The Socioeconomic Burden of Coronary Heart Disease in Korea / 예방의학회지

OBJECTIVES: We aimed to estimate the annual socioeconomic burden of coronary heart disease (CHD) in Korea in 2005, using the National Health Insurance (NHI) claims data. METHODS: A prevalence-based, top-down, cost-of-treatment method was used to assess the direct and indirect costs of CHD (International Classification of Diseases, 10th revision codes of I20-I25), angina pectoris (I20), and myocardial infarction (MI, I21-I23) from a societal perspective. RESULTS: Estimated national spending on CHD in 2005 was 2.52 billion dollar . The majority of the spending was attributable to medical costs (53.3%), followed by productivity loss due to morbidity and premature death (33.6%), transportation (8.1%), and informal caregiver costs (4.9%). While medical cost was the predominant cost attribute in treating angina (74.3% of the total cost), premature death was the largest cost attribute for patients with MI (66.9%). Annual per-capita cost of treating MI, excluding premature death cost, was 3183 dollar, which is about 2 times higher than the cost for angina (1556 dollar). CONCLUSIONS: The total insurance-covered medical cost (1.13 billion dollar) of CHD accounted for approximately 6.02% of the total annual NHI expenditure. These findings suggest that the current burden of CHD on society is tremendous and that more effective prevention strategies are required in Korea.

Análise dos valores SUS para a revascularização miocárdica percutânea completa em multiarteriais / Analysis of Brazilian Public Health System values for complete percutaneous myocardial revascularization in multi-arterial patients

FUNDAMENTO: O Sistema Único de Saúde (SUS) estabelece que a angioplastia coronariana com o implante de duplo stent não deve exceder 20 por cento das angioplastias, resultando na necessidade de escalonar a maioria dos procedimentos nos pacientes com doença multiarterial. OBJETIVO: O objetivo do presente estudo foi avaliar os valores remunerados pelo SUS para a obtenção da revascularização miocárdica percutânea completa em pacientes do SUS com doença multiarterial relacionados ao número de procedimentos necessários e de stents implantados. MÉTODOS: Foram incluídos 141 pacientes com doença coronariana multiarterial, submetidos à revascularização completa com sucesso pelo implante de stent, com coronariografia aos 6 meses pós-implante. A revascularização completa foi definida como o tratamento percutâneo de todas as lesões com percentual de estenose > 70 por cento, em vasos com diâmetro > 2 mm. Para análise dos custos, foram considerados os valores da Tabela SIH/SUS de R$ 2.263,77 para o procedimento e R$ 2.034,23 por stent implantado. RESULTADOS: No período de 07/2006 a 12/2007 foram implantados 416 stents em 141 pacientes. A idade média foi de 59,7 ± 9,9 anos, com predomínio do sexo masculino (68,1 por cento). O número de vasos foi 356 e o número de lesões 416. Para a obtenção da revascularização completa pelo implante de stent coronáriano foi necessário o escalonamento em até 4 procedimentos. O tempo médio entre a 1ª e 2ª, 2ª e 3ª e 3ª e 4ª angioplastias foi de 45,8 ± 37,7, 55,4 ± 55,3 e 33,5 ± 19,1 dias, respectivamente. CONCLUSÃO: A revascularização percutânea completa em pacientes do SUS com doença coronariana multiarterial, realizada em sua grande maioria de forma escalonada, ocasiona considerável elevação de gastos públicos devido ao aumento do número de procedimentos.

BACKGROUND: The Brazilian Public Health System (SUS, acronym in Portuguese) establishes that coronary angioplasty with the double implant stent must not exceed 20 percent of the angioplasties, resulting in the need of assigning most of the procedures in patients with multiarterial disease. OBJECTIVE: The objective of the present study was to assess the paid values by the SUS in order to obtain the complete percutaneous myocardial revascularization in the SUS patients with the multiarterial disease, related to the number of necessary procedures and of implanted stents. METHODS: A total of 141 patients with multiarterial coronary disease, submitted to a successful complete revascularization, were included by the stent implant with coronariography in a 6-month period of post-implant. The complete revascularization was defined as the percutaneous treatment of all stenosis > 70 percent in vessels with diameter > 2 mm. For the costs analysis, the values from the Sistema de Informações Hospitalares (SIH) of the SUS table were considered as R$ 2,263.77, for the procedure; and R$ 2,034.23, per implanted stent. RESULTS: In the period from 7/2006 to 12/2007, 416 stents were implanted in 141 patients. The mean age was of 59.7 ± 9.9 years old, prevailing the male sex (68.1 percent). The number of vessels was 356 and the lesions number corresponded to 416. In order to obtain the complete revascularization by the coronary stent implant, it was necessary to stagger in up to four procedures. The mean time between the 1st and 2nd, 2nd and 3rd and 3rd and 4th angioplasties was of 45.8 ± 37.7; 55.4 ± 55.3 and 33.5 ± 19.1 days, respectively. CONCLUSION: The complete percutaneous revascularization in patients from the SUS with the multiarterial coronary disease, carried out in most of them staggered, causes considerable elevation of public expenses due to the increase of procedures' number.

