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A report of the American Association of Cardiovascular and Pulmonary Rehabilitation and the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures (Writing Committee to Develop Clinical [...]

Background: Inclusion of 12-lead electrocardiography (ECG) in preparticipation screening of young athletes is controversial because of concerns about cost-effectiveness. Objective: To evaluate the cost-effectiveness of ECG plus cardiovascular-focused history and physical examination compared with cardiovascular-focused history and physical examination alone for preparticipation screening. Design: Decision-analysis, cost-effectiveness model. Data Sources: Published epidemiologic and preparticipation screening data, vital statistics, and other publicly available data. Target Population: Competitive athletes in high school and college aged 14 to 22 years. Time Horizon: Lifetime. Perspective: Societal. Intervention: Nonparticipation in competitive athletic activity and disease-specific treatment for identified athletes with heart disease. Outcome Measure: Incremental health care cost per life-year gained. Results of Base-Case Analysis: Addition of ECG to preparticipation screening saves 2.06 life-years per 1000 athletes at an incremental total cost of $89 per athlete and yields a cost-effectiveness ratio of $42 900 per life-year saved (95% CI, $21 200 to $71 300 per life-year saved) compared with cardiovascular-focused history and physical examination alone. Compared with no screening, ECG plus cardiovascular-focused history and physical examination saves 2.6 life-years per 1000 athletes screened and costs $199 per athlete, yielding a cost-effectiveness ratio of $76 100 per life-year saved ($62 400 to $130 000). Results of Sensitivity Analysis: Results are sensitive to the relative risk reduction associated with nonparticipation and the cost of initial screening. Limitations: Effectiveness data are derived from 1 major European study. Patterns of causes of sudden death may vary among countries. Conclusion: Screening young athletes with 12-lead ECG plus cardiovascular-focused history and physical examination may be cost-effective. Primary Funding Source: Stanford Cardiovascular Institute and the Breetwor Foundation. Ann Intern Med. 2010; 152:276-286. www.annals.org For author affiliations, see end of text.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.amjmed.2004.12.028 Byline: Paul A. Heidenreich (a), Matthew Chacko (a), Mary K. Goldstein (a), J. Edwin Atwood (b) Author Affiliation: (a) VA Palo Alto Health Care System, and the Department of Medicine, Stanford University, Stanford, Calif (b) Walter Reed Army Medical Center, Washington DC Article Note: (footnote) The study was supported by a grant from the American Society of Echocardiography. Dr. Heidenreich is supported by a Career Development Award from the Veteran's Affairs Health Services Research Development Office. Views expressed are those of the authors and not necessarily those of the Department of Veterans Affairs or other affiliated organizations.

Background: Although clopidogrel plus aspirin is more effective than aspirin alone in preventing subsequent vascular events in patients with unstable angina, the cost-effectiveness of this combination has yet to be examined in this high-risk population. Objective: To determine the cost-effectiveness of clopidogrel plus aspirin compared with aspirin alone. Design: Cost-utility analysis. Data Sources: Published literature. Target Population: Patients with unstable angina and electrocardiographic changes or non-Q-wave myocardial infarction. Time Horizon: Lifetime. Perspective: Societal. Interventions: Combination therapy with clopidogrel, 75 mg/d, plus aspirin, 325 mg/d, for 1 year, followed by aspirin monotherapy, was compared with lifelong aspirin therapy, 325 mg/d. Outcome Measures: Lifetime costs, life expectancy in quality-adjusted life-years (QALYs), and the incremental cost-effectiveness ratio. Results of Base-Case Analysis: Patients treated with aspirin alone lived 9.51 QALYs after their initial event and incurred expenses of $127 700; the addition of clopidogrel increased life expectancy to 9.61 QALYs and costs to $129 300. The incremental cost-effectiveness ratio for clopidogrel plus aspirin compared with aspirin alone was $15 400 per QALY. Results of Sensitivity Analyses: The analysis of 1 year of therapy was robust to all sensitivity analyses. In the probabilistic sensitivity analysis, fewer than 3% of simulations resulted in cost-effectiveness ratios over $50 000 per QALY. The cost-effectiveness of longer combination therapy depends critically on the balance of thrombotic event rates, durable efficacy, and the increased bleeding rate in patients taking clopidogrel. Limitations: This analysis may not apply to patients with severe heart failure, those undergoing long-term anticoagulant therapy, those recently managed with revascularization, or those undergoing short-term treatment with glycoprotein IIb/IIIa inhibitors. Conclusions: In patients with high-risk acute coronary syndromes, 1 year of therapy with clopidogrel plus aspirin results in greater life expectancy than aspirin alone, at a cost within the traditional limits of cost-effectiveness. The durable efficacy of clopidogrel relative to the risk for hemorrhage should be further explored before more protracted therapy can be recommended.

