclosed prices to characterize variation in TTE prices within and across hospitals. We linked these price data to hospital and regional characteristics using Medicare Facility IDs.
A total of 1,949 hospitals reported commercial prices. Among reporting hospitals, median commercial and self-pay prices were 2.93 and 3.06 times greater than the median Medicare price ($1,313 and $1,422, respectively, vs $464). Within hospitals, the 90th percentile payer-negotiated rate was 2.78 (interquartile range, 1.80-5.09) times the 10th percentile rate (within-center ratio). Across hospitals within the same hospital referral region, the median price at the 90th percentile hospital was 2.47 (interquartile range, 1.69-3.75) times that at the 10th percentile hospital (across-center ratio). On univariate analysis, for-profit (P = .04), teaching (P < .01), investor-owned (P < .01), and higher-rated hospitals (P < .01) charged higher prices, whereas rural referral centers (P = .01) and disproportionate share hospitals (P < .01) charged less. On multivariate analysis, the association between these characteristics and TTE prices persisted, except for investor ownership and rural referral centers.
Self-pay and commercial TTE prices were higher than Medicare prices and varied significantly within and across hospitals. For-profit, teaching, and higher-rated hospitals had higher prices, in contrast to DSH hospitals. A better understanding of the relationship between this cost variation and quality of care is critical given the impact of cost on health care access and affordability.
IMPORTANCE: Noninvasive testing and coronary angiography are used to evaluate patients who present to the emergency department (ED) with chest pain, but their effects on outcomes are uncertain. ...OBJECTIVE: To determine whether cardiovascular testing—noninvasive imaging or coronary angiography—is associated with changes in the rates of coronary revascularization or acute myocardial infarction (AMI) admission in patients who present to the ED with chest pain without initial findings of ischemia. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort analysis used weekday (Monday-Thursday) vs weekend (Friday-Sunday) presentation as an instrument to adjust for unobserved case-mix variation (selection bias) between 2011 and 2012. National claims data (Truven MarketScan) was used. The data included a total of 926 633 privately insured patients ages 18 to 64 years who presented to the ED with chest pain without initial diagnosis consistent with acute ischemia. EXPOSURES: Noninvasive testing or coronary angiography within 2 days or 30 days of presentation. MAIN OUTCOMES AND MEASURES: The primary end points were coronary revascularization (percutaneous coronary intervention or coronary artery bypass graft surgery) and AMI admission at 7, 30, 180, and 365 days. The secondary end points were coronary angiography and coronary artery bypass grafting in those who underwent angiography. RESULTS: The patients were ages 18 to 64 years with an average age of 44.4 years. A total of 536 197 patients (57.9%) were women. Patients who received testing (224 973) had increased risk at baseline and had greater risk of AMI admission than those who did not receive testing (701 660) (0.35% vs 0.14% at 30 days). Weekday patients (571 988) had similar baseline comorbidities to weekend patients (354 645) but were more likely to receive testing. After risk factor adjustment, testing within 30 days was associated with a significant increase in coronary angiography (36.5 per 1000 patients tested; 95% CI, 21.0-52.0) and revascularization (22.8 per 1000 patients tested; 95% CI, 10.6-35.0) at 1 year but no significant change in AMI admissions (7.8 per 1000 patients tested; 95% CI, −1.4 to 17.0). Testing within 2 days was also associated with a significant increase in coronary revascularization but no difference in AMI admissions. CONCLUSIONS AND RELEVANCE: Cardiac testing in patients with chest pain was associated with increased downstream testing and treatment without a reduction in AMI admissions, suggesting that routine testing may not be warranted. Further research into whether specific high-risk subgroups benefit from testing is needed.
Statins decrease mortality in those with atherosclerotic cardiovascular disease (ASCVD), but statin adherence remains suboptimal.
To determine the association between statin adherence and mortality ...in patients with ASCVD who have stable statin prescriptions.
This retrospective cohort analysis included patients who were between ages 21 and 85 years and had 1 or more International Classification of Diseases, Ninth Revision, Clinical Modification codes for ASCVD on 2 or more dates in the previous 2 years without intensity changes to their statin prescription who were treated within the Veterans Affairs Health System between January 1, 2013, and April 2014.
Statin adherence was defined by the medication possession ratio (MPR). Adherence levels were categorized as an MPR of less than 50%, 50% to 69%, 70% to 89%, and 90% or greater. For dichotomous analyses, adherence was defined as an MPR of 80% or greater.
The primary outcome was death of all causes adjusted for demographic and clinical characteristics, as well as adherence to other cardiac medications.
Of 347 104 eligible adults with ASCVD who had stable statin prescriptions, 5472 (1.6%) were women, 284 150 (81.9%) were white, 36 208 (10.4%) were African American, 16 323 (4.7%) were Hispanic, 4093 (1.2%) were Pacific Islander, 1293 (0.4%) were Native American, 1145 (0.3%) were Asian, and 1794 (0.5%) were other races. Patients taking moderate-intensity statin therapy were more adherent than patients taking high-intensity statin therapy (odds ratio OR, 1.18; 95% CI, 1.16-1.20). Women were less adherent (OR, 0.89; 95% CI, 0.84-0.94), as were minority groups. Younger and older patients were less likely to be adherent compared with adults aged 65 to 74 years. During a mean (SD) of 2.9 (0.8) years of follow-up, there were 85 930 deaths (24.8%). Compared with the most adherent patients (MPR ≥ 90%), patients with an MPR of less than 50% had a hazard ratio (HR; adjusted for clinical characteristics and adherence to other cardiac medications) of 1.30 (95% CI, 1.27-1.34), those with an MPR of 50% to 69% had an HR of 1.21 (95% CI, 1.18-1.24), and those with an MPR of 70% to 89% had an HR of 1.08 (95% CI, 1.06-1.09).
