Abstract Background Atrial fibrillation (AF) is common in patients with heart failure. Rhythm- and rate-control strategies are associated with similar efficacy outcomes. We compared the economic ...impact of the 2 treatment strategies in patients with AF and heart failure from the province of Québec, Canada. Methods In a substudy of the Atrial Fibrillation and Congestive Heart Failure trial, health care expenditures of patients from Québec randomized to rhythm and rate-control treatment strategies were compared from a single-payer perspective using a cost-minimization approach. In-trial resource utilization and unit costs were estimated from Québec Health Insurance Board databases supplemented by disease-specific costs from the Ontario Case Costing Initiative. Results In all, 304 patients were included, aged 68 ± 9 years; 86% male; ejection fraction, 26% ± 6%. Baseline characteristics were similar in rhythm-control (n = 149) and rate-control (n = 155) groups. Arrhythmia-related costs accounted for 45% of total expenditures. Rate-control patients had fewer cardiac procedures (146 vs 238, P < 0.001), driven by fewer cardioversions, and lower costs related to antiarrhythmic drugs (CAD$48 per patient 95% confidence interval {CI}, $21-$96 vs $1319 per patient 95% CI, $1124-$1522). However, these differences were offset by higher expenditures due to hospitalizations for noncardiovascular diagnoses, implantable cardiac arrhythmia devices, and noncardiovascular drugs in the rate-control group. The total cost per patient was not significantly different between rhythm-control ($72,764 95% CI, $61,575-$85,145) and rate-control ($78,767 95% CI, $67,101-$92,139) strategies. Conclusion In the study population, the therapeutic strategy used to manage AF in patients with severe heart failure appears to have little influence on the overall financial burden, which remains substantial.
Despite being effective in the primary and secondary prevention of sudden cardiac arrest, the cost-effectiveness of implantable cardioverter–defibrillator (ICD) therapy remains debated. We attempted ...to estimate the value ICD recipients place on their ICD device. We used the contingent valuation method to evaluate the willingness to pay (WTP) and the cost benefit of ICD therapy in an unselected population of 237 recipients. A hypothetical scenario was presented to patients in which at the end of their current ICD no public reimbursement for the replacement would occur. Patients were asked to indicate their out-of-pocket WTP for a replacement ICD using a close-ended question format. Seven different “take-it-or-leave-it” bids were randomly varied and assigned to patients. Median WTP was calculated with nonparametric methods, and multiple logistic regression models were generated to identify factors associated with WTP. Only cost of the device was considered. Median WTP was estimated at CAN $4,125, which corresponds to 21% of the cost of the device (CAN $20,000). In multiple logistic regression analysis, a higher bid (odds ratio OR 0.95, 95% confidence interval CI 0.91 to 0.99, per CAN $1,000 increase) was associated with a lower WTP, whereas a higher gross family income (OR 2.3, 95% CI 0.9 to 9.0) and higher education (OR 2.2, 95% CI 0.9 to 5.1) were associated with a trend for higher WTP. In conclusion, ICD recipients would be willing to pay a substantial amount for a replacement ICD. Considering the expensive price of the device, ICD recipients value favorably the benefits provided by the ICD.
Morbidity associated with cardiovascular disease is increasing in the HIV-infected population. We aimed to study the impact of HIV and of antiretrovirals on acute myocardial infarction (AMI).
We ...performed a cohort and a nested case-control study using the dataset of the Régie de l'Assurance Maladie du Québec. HIV-positive patients were identified using ICD-9 diagnostic codes and matched to HIV-negative patients. Within the HIV-positive cohort, cases of AMI were identified and matched to HIV-positive patients without AMI. The coprimary outcomes were the risk of AMI associated with HIV exposure in the cohort study and that associated with exposure to antiretrovirals in the case-control study. Data were analysed using Poisson and conditional logistic regression.
