global costs health economics jargon...nuclear cardiac laboratory, national heart centre, singapore...

3/2/2011

1

Dr Felix Keng

IAEA Regional Training Course, Manila, Philippines 1-5 Feb 2011

Health Economics Jargon

• cost minimisation

• cost effectiveness

• cost utility

• cost benefit

Global costs

Rest ECG £ 20

Exercise ECG £ 70

Echocardiogram (rest) £ 100

Echocardiogram (stress) £ 200

Myocardial perfusion imaging £ 220

Coronary angiography £ 1100

PTCA £ 2500

CABG £ 4500

Hospital bed £ 300

3/2/2011

2

Historical Background

• Nuclear Perfusion Imaging as “a better

stress test”

• Detection of anatomic CAD as benchmark

for success

• Gold standard : Coronary Angiography ?

Nuclear Cardiac Laboratory, National Heart Centre, Singapore

Nuclear Cardiology

• Misconceptions:

– Expensive stress test

– Sensitivity < 100%

– False positives, negatives

– Imperfect correlation with angiography

• Disappointment led to the preference for

coronary angiography instead


The Changing Paradigm

• Angiography provides information on anatomy

• Nuclear cardiology provides information on

function/physiology

• Physiology is as important as anatomy, and perhaps

more important

• Functional testing with nuclear imaging provides

comparable prognostic information at lower cost than

angiography, non-invasively

• Information provided by nuclear cardiology can

reduce cost and optimize treatment

Is Physiology as important as Anatomy?

• Diagnosis of CAD is based on anatomy

• Amount of diseased myocardium, LVEF are

powerful predictors of prognosis

• Can nuclear cardiology provide comparable

prognostic information ?


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Prognostic value:

Perfusion imaging vs Angiography

• Normal perfusion scan indicates good prognosis,

even in patients with known CAD

• Nuclear imaging provides significantly greater

information than clinical and stress test data

• Coronary angiography adds little additional data

when nuclear, clinical and stress test data available


Prognostic value: Perfusion imaging

vs angiography (The Proof)

• VANQWISH Study

• Post MI Risk Stratification Studies

– INSPIRE study (post infarction study)

– Patients with stable Chest Pain (COURAGE)

– Heart Failure (IMAGING-HF)

– Diabetic Heart Disease (DIAD)

Heart Centre Heart CentreNational National

Pharmacologic stress testing post-infarction

• Sensitivity for detection of residual stenosis at infarct-related artery 97%

• Sensitivity for detecting multivessel disease 70%

• Prediction of events by perfusion defect size

• Multivariate analysis

• Perfusion defect size - potent predictor

• LV ejection fraction - additional value

• Number of diseased vessels - P = NS

Quantitative Adenosine Thallium SPECT for early assessment post-MI Mahmarian et al Circ 1993

The VANQWISH Trial

(Veterans Affairs Non-Q Wave Infarction Strategies in Hospital)

920 patients with non-Q MI randomised:

Invasive Conservative

Angiogram

Revascularise (PTCA/CABG)

MUGAExercise/dip thallium

Cath if angina + ECG change, ST depression on TMX or reversible ischaemia in >1 territory

Revascularise (PTCA/CABG)

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The VANQWISH Trial (Veterans Affairs Non-Q Wave Infarction Strategies in Hospital)

920 patients with non-Q MI randomised:

Death or Nonfatal Infarct

36

48

111

1526

85

Invasive Conservative0

20

40

60

80

100

120

Discharge

One month

One year

p <0.004

p<0.012

p<0.05

How can use of Nuclear Cardiology

reduce cost$?

• By reducing need for angiography / revascularization

in low risk patients

• By identifying high risk patients who need intervention

• Evidence: studies comparing diagnostic approaches

– Comparing outcome of medical vs invasive treatment in non-

high risk patients

– Economics of Non-invasive Diagnosis (ENDS study)

– Economics of Myocardial Perfusion Imaging in Europe

(EMPIRE study)Nuclear Cardiac Laboratory, National Heart Centre, Singapore

Cost effectiveness of MPI

Where are the savings?