The Veterans Administration has a long history of measuring the quality of care it provides. In the 1970s deficiencies in care were documented and the potential for the VA to [...]

Background: While the beneficial effect of exercise capacity on mortality is well-accepted, its effect on health-care costs remains uncertain. This study investigates the relationship between exercise capacity and health-care costs. [...]

Background: patients with end-stage renal disease are known to have decreased survival after myocardial infarction, but the association of less severe renal dysfunction with survival after myocardial infarction is unknown. Objectives: To determine how patients with renal insufficiency are treated during hospitalization for myocardial infarction and to determine the association of renal insufficiency with survival after myocardial infarction. Design: Cohort study. Setting: All nongovernment hospitals, in the United States. Patients: 130 099 elderly patients with myocardial infarction hospitalized between April 1994 and July 1995. Measurements: Patients were categorized according to initial serum creatinine level: no renal insufficiency (creatinine level < 1.5 mg/dL [< 132 micromol/L]; n=82 455), mild renal insufficiency (creatinine levels, 1.5 to 2.4 mg/dL [132 to 212 micromol/L]; n=36 765), or moderate renal insufficiency (creatinine level, 2.5 to 3.9 mg/dL [221 to 345 micromol/L]; n=10 888). Vital status up to 1 year after discharge was obtained from Social Security records. Results: Compared with patients with no renal insufficiency, patients with moderate renal insufficiency were less likely to receive aspirin, beta-blockers, thrombolytic therapy, angiography, and angioplasty during hospitalization. One-year mortality was 24% in patients with no renal insufficiency, 46% in patients with mild renal insufficiency, and 66% in patients with moderate renal insufficiency (P Conclusions: Renal insufficiency was an independent risk factor for death in elderly patients after myocardial infarction. Targeted interventions may be needed to improve treatment for this high-risk population.

Background: Clinical trials have shown that implantable cardioverter defibrillators (ICDs) improve survival in patients with sustained ventricular arrhythmias. Objective: To determine the efficacy necessary to make prophylactic ICD or amiodarone therapy cost-effective in patients with myocardial infarction. Design: Markov model-based cost utility analysis. Data Sources: Survival, cardiac death, and inpatient costs were estimated on the basis of the Myocardial Infarction Triage and Intervention registry. Other data were derived from the literature. Target Population: Patients with past myocardial infarction who did not have sustained ventricular arrhythmia. Time Horizon: Lifetime. Perspective: Societal. Interventions: ICD or amiodarone compared with no treatment. Outcome Measures: Life-years, quality-adjusted life-years (QALYs), costs, number needed to treat, and incremental cost-effectiveness. Results of Base-Case Analysis: Compared with no treatment, ICD use led to the greatest QALYs and the highest expenditures. Amiodarone use resulted in intermediate QALYs and costs. To obtain acceptable cost-effectiveness thresholds ( Results of Sensitivity Analysis: For moderate efficacies, in patients with ejection fractions less than or equal to 0.3, 0.31 to 0.4, and greater than 0.4, the cost-effectiveness of amiodarone compared with no therapy was $43 100/QALY, $66 500/QALY, and $132 500/QUALY, respectively, and the cost-effectiveness of ICD compared with amiodarone was $17 800/QUALY, $195 700/QUALY, and $557 900/QUALY, respectively. Conclusions: Use of ICD or amiodarone in patients with past myocardial infarction and severely depressed left ventricular function may provide substantial clinical benefit at an acceptable cost. These results highlight the importance of clinical trials of ICDs in patients with low ejection fractions who have had myocardial infarction.

