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Economic Evaluation of Percutaneous Coronary Intervention in Stable Coronary Artery Disease: Studies in Utilities and Decision ModelingWijeysundera, Harindra Channa 29 February 2012 (has links)
The initial treatment options for patients with stable coronary artery disease include optimal medical therapy alone, or coronary revascularization with optimal medical therapy. The most common revascularization modality is percutaneous coronary intervention (PCI) with either bare metal stents (BMS) or drug-eluting stents (DES). PCI is believed to reduce recurrent angina and thereby decrease the need for additional procedures compared to optimal medical therapy alone. It remains unclear if these benefits are sufficient to offset the increased costs and small increase in adverse events associated with PCI.
The objectives of this thesis were to determine the degree of angina relief afforded by PCI and develop a tool to provide contemporary estimates of the impact of angina on quality of life. In addition, we sought to develop a comprehensive state-transition model, calibrated to real world costs and outcomes to compare the cost-effectiveness of initial medical therapy versus PCI with either BMS or DES in patients with stable coronary artery disease.
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We performed a systematic search and meta-analysis of the published literature. Although PCI was associated with an overall benefit on angina relief (odds ratio [OR] 1.69; 95% Confidence Interval [CI] 1.24-2.30), this benefit was largely attenuated in contemporary studies (OR 1.13; 95% CI 0.76-1.68). Our meta-regression analysis suggests that this observation was related to greater use of evidence-based medications in more recent trials.
Using simple linear regression, we were able to create a mapping tool that could accurately estimate utility weights from data on the Seattle Angina Question, the most common descriptive quality of life instrument used in the cardiovascular literature.
In our economic evaluation, we found that an initial strategy of PCI with a BMS was cost- effective compared to medical therapy, with an incremental cost-effectiveness ratio (ICER) of $13,271 per quality adjusted life year gained. In contrast, DES had a greater cost and lower survival than BMS and was therefore a dominated strategy.
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Retrospective analysis of the prescribing patterns of calcium channel blockers in a section of the private health care sector of South Africa / Ruan SmitSmit, Ruan January 2010 (has links)
Background: Calcium channel blockers are mainly divided into antihypertensive and antianginal
treatment agents. In 2000 it was estimated that 972 million adults worldwide were
living with hypertension and it is expected to affect 1.56 billion patients by 2025. The
incremental expenditure for the antihypertensive therapeutic group in the United States of
America was estimated at $US 55 billion per annum in 2006.
It was stated that around seven million people in the United States of America suffered from
angina, with around 400 000 new reports every year.
Objective: To determine the prescribing patterns of calcium channel blocker medicine items
during 2005 to 2008 in a section of the private health care sector of South Africa.
Methods: A retrospective quantitative drug utilisation review was done using a medicine
claims database ranging over four years from 1 January 2005 to 31 December 2008. The
total medicine claims database was divided into cardiovascular medicine items and then into
calcium channel blockers. These were analysed according to age as well as gender. Further
analysis included adherence of calcium channel blockers as well as an analysis of
prescribers of these items during the study period.
Results: The total number of patients on the medicine claims database consisted of
1 509 621 patients in 2005. This number decreased to 974 497 patients in 2008. The most
medicine items were dispensed in 2006 (n = 21 113 422) with an average cost of
R 92.82 (SD = 196.42) per medicine item.
It was noted that 16.05% (n = 242 264) of patients used at least one cardiovascular item in
2005. The percentage of cardiovascular medicine item users increased by 4.36% during the
study period to 20.41% (n = 198 847) in 2008. In 2008 the cardiovascular medicine items
dispensed were responsible for 19.18% (R 342 565 308.41) of the total cost of all medicine
items claimed.