Custo-efetividade dos stents recobertos por rapamicina em procedimentos percutâneos coronarianos no Brasil / Cost-effectiveness of sirolimus-eluting stents in percutaneous coronary interventions in Brazil

OBJETIVOS: Comparar as relações de custo-efetividade do stent recoberto (SR) por rapamicina com o stent convencional (SC), sob duas perspectivas: medicina suplementar e sistema público (SUS). MÉTODOS: Modelo de decisão analítico com três estratégias de tratamento de lesão coronariana: intervenção coronária percutânea (icP) com SC; com SR com rapamicina e SC seguido de SR para manejo de reestenose sintomática. Os desfechos foram: sobrevida livre de eventos em um ano e expectativa de vida. As árvores de decisão foram construídas com resultados de registros e ensaios clínicos publicados. RESULTADOS: A sobrevida em um ano livre de reestenose foi de 92,7 por cento com SR e de 78,8 por cento com SC. A expectativa de vida estimada das estratégias foi muito semelhante, entre 18,5 e 19 anos. Sob a perspectiva não-pública, a diferença de custo no primeiro ano entre SC e SR foi de R$ 3.816, com relação de custo-efetividade incremental de R$ 27.403 por evento evitado em um ano. Sob a perspectiva do SUS, o custo por evento evitado em um ano foi de R$ 47.529. Na análise de sensibilidade, foram preditores relevantes a probabilidade de reestenose, a redução de risco esperada com SR, o custo do stent e o custo do manejo da reestenose. Os dados por anos de vida demonstraram relações de custo-efetividade bastante elevadas na simulação de Monte Carlo. CONCLUSÃO: As relações de custo-efetividade do SR por rapamicina foram elevadas em modelo brasileiro. O uso de SR foi mais favorável em pacientes de alto risco de reestenose, com elevado custo do manejo de reestenose e sob a perspectiva não-pública.

OBJECTIVES: To compare the cost-effectiveness ratios of sirolimus-eluting stents (SES) with bare-metal stents (BMS) under two perspectives: the "supplementary medical system" (health plans and private patients) and the public health (SUS) system. METHODS: A decision-analytic model using three different therapeutic strategies for coronary lesions: percutaneous coronary intervention (PCI) with BMS; with SES; or with BMS followed by SES to treat symptomatic restenosis. Study endpoints were one-year event-free survival and life expectancy. Decision trees were constructed using the results of published registries and clinical trials. RESULTS: One-year restenosis-free survival was 92.7 percent with SES and 78.8 percent with BMS. Estimated life expectancy was very similar for all the strategies, ranging from 18.5 to 19 years. Under a nonpublic perspective, the cost difference in the first year between BMS and SES was R$3,816, with an incremental cost-effectiveness ratio of R$27,403 per event avoided in one year. Under the SUS perspective, the cost per event avoided in one year was R$47,529. In the sensitivity analysis, probability of restenosis, risk reduction expected with SES, the price of the stent and cost of treating restenosis were all important predictors. In the Monte Carlo simulation, data per years of life saved showed very high cost-effectiveness ratios. CONCLUSION: In the Brazilian model, the cost-effectiveness ratios for SES were elevated. The use of SES was more favorable for patients with high risk of restenosis, as it is associated with elevated costs in restenosis management of and under a nonpublic perspective.

Angioplasty versus coronary artery by-pass surgery: a reappraisal.

Revascularisation is the main principle of treatment of obstructive coronary artery disease. This technique is available either by catheter intervention like angioplasty or by-pass surgery. The superiority of one over the other is still undetermined. In symptomatic single vessel disease angioplasty may be a better option than by-pass surgery. In two-vessel coronary artery disease angioplasty may also be preferred especially with good left ventricular function. In patients with double-vessel disease particularly involving proximal left anterior descending artery in association with diabetes mellitus surgery has better long term results. In multivessel disease by-pass surgery is a preferred option although initial results of angioplasty in this group may be very satisfactory. The incidence of further intervention either by surgery or repeat angioplasty is high in patients undergoing angioplasty in multivessel disease. Left main stem disease should be dealt with by-pass surgery. With continued advancement in the revascularisation technology of coronary artery disease both in catheter intervention and surgical fronts there is no room for unequivocal or universal strategy plan in the management of coronary artery disease. Both the techniques are complimentary to each other. Cost consideration is a major consideration in India. Choice should be made after proper evaluation of coronary anatomy, underlying clinical condition, local experience, social and especially economic circumstances.