Background: Radiofrequency ablation is an established but expensive treatment option for many forms of supraventricular tachycardia. Most cases of supraventricular tachycardia are not life-threatening; the goal of therapy is therefore to improve the patient's quality of life. Objective: To compare the cost-effectiveness of radiofrequency ablation with that of medical management of supraventricular tachycardia. Design: Markov model. Data Sources: Costs were estimated from a major academic hospital and the literature, and treatment efficacy was estimated from reports from clinical studies at major medical centers. Probabilities of clinical outcomes were estimated from the literature. To account for the effect of radiofrequency ablation on quality of life, assessments by patients who had undergone the procedure were used. Target Population: Cohort of symptomatic patients who experienced 4.6 unscheduled visits per year to an emergency department or a physician's office while receiving long-term drug therapy for supraventricular tachycardia. Time Horizon: Patient lifetime. Perspective: Societal. Interventions: Initial radiofrequency ablation, long-term antiarrhythmic drug therapy, and treatment of acute episodes of arrhythmia with antiarrhythmic drugs. Outcome Measures: Costs, quality-adjusted life-years, life-years, and marginal cost-effectiveness ratios. Results of Base-Case Analysis: Among patients who have monthly episodes of supraventricular tachycardia, mdiofrequency ablation was the most effective and least expensive therapy and therefore dominated the drug therapy options. Radiofrequency ablation improved quality-adjusted life expectancy by 3.10 quality-adjusted life-years and reduced lifetime medical expenditures by $27 900 compared with long-term drug therapy. Long-term drug therapy was more effective and had lower costs than episodic drug therapy. Results of Sensitivity Analysis: The findings were highly robust over substantial variations in assumptions about the efficacy and complication rate of radiofrequency ablation, including analyses in which the complication rate was tripled and efficacy was decreased substantially. Conclusions: Radiofrequency ablation substantially improves quality of life and reduces costs when it is used to treat highly symptomatic patients. Although the benefit of radiofrequency ablation has not been studied in less symptomatic patients, a small improvement in quality of life is sufficient to give preference to radiofrequency ablation over drug therapy.