In 2005 the results revealed that 1.63% (n = 318 258) of all medicine items dispensed were
calcium channel blocker medicine items. The percentage of calcium channel blockers
increased to 2.24% (n = 367 437) of the total number of medicine items in 2008. The cost
prevalence index was calculated for the calcium channel blockers and the value declined
from 1.5 in 2005 to 1.22 in 2008, which indicated that the items dispensed were relatively
expensive, but less than in 2005. An increase of 16.17% in the usage of generic medicine
items were noted from 2005 to 2008.
More female patients than male patients claimed medicine items during the study period. A
higher percentage of male patients used a cardiovascular medicine item as well as calcium
channel blockers during the study period compared to females and a larger percentage of
their medicine expenditure was used on cardiovascular medicine items as well as calcium
channel blockers compared to females.
The usage of cardiovascular medicine items as well as calcium channel blocker medicine
items increased with patient age. In 2008, 17.98% of patients older than 65 years of age
used a calcium channel blocker compared to 0.97% of patients aged > 25 <= 35 years. Only
60.34% of calcium channel blockers items were used with acceptable refill adherence rates
during the study. More than a third of the calcium channel blockers medicine items used had
unacceptable low adherence rates from 2005 to 2008.
In each of the study years the highest potential saving with generic substitution was seen
with amlodipine containing items. It was also observed that some generic substitutions could
be relatively more expensive than the innovator products and an increased cost instead of a
saving through generic substitution may have occurred.
Conclusion: This study highlighted the prescribing patterns and cost implications of calcium
channel blockers in the private health care sector of South Africa.
It is recommended that a more in–depth study of the adherence of calcium channel blockers
be done. This study should also include the cost strategies of generic substitution of calcium
channel blockers in South Africa. / Thesis (M.Pharm (Pharmacy Practice))--North-West University, Potchefstroom Campus, 2011.
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Retrospective analysis of the prescribing patterns of calcium channel blockers in a section of the private health care sector of South Africa / Ruan SmitSmit, Ruan January 2010 (has links)
Background: Calcium channel blockers are mainly divided into antihypertensive and antianginal
treatment agents. In 2000 it was estimated that 972 million adults worldwide were
living with hypertension and it is expected to affect 1.56 billion patients by 2025. The
incremental expenditure for the antihypertensive therapeutic group in the United States of
America was estimated at $US 55 billion per annum in 2006.
It was stated that around seven million people in the United States of America suffered from
angina, with around 400 000 new reports every year.
Objective: To determine the prescribing patterns of calcium channel blocker medicine items
during 2005 to 2008 in a section of the private health care sector of South Africa.
Methods: A retrospective quantitative drug utilisation review was done using a medicine
claims database ranging over four years from 1 January 2005 to 31 December 2008. The
total medicine claims database was divided into cardiovascular medicine items and then into
calcium channel blockers. These were analysed according to age as well as gender. Further
analysis included adherence of calcium channel blockers as well as an analysis of
prescribers of these items during the study period.
Results: The total number of patients on the medicine claims database consisted of
1 509 621 patients in 2005. This number decreased to 974 497 patients in 2008. The most
medicine items were dispensed in 2006 (n = 21 113 422) with an average cost of
R 92.82 (SD = 196.42) per medicine item.
It was noted that 16.05% (n = 242 264) of patients used at least one cardiovascular item in
2005. The percentage of cardiovascular medicine item users increased by 4.36% during the
study period to 20.41% (n = 198 847) in 2008. In 2008 the cardiovascular medicine items
dispensed were responsible for 19.18% (R 342 565 308.41) of the total cost of all medicine
items claimed.
In 2005 the results revealed that 1.63% (n = 318 258) of all medicine items dispensed were
calcium channel blocker medicine items. The percentage of calcium channel blockers
increased to 2.24% (n = 367 437) of the total number of medicine items in 2008. The cost
prevalence index was calculated for the calcium channel blockers and the value declined
from 1.5 in 2005 to 1.22 in 2008, which indicated that the items dispensed were relatively
expensive, but less than in 2005. An increase of 16.17% in the usage of generic medicine
items were noted from 2005 to 2008.