• patient without CAD discharged without angiography

• patient with CAD managed medically without angiography

• avoid morbidity of angiography

• revascularisation targeted more effectively at high risk

patients with most to gain

Economics of Myocardial Perfusion

Imaging in Europe (EMPIRE)

• Comparison of diagnostic strategy, cost, diagnostic

accuracy & clinical outcome

• 396 patients seen in 8 hospitals for suspected CAD,

FU 2 years

• 2 hospitals (one MPI user, one non-user) in each

country:

– France, Germany, Italy, United Kingdom

– Underwood et al. Eur Heart J 1999;20:157-166

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Imaging in Europe (EMPIRE)

• Comparison of 4 diagnostic strategies:

– 1. Ex ECG -> Cath

– 2. Ex ECG -> MPI -> Cath

– 3. MPI -> Cath

– 4. Cath

• Endpoints: Accuracy and cost of diagnosis,

management, clinical outcome


Imaging in Europe (EMPIRE): Results

• Lower costs with myocardial perfusion imaging

– 32% less in patients without CAD

• Better diagnostic/treatment yield for angiography with myocardial

perfusion imaging as gatekeeper

– lower normal angiogram rate (p = 0.07, 26% vs 43% in non-MPI cath)

– higher proportion of patients proceed to revascularization (p<0.05, 47% vs

31%)

• Better long-term freedom from symptoms in MPI users

– (63% vs 37%, p<0.001)

– Better targeted revascularization?

Economics of Myocardial Perfusion Imaging in Europe

(EMPIRE)

335

208

269

207323

358 1061

463

289

229514

270

0

500

1000

1500

2000

Strategy 1 Strategy 2 Strategy 3 Strategy 4 MPI use No MPI use

Mean 2 yr costs (UK pounds) for Pts without CAD

Management Diagnostic

p < 0.0001

p < 0.0001

4626

391

4022

402

4159

354

6047

1096

4854

591

4741

510

0

1000

2000

3000

4000

5000

6000

7000

8000

Strategy 1 Strategy 2 Strategy 3 Strategy 4 MPI use No MPI use

Mean 2 yr costs (UK pounds) for Pts with CAD



(EMPIRE)

p < 0.05

3/2/2011

6

15

25

12

16

812

13

39

27

44

21

48

0

20

40

60

80

Strategy

1

Strategy

2

Strategy

3

Strategy

4

MPI use No MPI

use

Cardiac Events on follow-up

Hard Soft

p = nsp < 0.0001


(EMPIRE)

289

229

514

270

0

200

400

600

800

MPI user Non-MPI user

Mean 2 yr costs (UK pounds) for Pts without CAD


p < 0.0001


(EMPIRE)

32% lower costs

0.14%

23%

0.10%

23%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

MPI user Non-MPI user

Clinical Outcome (Event rate)

Hard Soft


(EMPIRE)

Economics of Non-Invasive Diagnosis Study

(ENDS)

• Observational study comparing 2 diagnostic strategies:

– 5,423 patients referred for direct cath vs

– 5,826 patients referred for myocardial perfusion imaging

with selective cardiac cath.

• 2 groups matched for pretest likelihood of CAD

• Comparisons of clinical outcome and costs

• 7 hospitals (Cedars-Sinai, Cleveland Clinic, Duke University, Hartford

Hospital, Roger Williams Medical Centre, St Louis VA and St Louis

University Health Sciences Center)

• Shaw et al. JACC 1999;33:661-9

3/2/2011

7

2.5

18

5

27

9

30

2.1

14

4.7

13

8.3

16

0

5

10

15

20

25

30

Cath

Low

Cath

Int

Cath

High

MPI

Low

MPI

Int

MPI

High

Death/MI

PTCA/CABG


(ENDS)

Strategy

Pretest risk

Clinical Outcome

(Death, MI,

PTCA/CABG)