PURPOSE: To determine the impact of echocardiography on the use of antibiotic prophylaxis in patients with suspected mitral valve prolapse (MVP). PATIENTS AND METHODS: We evaluated 147 consecutive patients who were referred for 'rule out mitral valve prolapse' to a university hospital echocardiography laboratory. Chart review and phone contact were used to determine the demographic characteristics of the patients; past diagnosis of MVP, symptoms, and exam at referral; practice specialty of referring MD; echocardiographic findings; and change in prophylaxis usage as a result of the echocardiogram (ECHO). Prophylaxis was considered to be indicated if the echocardiogram demonstrated MVP with at least mild regurgitation or abnormal thickening of at least one mitral leaflet. RESULTS: Based on the ECHO a change in antibiotic prophylaxis was indicated in 20 of 147 (14%) patients including initiation of prophylaxis in 6, and discontinuation of prophylaxis in 14. However, only 4 of 20 patients (20%) actually changed their prophylaxis habits leading to an actual yield of 4 management changes per 131 ECHOs ordered (3%). This corresponded to 1 change in management per $36,250 in hospital and physician costs. Younger age, female gender, and presence of symptoms were associated with a benign ECHO. Indications for a change in management were not significantly different between physician specialties: 18% for generalists (internal medicine and family practice), 12% for cardiologists, and 7% for other specialists, P = 0.3. CONCLUSIONS: In patients referred for evaluation of MVP, echocardiography infrequently resulted in changes in antibiotic prophylaxis management and was associated with significant expense.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/S0002-9343(97)00084-3 Byline: Paul A. Heidenreich, Jeffrey Bear, Warren Brower, Elyse Foster Abstract: PURPOSE: To determine the impact of echocardiography on the use of antibiotic prophylaxis in patients with suspected mitral valve prolapse (MVP). PATIENTS AND METHODS: We evaluated 147 consecutive patients who were referred for 'rule out mitral valve prolapse' to a university hospital echocardiography laboratory. Chart review and phone contact were used to determine the demographic characteristics of the patients; past diagnosis of MVP, symptoms, and exam at referral; practice specialty of referring MD; echocardiographic findings; and change in prophylaxis usage as a result of the echocardiogram (ECHO). Prophylaxis was considered to be indicated if the echocardiogram demonstrated MVP with at least mild regurgitation or abnormal thickening of at least one mitral leaflet. RESULTS: Based on the ECHO a change in antibiotic prophylaxis was indicated in 20 of 147 (14%) patients including initiation of prophylaxis in 6, and discontinuation of prophylaxis in 14. However, only 4 of 20 patients (20%) actually changed their prophylaxis habits leading to an actual yield of 4 management changes per 131 ECHOs ordered (3%). This corresponded to 1 change in management per $36,250 in hospital and physician costs. Younger age, female gender, and presence of symptoms were associated with a benign ECHO. Indications for a change in management were not significantly different between physician specialties: 18% for generalists (internal medicine and family practice), 12% for cardiologists, and 7% for other specialists, P = 0.3. CONCLUSIONS: In patients referred for evaluation of MVP, echocardiography infrequently resulted in changes in antibiotic prophylaxis management and was associated with significant expense. Author Affiliation: (a) Department of Health Research and Policy, Stanford University, San Francisco, CaliforniaUSA (b) Division of Cardiology, Department of Medicine University of California San Francisco, San Francisco, CaliforniaUSA (c) Department of Medicine, Department of Veterans Affairs San Francisco, CaliforniaUSA Article History: Received 2 July 1996; Accepted 13 December 1996

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/S0002-9343(97)00084-3 Byline: Paul A. Heidenreich, MD, Jeffrey Bear, BS, Warren Brower, MD, Elyse Foster, MD Abstract: PURPOSE: To determine the impact of echocardiography on the use of antibiotic prophylaxis in patients with suspected mitral valve prolapse (MVP). PATIENTS AND METHODS: We evaluated 147 consecutive patients who were referred for 'rule out mitral valve prolapse' to a university hospital echocardiography laboratory. Chart review and phone contact were used to determine the demographic characteristics of the patients; past diagnosis of MVP, symptoms, and exam at referral; practice specialty of referring MD; echocardiographic findings; and change in prophylaxis usage as a result of the echocardiogram (ECHO). Prophylaxis was considered to be indicated if the echocardiogram demonstrated MVP with at least mild regurgitation or abnormal thickening of at least one mitral leaflet. RESULTS: Based on the ECHO a change in antibiotic prophylaxis was indicated in 20 of 147 (14%) patients including initiation of prophylaxis in 6, and discontinuation of prophylaxis in 14. However, only 4 of 20 patients (20%) actually changed their prophylaxis habits leading to an actual yield of 4 management changes per 131 ECHOs ordered (3%). This corresponded to 1 change in management per $36,250 in hospital and physician costs. Younger age, female gender, and presence of symptoms were associated with a benign ECHO. Indications for a change in management were not significantly different between physician specialties: 18% for generalists (internal medicine and family practice), 12% for cardiologists, and 7% for other specialists, P = 0.3. CONCLUSIONS: In patients referred for evaluation of MVP, echocardiography infrequently resulted in changes in antibiotic prophylaxis management and was associated with significant expense. Author Affiliation: (a) Department of Health Research and Policy, Stanford University, San Francisco, CaliforniaUSA (b) Division of Cardiology, Department of Medicine University of California San Francisco, San Francisco, CaliforniaUSA (c) Department of Medicine, Department of Veterans Affairs San Francisco, CaliforniaUSA Article History: Received 2 July 1996; Accepted 13 December 1996