More female patients than male patients claimed medicine items during the study period. A
higher percentage of male patients used a cardiovascular medicine item as well as calcium
channel blockers during the study period compared to females and a larger percentage of
their medicine expenditure was used on cardiovascular medicine items as well as calcium
channel blockers compared to females.
The usage of cardiovascular medicine items as well as calcium channel blocker medicine
items increased with patient age. In 2008, 17.98% of patients older than 65 years of age
used a calcium channel blocker compared to 0.97% of patients aged > 25 <= 35 years. Only
60.34% of calcium channel blockers items were used with acceptable refill adherence rates
during the study. More than a third of the calcium channel blockers medicine items used had
unacceptable low adherence rates from 2005 to 2008.
In each of the study years the highest potential saving with generic substitution was seen
with amlodipine containing items. It was also observed that some generic substitutions could
be relatively more expensive than the innovator products and an increased cost instead of a
saving through generic substitution may have occurred.
Conclusion: This study highlighted the prescribing patterns and cost implications of calcium
channel blockers in the private health care sector of South Africa.
It is recommended that a more in–depth study of the adherence of calcium channel blockers
be done. This study should also include the cost strategies of generic substitution of calcium
channel blockers in South Africa. / Thesis (M.Pharm (Pharmacy Practice))--North-West University, Potchefstroom Campus, 2011.
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Exposures in utero and chronic disease : an alternative methodological approach /Hübinette, Anna, January 2002 (has links)
Diss. (sammanfattning) Stockholm : Karolinska institutet, 2002. / Härtill 4 uppsatser.
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Predição de desfechos clínicos e angiográficos após a angioplastia coronariana na angina instável : análise de duas classificações angiográficasZouvi, João Paulo January 2006 (has links)
Objetivo - Avaliar e comparar as classificações angiográficas do American College of Cardiology e American Heart Association (ACC/AHA) com a de Ambrose modificadas tendo por base sua efetividade na predição dos desfechos clínicos e angiográficos observados na fase hospitalar em pacientes com angina instável submetidos à angioplastia coronariana. Métodos - Numa coorte histórica constituída por 112 pacientes com angina instável submetidos à angioplastia coronariana foram aplicadas as classificações angiográficas do ACC/AHA e de Ambrose modificadas às lesões consideradas culpadas pelo quadro clínico. Num segundo momento, foram identificados os desfechos clínicos (alta hospitalar sem complicações, infarto do miocárdio, cirurgia de revascularização miocárdica e óbito) e angiográficos (sucesso, insucesso sem complicações e oclusão aguda). Resultados - ambas as classificações foram inefetivas para a predição dos desfechos clínicos (ACC/AHA modificada p=0,199; Ambrose modificada p=0,867). Para a predição dos desfechos angiográficos detectou-se uma tendência a uma diferença significativa entre as lesões simples e complexas quando aplicada a classificação do ACC/AHA modificada (p=0,08) e uma diferença significativa porém limítrofe (p=0,05) quando aplicada a classificação Ambrose modificada. 4 Conclusões - 1. Ambas as classificações foram inefetivas na predição de desfechos clínicos, porém apresentaram uma tendência à efetividade na predição de desfechos angiográficos intra-hospitalares em pacientes com angina instável submetidos à angioplastia coronariana. 2. A classificação angiográfica de Ambrose modificada não se mostrou mais efetiva que a classificação do ACC/AHA modificada na predição de desfechos clínicos e angiográficos. / Objective - To evaluate and compare the effectiveness of the ACC/AHA and Ambrose modified angiographic classifications in predicting clinical and angiographic outcomes. Methods - We studied 112 patients with unstable angina that had undergone coronary angioplasty and we applied the ACC/AHA and Ambrose modified angiographic classifications to the lesions that were considered to be culprit for the clinical findings in a historic cohort. Clinical and angiographic outcomes, wich were observed during hospitalization, were later identified. Results - According to the ACC/AHA and Ambrose modified classifications, the lesions were classified into complex ones in 58% and 46.4%, and into simple ones in 42% and 53.6%, respectively. Hospital discharge without complications was verified in 79.5% of the patients, “enzymatic” myocardial infarction in 14.5%, myocardial revascularization surgery in 2.4%, and death in 3.6%. The success rate