Using a national sample of Veterans Affairs patients with ASCVD, we found that a low adherence to statin therapy was associated with a greater risk of dying. Women, minorities, younger adults, and older adults were less likely to adhere to statins. Our findings underscore the importance of finding methods to improve adherence.
Background The purpose of this study was to assess temporal trends in clinical characteristics, treatments, quality indicators, and outcomes for heart failure (HF) hospitalizations. Methods ...Characteristics, treatments, quality measures, and inhospital outcomes were measured over 12 consecutive quarters (January 2002 to December 2004) using data from 159 168 enrollments from 285 ADHERE hospitals. Results Baseline characteristics were similar or showed only modest changes, and severity of illness by logistic regression was unchanged over all 12 quarters. Inhospital treatment changed significantly over time with inotrope use decreasing from 14.7% to 7.9% ( P < .0001). Discharge instructions increased 133%; smoking counseling, 132%; left ventricular function measurement, 8%; and β-blocker use, 29% (all P < .0001). Clinical outcomes improved over time, including need for mechanical ventilation, which decreased 5.3% to 3.4% (relative risk 0.64, P < .0001); length of stay (mean), 6.3 to 5.5 days; and mortality, 4.5% to 3.2% (relative risk 0.71, P < .0001). Conclusions Over a 3-year period, demographics and clinical characteristics were relatively similar, but significant changes in intravenous therapy, enhancements in conformity to quality-of-care measures, increased administration of evidence-based HF medications, and substantial improvements in inhospital morbidity and mortality were observed during hospitalization for HF.
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Disparities in care and outcomes for heart failure patients, particularly among Black individuals and female patients, are a significant concern. Black individuals develop heart failure at a younger ...age and have a higher incidence compared to other races. Despite improvements in hospitalization rates, there are still disparities in unrecognized heart failure and end-stage heart failure, with Black patients accounting for a higher proportion of hospitalizations. Heart transplant is the optimal treatment for end-stage heart failure, and while the number of heart transplants has increased for all groups, racial and ethnic differences persist. Asian patients have the highest probability of receiving a transplant, followed by Hispanic patients, and then Black patients. There is also evidence of fewer heart transplant listings for female patients. The process of offering donor organs may contribute to these disparities, as there are differences in organ offer acceptance based on race and sex. The new heart transplant allocation system has increased access to transplants but its effect on equity is unclear. Further research is needed to understand and address these disparities in heart transplant rates.
Table 4 Retired STEMI and NSTEMI Measures From the 2008 Set AMI indicates acute myocardial infarction; LDL, low-density lipoprotein; NSTEMI, non-ST-elevation myocardial infarction; PM, performance ...measure; QM, quality measure; and STEMI, ST-elevation myocardial infarction. # Care Setting Measure Title Rationale for Retiring the Measure PM-12 Inpatient Adult Smoking Cessation Advice/Counseling This measure is being retired because perfect scores are consistently achieved and the measure appears to have reached a ceiling effect. ...given absence of room for further improvement, the writing committee opted to omit this measure from the inpatient performance measure set for AMI (realizing also that a separate outpatient CAD measure set will likely address smoking cessation advice/counseling). ...the benefit of fibrinolytic therapy is most effective when provided promptly, and the ACCF/AHA guideline set a benchmark time goal from hospital arrival to drug administration, or DTN time, to be <=30 min (12). ...measuring troponin levels expeditiously help in the early diagnosis and risk stratification of these patients, which can lead to earlier triage and institution of appropriate medical and interventional treatments (11). Numerator Eligible∗ patients with AMI who are prescribed an aldosterone antagonist at hospital discharge Denominator All post-AMI patients who:a are receiving an ACE inhibitor and a beta blocker;ANDb have a LVEF <=40%;ANDc have either diabetes mellitus or HF Denominator Exclusions Patients age <18 y Patients who leave against medical advice Patients who die during hospitalization Patients who are on comfort care measures only or hospice Patients who are transferred to another hospital for inpatient acute care Denominator Exceptions Documentation of a medical reason for not prescribing an aldosterone antagonist at hospital discharge (e.g., allergy or intolerance to aldosterone antagonist, significant renal dysfunction Cr >2.5 mg/dL in men; >2.0 mg/dL in women, hyperkalemia K >5.0 mEq/L) Patient currently enrolled in a clinical trial related to AMI (e.g., trials involving renin-angiotensin-aldosterone system inhibitors) Measurement Period Encounter Sources of Data Medical record or other database (e.g., administrative, clinical, registry) Attribution Measure reportable at the facility or provider level Care Setting Inpatient Rationale The EPHESUS (Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival) study demonstrated benefits from adding eplerenone, a selective aldosterone antagonist, to ACE inhibitors or ARBs (in 87% of patients) and beta blockers (75%), including a 15% and 17% reduction in overall and cardiovascular mortality, respectively. ...in the absence of contraindications, post-MI patients with HF may benefit from adding an aldosterone antagonist to an ACE inhibitor or ARB, and a beta blocker.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
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