Byline: Paul A. Heidenreich (1), Jeffrey Bear (2), Warren Browner (3), Elyse Foster (2) Abstract: To determine the impact ofechocardiography on the use of antibiotic prophylaxis in patients with suspected mitral valve prolapse (MVP). Author Affiliation: (1) Department of Health Research and Policy, Stanford University, San Francisco, California, USA (2) Division of Cardiology, Department of Medicine Universityof California San Francisco, USA (3) Department of Medicine,Department of Veterans Affairs, San Francisco, California, USA

Background: The Asymptomatic Carotid Atherosclerosis Study (ACAS) showed that carotid endarterectomy was beneficial for symptom-free patients with carotid stenosis of 60% or more. This finding raises the question of whether widespread screening to identify cases of asymptomatic carotid stenosis should be implemented. Objective: To determine whether a screening program to identify cases of asymptomatic carotid stenosis would be a cost-effective strategy for stroke prevention. Design: Cost-effectiveness analysis using published data from clinical trials. Setting: General population of asymptomatic 65-year-old men. Intervention: Patients who were screened for carotid disease with duplex Doppler ultrasonography were compared with patients who were not screened. If ultrasonography found significant carotid stenosis ([is greater than or equal to] 60%), disease was confirmed by angiography before carotid endarterectomy was done. Measurements: Quality-adjusted life-years, costs, and marginal cost-effectiveness ratios. Results: When the conditions and results of ACAS were modeled and it was assumed that the survival advantage produced by endarterectomy would last for 30 years, the lifetime marginal cost-effectiveness of screening relative to no screening was $120000 per quality-adjusted life-year. Sensitivity analysis showed that marginal cost-effectiveness decreased to $50000 or less per quality-adjusted life-year only under implausible conditions (for example, if a free screening instrument with perfect test characteristics was used or an asymptomatic population with a 40% prevalence of carotid stenosis was found). Conclusions: Surgery offers a real but modest absolute reduction in the rate of stroke at a substantial cost. A program to identify candidates for endarterectomy by screening asymptomatic populations for carotid stenosis costs more per quality-adjusted life-year than is usually considered acceptable., It does not appear to be cost-effective to routinely screen older men for evidence of stroke. Researchers used a statistical model to evaluate the cost-effectiveness of routinely screening otherwise healthy 65-year-old men for evidence of blockage in the major blood vessel supplying the head. An acceptable cost per year of life saved is generally considered to be $50,000. This stroke screening procedure would cost $120,000 per year of life saved. Unrealistic conditions would have to occur for the cost per year of life saved to approach $50,000.