achieved in angioplasty was of 73.2%, failure without complications of 20.5%, and acute occlusion of 6.3%. Both classifications were ineffective in predicting the clinical outcomes (modified ACC/AHA p=0.199; modified Ambrose p=0.867). In the prediction of the angiographic outcomes, a tendency to a significant difference between the simple and the complex lesions was observed when the ACC/AHA classification was applied (p=0.08) and a 6 significant though borderline difference, when it was applied the modified Ambrose classification (p=0.05). Conclusions – 1. Both angiographic classifications were ineffective in predicting clinical outcomes, though they presented a tendency to be effective in predicting angiographic in-hospital outcomes in patients with unstable angina that had undergone coronary angioplasty The Ambrose modified angiographic classification was not more effective than the ACC/AHA modified classification in predicting clinical and angiographic outcomes.
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Predição de desfechos clínicos e angiográficos após a angioplastia coronariana na angina instável : análise de duas classificações angiográficasZouvi, João Paulo January 2006 (has links)
Objetivo - Avaliar e comparar as classificações angiográficas do American College of Cardiology e American Heart Association (ACC/AHA) com a de Ambrose modificadas tendo por base sua efetividade na predição dos desfechos clínicos e angiográficos observados na fase hospitalar em pacientes com angina instável submetidos à angioplastia coronariana. Métodos - Numa coorte histórica constituída por 112 pacientes com angina instável submetidos à angioplastia coronariana foram aplicadas as classificações angiográficas do ACC/AHA e de Ambrose modificadas às lesões consideradas culpadas pelo quadro clínico. Num segundo momento, foram identificados os desfechos clínicos (alta hospitalar sem complicações, infarto do miocárdio, cirurgia de revascularização miocárdica e óbito) e angiográficos (sucesso, insucesso sem complicações e oclusão aguda). Resultados - ambas as classificações foram inefetivas para a predição dos desfechos clínicos (ACC/AHA modificada p=0,199; Ambrose modificada p=0,867). Para a predição dos desfechos angiográficos detectou-se uma tendência a uma diferença significativa entre as lesões simples e complexas quando aplicada a classificação do ACC/AHA modificada (p=0,08) e uma diferença significativa porém limítrofe (p=0,05) quando aplicada a classificação Ambrose modificada. 4 Conclusões - 1. Ambas as classificações foram inefetivas na predição de desfechos clínicos, porém apresentaram uma tendência à efetividade na predição de desfechos angiográficos intra-hospitalares em pacientes com angina instável submetidos à angioplastia coronariana. 2. A classificação angiográfica de Ambrose modificada não se mostrou mais efetiva que a classificação do ACC/AHA modificada na predição de desfechos clínicos e angiográficos. / Objective - To evaluate and compare the effectiveness of the ACC/AHA and Ambrose modified angiographic classifications in predicting clinical and angiographic outcomes. Methods - We studied 112 patients with unstable angina that had undergone coronary angioplasty and we applied the ACC/AHA and Ambrose modified angiographic classifications to the lesions that were considered to be culprit for the clinical findings in a historic cohort. Clinical and angiographic outcomes, wich were observed during hospitalization, were later identified. Results - According to the ACC/AHA and Ambrose modified classifications, the lesions were classified into complex ones in 58% and 46.4%, and into simple ones in 42% and 53.6%, respectively. Hospital discharge without complications was verified in 79.5% of the patients, “enzymatic” myocardial infarction in 14.5%, myocardial revascularization surgery in 2.4%, and death in 3.6%. The success rate achieved in angioplasty was of 73.2%, failure without complications of 20.5%, and acute occlusion of 6.3%. Both classifications were ineffective in predicting the clinical outcomes (modified ACC/AHA p=0.199; modified Ambrose p=0.867). In the prediction of the angiographic outcomes, a tendency to a significant difference between the simple and the complex lesions was observed when the ACC/AHA classification was applied (p=0.08) and a 6 significant though borderline difference, when it was applied the modified Ambrose classification (p=0.05). Conclusions – 1. Both angiographic classifications were ineffective in predicting clinical outcomes, though they presented a tendency to be effective in predicting angiographic in-hospital outcomes in patients with unstable angina that had undergone coronary angioplasty The Ambrose modified angiographic classification was not more effective than the ACC/AHA modified classification in predicting clinical and angiographic outcomes.