Compared to direct cath, myocardial perfusion imaging followed by selective

cath associated with 30-40% lower revasc rate and equivalent death or MI rate


(ENDS)

2900

4200

4800

20002400

2800

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

Cath

Low

Cath

Int

Cath

High

MPI

Low

MPI

Int

MPI

Low

Strategy

Pretest risk

Cost

US$

Compared to direct cath, myocardial perfusion imaging followed by selective

cath associated with 30-40% lower cost, with equivalent clinical outcome

Management of CAD:

Balancing Risk vs Benefit

PTCA,

CABG*

Interventional treatment

Aspirin**,

ACE Inhibitors**,

Betablockers**,

Cholesterol lowering**

Medical Treatment

* improved survival in

selected subgroups**improved survival in CAD

PTCA,

CABG

Interventional treatment

Antiplatelet,

ACE Inhibitors,

Betablockers,

Cholesterol lowering

Medical Treatment

Management of CAD:

Balancing Risk vs Benefit

AMI UANON-Q MI NORMALSTABLE CAD

High risk (>> 1% risk event) Low risk (< 1% risk event)

1% mortality

3/2/2011

8

Interventional treatment Medical Treatment

AMI NORMALSTABLE CAD

High risk (>> 1% risk event) Low risk (< 1% risk event)

Approach

HIGH RISK CAD

NORMAL/EQUIVOCALNON-HIGH RISK

MYOCARDIAL PERFUSION IMAGING

HIGH RISK

Nuclear Cardiology Examinations

US

Europe

million

s

0

1

2

3

4

5

6

7

1992 1994 1996 1998 20001990

USA linear compound growth = 11.5% / yr

Investigation rates

0

2000

4000

6000

8000

10000

12000

14000

MPI CAG Revasc

stud

ies

/ mill

ion

/ yr

USA 1996

UK 2000

USA 2.5 : 1.4 : 1

UK 1 : 2.2 : 1

Is Western data valid in Developing Countries?

• Many patients cannot afford numerous tests!

• Limited healthcare resources: concentrate on

essentials!

• Price of coronary angiography may be subsidized

more than cost of nuclear cardiology: Cheaper to do

angiogram!

• Therefore, direct use of coronary angiography may

be more cost effective than nuclear cardiology??

3/2/2011

9

Price is not the same as cost!

• Price = Amount paid by patient

• Cost = Actual cost of providing service,

contrast, catheters, operating equipment,

hospitalization, effect on subsequent Rx

• Subsidies can hide true cost of procedure

• Subsidies do not reduce cost but transfer

cost from patient to taxpayer

Is nuclear cardiology cost-effective in

developing countries?

• Due to subsidies, price of angiography may be only

slightly more than price of nuclear test

• True cost of angiography is always greater than

nuclear cardiology but may be subsidized (Paid for

by taxpayer!)

• Subsidies favoring angiography may result in

inappropriate use of angiography and/or

PTCA/CABG with hidden costs to healthcare

system/taxpayer

Is nuclear cardiology cost-effective in

developing countries?

• Price of nuclear cardiology test can be kept low by

combination of high volume, pricing and use of

subsidy

• Ratio of cost of nuclear test to cost of angiography

important

• Prognosis and risk of cardiac events varies widely

in patients with known or suspected CAD

• High risk patients should have early/urgent

angiography and revascularization

• Low risk patients should be treated medically

• Non-selective approach to coronary angiography

increases costs without reducing event rate

Summary

3/2/2011

10

Summary

• Nuclear cardiology provides functional data which is

prognostically as important as anatomic data

• Nuclear cardiology provides comparable prognostic

information at lower cost than angiography, non-

invasively

• Use of nuclear cardiology can reduce cost and

optimize treatment

Summary

• Optimal choice of treatment in CAD requires

balancing risk against benefit

• Nuclear cardiology is a valuable, non-invasive,

relatively low cost tool in assessing that risk

Atypical chest pain

Stress Rest

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