About 7053 HIV-positive patients were matched to 27,681 HIV-negative patients. Incidence rates of AMI in the HIV+ cohort was 3.88 95% confidence interval (CI) (3.26 to 4.58) per 1000 patient-years, compared to 2.21 95% CI (1.93 to 2.52) per 1000 patient-years in the HIV cohort. The adjusted incidence ratio of AMI for HIV-infected patients was 2.11 95%CI (1.69 to 2.63). Among HIV+ patients, 125 AMI cases were matched with 1084 HIV+ patients. We found increased odds ratio (95% CI) of AMI associated with any exposure to abacavir 1.79 (1.16 to 2.76), P = 0.02, efavirenz 1.83 (1.21 to 2.76) P = 0.004, lopinavir 1.98 (1.24 to 3.16) P = 0.004, and ritonavir 2.29 (1.48 to 3.54) P < 0.001.
HIV+ individuals were at higher risk of AMI than the general population, and several antiretrovirals were associated with an increased risk of AMI. Results should be interpreted with caution in absence of data on smoking and HIV clinical status.
To compare functional autonomy, quality of life (QOL), and pain control after endovascular and open repair (OR) of abdominal aortic aneurysms.
Forty patients with a low surgical risk profile and ...anatomic compatibility for stent-graft therapy were randomized to receive OR or endovascular aneurysm repair (EVAR). Technical and clinical success as well as mortality were assessed in both groups and compared by Kaplan-Meier analysis. Functional autonomy and QOL were assessed by Karnofsky score and Short Form 36 (SF-36) questionnaire. Pain control was assessed by a numeric rating scale and Brief Pain Inventory questionnaire. QOL outcomes by means of the SF-36 and pain questionnaires were compared with use of mixed-effects models for repeated-measures analysis.
All procedures were technically successful in both groups. Three late clinical failures requiring surgical conversion or repeated intervention were observed in the EVAR group and one was observed in the OR group. There was no significant difference between groups in terms of functional autonomy or QOL. No difference in pain level was evident during the early postoperative period, whereas the pain level was lower in the OR group after 1 month. Opioid analgesic drug consumption was significantly greater in the OR group during the postoperative period. Mean hospitalization duration was shorter in the EVAR group than in the OR group (4.5 days +/- 2.4 vs 11.5 days +/- 8.1; P= .001).
EVAR has no advantage over OR in patients at low risk in terms of functional autonomy, QOL, and pain control. However, EVAR was associated with shorter hospitalization durations compared with OR.
Ocular hypertension and open-angle glaucoma are well-known side-effects of treatment with topical ophthalmic glucocorticoids. There is uncertainty about the risk of these disorders with oral ...glucocorticoid therapy.
Data from the Quebec universal health insurance programme for the elderly were used to identify 9793 patients with a new diagnosis of ocular hypertension or open-angle glaucoma, or on newly prescribed treatment for these disorders (cases). 38 325 controls were randomly selected from ophthalmology patients seen in the same month and year as the case (index date). Current use of oral glucocorticoids was defined as that within 14 days of the index date. All glucocorticoid doses were converted to the equivalent amount of hydrocortisone. The case-control analysis was done by conditional logistic regression and adjusted for age, sex, systemic hypertension, diabetes mellitus, ophthalmic glucocorticoids, glucocorticoid injections, and variables related to general health.
The mean ages of cases and controls were similar (74·9 SD 6·3
vs 74·7 6·4). The adjusted odds ratio of ocular hypertension or open-angle glaucoma for current users of oral glucocorticoids compared with non-users was 1·41 (95% Cl 1·22–1·63). There was a dose-related increase in the adjusted odds ratios for current users: 1·26 (1·01–1·56) for less than 40 mg per day of hydrocortisone, 1·37 (1·06–1·76) for patients on 40–79 mg per day, and 1·88 (1·40–2·53) for patients on 80 mg or more per day. The odds ratios also increased with the duration of treatment over the first 11 months of exposure.
The use of oral glucocorticoids increases the risk of ocular hypertension or open-angle glaucoma in elderly patients. In patients in this age-group who need long-term treatment with high doses of oral glucocorticoids, monitoring of intraocular pressure may be justified.