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Predição de desfechos clínicos e angiográficos após a angioplastia coronariana na angina instável : análise de duas classificações angiográficasZouvi, João Paulo January 2006 (has links)
Objetivo - Avaliar e comparar as classificações angiográficas do American College of Cardiology e American Heart Association (ACC/AHA) com a de Ambrose modificadas tendo por base sua efetividade na predição dos desfechos clínicos e angiográficos observados na fase hospitalar em pacientes com angina instável submetidos à angioplastia coronariana. Métodos - Numa coorte histórica constituída por 112 pacientes com angina instável submetidos à angioplastia coronariana foram aplicadas as classificações angiográficas do ACC/AHA e de Ambrose modificadas às lesões consideradas culpadas pelo quadro clínico. Num segundo momento, foram identificados os desfechos clínicos (alta hospitalar sem complicações, infarto do miocárdio, cirurgia de revascularização miocárdica e óbito) e angiográficos (sucesso, insucesso sem complicações e oclusão aguda). Resultados - ambas as classificações foram inefetivas para a predição dos desfechos clínicos (ACC/AHA modificada p=0,199; Ambrose modificada p=0,867). Para a predição dos desfechos angiográficos detectou-se uma tendência a uma diferença significativa entre as lesões simples e complexas quando aplicada a classificação do ACC/AHA modificada (p=0,08) e uma diferença significativa porém limítrofe (p=0,05) quando aplicada a classificação Ambrose modificada. 4 Conclusões - 1. Ambas as classificações foram inefetivas na predição de desfechos clínicos, porém apresentaram uma tendência à efetividade na predição de desfechos angiográficos intra-hospitalares em pacientes com angina instável submetidos à angioplastia coronariana. 2. A classificação angiográfica de Ambrose modificada não se mostrou mais efetiva que a classificação do ACC/AHA modificada na predição de desfechos clínicos e angiográficos. / Objective - To evaluate and compare the effectiveness of the ACC/AHA and Ambrose modified angiographic classifications in predicting clinical and angiographic outcomes. Methods - We studied 112 patients with unstable angina that had undergone coronary angioplasty and we applied the ACC/AHA and Ambrose modified angiographic classifications to the lesions that were considered to be culprit for the clinical findings in a historic cohort. Clinical and angiographic outcomes, wich were observed during hospitalization, were later identified. Results - According to the ACC/AHA and Ambrose modified classifications, the lesions were classified into complex ones in 58% and 46.4%, and into simple ones in 42% and 53.6%, respectively. Hospital discharge without complications was verified in 79.5% of the patients, “enzymatic” myocardial infarction in 14.5%, myocardial revascularization surgery in 2.4%, and death in 3.6%. The success rate achieved in angioplasty was of 73.2%, failure without complications of 20.5%, and acute occlusion of 6.3%. Both classifications were ineffective in predicting the clinical outcomes (modified ACC/AHA p=0.199; modified Ambrose p=0.867). In the prediction of the angiographic outcomes, a tendency to a significant difference between the simple and the complex lesions was observed when the ACC/AHA classification was applied (p=0.08) and a 6 significant though borderline difference, when it was applied the modified Ambrose classification (p=0.05). Conclusions – 1. Both angiographic classifications were ineffective in predicting clinical outcomes, though they presented a tendency to be effective in predicting angiographic in-hospital outcomes in patients with unstable angina that had undergone coronary angioplasty The Ambrose modified angiographic classification was not more effective than the ACC/AHA modified classification in predicting clinical and angiographic outcomes.