Background: Implantable cardioverter defibrillators (ICDs) are remarkably effective in terminating ventricular arrhythmias, but they are expensive and the extent to which they extend life is unknown. The marginal cost-effectiveness of ICDs relative to amiodarone has not been clearly established. Objective: To compare the cost-effectiveness of a third-generation implantable ICD with that of empirical amiodarone treatment for preventing sudden cardiac death in patients at high or intermediate risk. Design: A Markov model was used to evaluate health and economic outcomes of patients who received an ICD, amiodarone, or a sequential regimen that reserved ICD for patients who had an arrhythmia during amiodarone treatment. Measurements: Life-years gained, quality-adjusted life-years gained, costs, and marginal cost-effectiveness. Results: For the base-case analysis, it was assumed that treatment with an ICD would reduce the total mortality rate by 20% to 40% at I year compared with amiodarone and that the ICD generator would be replaced every 4 years. In high-risk patients, if an ICD reduces total mortality by 20%, patients who receive an ICD live for 4.18 quality-adjusted life-years and have a lifetime expenditure of $88,400. Patients receiving amiodarone live for 3.68 quality-adjusted life-years and have a lifetime expenditure of $51,000. Marginal cost-effectiveness of an ICD relative to amiodarone is $74 000 per quality-adjusted life-year saved. if an ICD reduces mortality by 40%, the cost-effectiveness of ICD use is $37 300 per quality-adjusted life-year saved. Both choice of therapy (an ICD or amiodarone) and the cost-effectiveness ratio are sensitive to assumptions about quality of life. Conclusions: Use of an ICD will cost more than $50 000 per quality-adjusted life-year gained unless it reduces all-cause mortality by 30% or more relative to amiodarone. Current evidence does not definitively support or exclude a benefit of this magnitude, but ongoing randomized trials have sufficient statistical power to do so., It appears that implantable cardioverter defibrillators (ICDs) are more costly but may extend patient life longer compared to amiodarone drug treatment. An ICD is a device that detects an abnormal heart rhythm and shocks the heart back to normal rhythm. Researchers evaluated the theoretical cost-effectiveness of ICDs, amiodarone, and amiodarone possibly followed by an ICD based on a range of death rate reduction assumptions. ICDs may cost more than $50,000 per year of extended life and may be more costly for high-risk patients. This figure may be lower if ICDs are more than 30% more effective than amiodarone treatment.

Objective: This study was designed to determine the diagnostic value of 12-lead ECG for pericardial effusion and cardiac tamponade. Design: Cross-sectional study. Setting: University hospital. Patients: Hospitalized patients with and [...]

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.amjmed.2005.11.019 Byline: Mikhail Kosiborod (a), Judith H. Lichtman (b), Paul A. Heidenreich (c), Sharon-Lise T. Normand (d), Yun Wang (e), Lawrence M. Brass (b)(f)(g), Harlan M. Krumholz (e)(h)(i)(j) Keywords: Heart failure; Health services research; Trends Abstract: Despite dramatic changes in heart failure management during the 1990s, little is known about the national heart failure mortality trends during this time period, particularly among the elderly. The purpose of this study was to determine temporal trends in outcomes of elderly patients with heart failure between 1992 and 1999. Author Affiliation: (a) Mid America Heart Institute of Saint Luke's Hospital and the University of Missouri, Kansas City, Mo (b) Section of Chronic Disease Epidemiology, Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Conn (c) VA Palo Alto Health Care System, and the Department of Medicine, Stanford University, Stanford, Calif (d) Department of Health Care Policy, Harvard Medical School and the Department of Biostatistics, Harvard School of Public Health, Boston, Mass (e) Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Conn (f) Department of Neurology, Yale University School of Medicine, New Haven, Conn (g) Neurology Service of the VA Connecticut Healthcare System, West Haven, Conn (h) Section of Health Policy and Administration, Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Conn (i) Robert Wood Johnson Clinical Scholars Program, Yale University School of Medicine, New Haven, Conn (j) Section of Cardiovascular Medicine, Department of Medicine, Yale University School of Medicine, New Haven, Conn. Article Note: (footnote) This publication was supported by grant number 1 K01 DP000085-01 from the Centers for Disease Control and Prevention (CDC). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of CDC. The Centers for Medicare and Medicaid Services (CMS) reviewed and approved the use of its data for this work, and approved submission of the manuscript; this approval is based on data use only, and does not represent a CMS endorsement of or comment on the manuscript content. Neither CDC nor CMS played a role in the design and conduct of the study, or in the analysis and interpretation of the data. All authors had full access to the data in the study and take responsibility for the integrity of the data and the accuracy of the analysis.

Objective. To determine the effect of treatment by a cardiologist on mortality of elderly patients with acute myocardial infarction (AMI, heart attack), accounting for both measured confounding using risk-adjustment techniques [...]