Background and Objective To evaluate utilization patterns with extended-release niacin (ERN) compared with those observed with other lipid-modifying drugs (LMDs). Methods A random sample of 17% of ...patients who had at least one LMD dispensation between January 2004 and February 2007 was obtained from the administrative databases of the Régie de l’assurance maladie du Québec. Primary outcomes included drug adherence, persistence and discontinuation with ERN and other LMDs, and daily maintenance dose attainment (1500 mg and 2000 mg) with ERN at one-year follow-up. Adherence was defined as the sum of days of all dispensations divided by the total number of days of follow-up. Persistence was defined as renewal of prescription before the end of dispensation plus a grace period (50% prescription duration). Results Among 26,862 patients, the majority received statins (73.4%), whereas 867 (3.2%) received ERN. The mean age of ERN patients was 62 years and 75% were male. After one year, adherence with ERN was below that of statins (62.0% versus 74.9%), as was persistence (36.1% versus 46.7%), while discontinuation rates were higher (64.0% versus 53.3%). The median time until discontinuation for ERN was shorter than for statins (66 days versus 99 days). After one year, 5.8% of patients were taking 1500 mg or more and 3.2% were on 2000 mg. Conclusions In the present cohort of patients from regular clinical practice in Quebec, ERN use was associated with low prescription rates, inferior adherence and persistence compared with other LMDs, high discontinuation rates, and very low 2000 mg dose attainment.
To assess the risks of ventricular tachyarrhythmia/sudden cardiac death (VT/SCD) with domperidone use in Parkinson’s disease (PD).
Using Bayesian methods, results from an observationalstudy were ...combined with prior beliefs to calculate posterior probabilities of increasedrelative risk (RR)) of VT/SCD with use of domperidone compared to non-use and ofharm, defined as risk exceeding 15%. The analyses were carried with normallydistributed priors (log (RR)): uninformative (N(0,10)) or informative (N(0.53,179)),derived from a meta-analysis (OR (95%CI):1.70 (1.47-1.97)). Sensitivity analyses used:different priors’ strengths, different priors, and Bayesian meta-analysis
The uninformative prior yielded a RR: 1.23 (95% credible interval (CrI):0.94-1.62), like the published frequentist RR: 1.22 (95% CI:0.99-1.50), with 69% probabilityof harm. With an informative prior weighted at 100%, 50% and 10%, the RR were 1.63(1.41-1.88), 1.57 (1.31-1.91) and 1.39 (1.10-1.93), respectively. The correspondingprobabilities of harm were 100%, 99%, and 94%, respectively.
While both the frequentist and Bayesian approaches with anuninformative prior were unable to reach a definitive conclusion concerning thearrhythmic risk of domperidone in PD patients, the Bayesian analysis with informativepriors showed a high probability of increased risk that was robust to multiple priorsensitivity analyses.
Abstract Background Atrial fibrillation (AF) is the most common cardiac arrhythmia and has been associated with heart failure, stroke, and mortality. The prevalence of AF is expected to rise with the ...aging population. Our objectives were to characterize the Québec AF patient population at the time of diagnosis of AF, quantify medical resource use prior to and after the initial diagnosis of AF, and determine overall survival. Methods A retrospective cohort study was undertaken using the Régie de l'Assurance Maladie du Québec databases to evaluate patients diagnosed with AF between January 1, 1998, and April 30, 2009. Results A total of 64,157 patients were included in our study population. At the time of diagnosis of AF, patients also suffered from several diseases, including heart failure (15.8%) and angina pectoris (15.1%). Compared with the year prior to AF diagnosis, in the year after AF diagnosis patients were more frequently hospitalized (1.5 vs 1.1 hospitalizations) and for longer periods (5.6 vs 3.3 days), and had more outpatient visits (12.9 vs 11.7). Survival rapidly decreased during the first 60 days (60-day mortality, 6.1%) and steadily declined thereafter, with mortality rates of 14.7% and 36.8% at 1 and 5 years, respectively. Conclusion At the time of diagnosis of AF, patients often suffer from several comorbidities. Diagnosis of AF is associated with an increase in medical resource use and higher mortality rates, particularly within the first 60 days.
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