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Review of Acute Coronary Syndrome Diagnosis and ManagementKalra, Sumit, Duggal, Sonia, Valdez, Gerson, Smalligan, Roger D. 01 April 2008 (has links)
Acute coronary syndrome (ACS) refers to a group of clinical conditions caused by myocardial ischemia including unstable angina, non-ST-segment elevation myocardial infarction (NSTEMI), and ST-segmcnt elevation myocardial infarction (STEMI). Appropriate and accurate diagnosis has life-saving implications and requires a quick but thorough evaluation of the patient's history, physical examination, electrocardiogram, radiographic studies, and cardiac biomarkers. The management of patients with suspected or confirmed ACS continues to evolve as new evidence from clinical trials is considered and as new technology becomes available to both primary care physicians and cardiologists. Low- and intermediate-risk patients have frequently been managed in a chest pain center or in the emergency department. While stress testing with or without radionuclide imaging is the most common evaluation method, a CT angiogram is sometimes substituted High-risk patients are often managed with an early invasive strategy involving left heart catheterization with a goal of prompt revascularization of at-risk, viable myocardium. With the increased availability of cardiac catheterization facilities, patients with STEMI are more commonly being managed with primary percutaneous coronary intervention, although thrombolysis is still used where such facilities are not immediately available. This article provides primary care physicians with a concise review of the pathophysiology, clinical evaluation, and management of ACS based on the best available evidence in 2008.
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The Impact of the COVID-19 Pandemic on Avoidance of Health Care, Symptom Severity, and Mental Well-Being in Patients With Coronary Artery DiseaseMaehl, Nathalie, Bleckwenn, Markus, Riedel-Heller, Steffi G., Mehlhorn, Sebastian, Lippmann, Stefan, Deutsch, Tobias, Schrimpf, Anne 27 March 2023 (has links)
The COVID-19 pandemic affected regular health care for patients with chronic diseases.
However, the impact of the pandemic on primary care for patients with coronary artery
disease (CAD) who are enrolled in a structured disease management program (DMP) in
Germany is not clear. We investigated whether the pandemic affected primary care and
health outcomes of DMP-CAD patients (n = 750) by using a questionnaire assessing
patients’ utilization of medical care, CAD symptoms, as well as health behavior and
mental health since March 2020. We found that out of concern about getting infected
with COVID-19, 9.1% of the patients did not consult a medical practitioner despite
having CAD symptoms. Perceived own influence on infection risk was lower and anxiety
was higher in these patients compared to symptomatic CAD patients who consulted
a physician. Among the patients who reported chest pain lasting longer than 30 min,
one third did not consult a medical practitioner subsequently. These patients were
generally more worried about COVID-19. Patients with at least one worsening CAD
symptom (chest pain, dyspnea, perspiration, or nausea without apparent reason) since
the pandemic showed more depressive symptoms, higher anxiety scores, and were less
likely to consult a doctor despite having CAD symptoms out of fear of infection. Our
results provide evidence that the majority of patients received sufficient medical care
during the COVID-19 pandemic in Germany. However, one in ten patients could be
considered particularly at risk for medical undersupply and adverse health outcomes.
The perceived infection risk with COVID-19 might have facilitated the decision not to
consult a medical doctor.
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Clinical Presentation of Acute Coronary Syndrome: Does Age Make a Difference? Implications for Emergency NursingHarris, Iesiah M. 11 August 2006 (has links)
No description available.
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