Cost Effectiveness. Nuclear Quanta Diagnostico Nuclear Curitiba - Brasil DISCLOSURES
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1 Cost Effectiveness João V. Vitola Cardiologista e Médico Nuclear Quanta Diagnostico Nuclear Curitiba - Brasil DISCLOSURES Honorarium Research and/or conferences in NC BMS, CVT, Astellas,, IAEA Royalties Publishers in the USA Springer-Verlag Verlag-Nuclear Cardiology and Correlative Imaging: a teaching file, NY, 2004 Lippincott Williams & Wilkins, - Nuclear Medicine teaching File,, 2009
2 Leader Cause of Mortality in Adults Men and Women 80% of 17.5 mi Deaths Due to CVD are in Low to Mid Income Countries Significant Economic Burden
3 Death from CAD - variation by country and gender
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5 Which nations will be most affected?
6 Projected Increase Deaths due to CVD from 1990 to Increase Deaths (%) Women Men 0 Developing Nations Developed Nations Yusuf S et al, Circulation 2001; 104: Leeder, S et al. A Race against time: the challenges of cardiovascular disease in developing countries. New York: Trustees of Columbia University; 2004
7 Projected Percentage of Deaths from Cardiovascular Disease Among Those yrs Health Affairs Jan/Feb 2007
8 Specific Issues to Discussed Increasing costs of health care Obesity and DM Aging Increasing chronic disease / CHF Importance of applying rational / cost effective strategies How nuclear cardiology fits
9 World Scenario Estimation for 2025 Diabetes International Federation Diabetes Atlas: 2006; DIF
10 DM, Age and SPECT Abnormalities (n=10594) Resultado anormal: idade x DM % A B N O R M A L Não diabético Diabético 33% 33% 44% 50% 62% 73% Até a a a a ou mais Vitola JV et al, Quanta Database Curitiba - Brazil
11
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13 What was the area at risk? Extent and severity of ischemia? TPD?
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15 Pre-Rx 12 m OMT Pre-Rx TPD: 28% 12m TPD: 2%
16 5 years F/U Cardiac deaths Med therapy 5.7 % Revasc 5.9 % More extensive (anatomy!!) n= pts 763 suitable to CABG Medical therapy alone MI 29.2 % Death 17.6% CABG: MI 21.1% Death 10%
17 Cost Effectiveness BARI 2D 2years costs treating CAD + type 2 DM Medical Therapy U$ CABG or PCI U$ AHA, 2009
18 The Elderly Population is Increasing $ Source: WHO
19 Age as a predictor of SPECT abnormality Vitola JV et al. Quanta Database Curitiba, Brazil (n=10594) Resultado anormal: idade x sexo Feminino Masculino 68% 46% 41% 55% 52% 10% 14% 23% 19% 21% 33% 30% Até a a a a ou mais P<0.048 P<0.611 P<0.001 P<0.036 P<0.001 RR 1,5 (CI 1,0-2,2) RR 1,1 (CI 0,9 1,3) RR 1,4 (CI 1,2-1,7) RR 1,2 (CI 1,0 1,5) RR 1,9 (1,3 2,7)
20 Prevalence of Heart Failure by Gender and Age in the Framingham Study 10 9,7 9,8 patients per 100 persons ,1 0,1 0,5 0,7 1,8 1,3 6,2 3,4 6,6 6,8 Women Men $ Age Ho, Pinsky, Kannel, Levy. J Am Coll Cardiol 1993; 22:6A
21 USA budget for health care 2 trillion US $ 16% of GDP Beller G, JNC 2008
22 What strategy an investment is ideal (Prevention + Investigation + Management)? BRIC 5-8% Porter ME, Teisberg EO: Redefining Health Care Harvard Business School Press, 2006
23
24 Cost Effectiveness treating CVD U$ per DALY = Disability Adjusted Life Year averted
25 CP in the ER Non cardiac 55 % Other CV Causes 22 % SA 6 % UA 9 % AMI 8 % Pope et al. N Eng J Med 2000;342:
26 CTA in the ER ROMICAT Study, Hoffmann U et al, JACC, 2009 CTA for ACS in 368 pts in the ER - low- to moderate-risk patients Normal initial troponin and a nonischemic electrocardiogram. 64-slice CT angiogram F/U 6 mo for MACE Average hospital stay - 40 hours - CT could have avoided that in 50% of patients. 31 of 368 patients (8%) were found to have ACS on the basis of further testing Sensitivity and negative predictive value for ACS were high for ACS 50% no CAD - R/O ACS in 50% of pts (could be sent home). 31% non obstructive CAD, 19% inconclusive or significant disease Specificity and positive predictive value were 17% and 54% (cost of F/U testing?) 24hrs / 7 days wk, fast acquisition, slow processing and interpretation
27 ROMICAT Study, Hoffmann U et al, JACC, 2009 ROMICAT - Análise (n=368 /31 com SCA) n=368 incluidos,, mas n=1869 foram considerados Idosos subrepresentados Total = 1869 Final = 368 Excluidos DAC, DM em Metformina, IRC, FA,...
28 ROMICAT Study, Hoffmann U et al, JACC, / 368 patients (8%) tiveram SCA baseado em outros testes Sensibilidade e VPN altos 50% sem DAC - OK (casa) 31% lesões, 19% inconclusivos ou DAC acentuada Especificidade e VPP 17% e 54% (qual o custo?)
29 3,4 hrs $ repeat 15 hrs $ repeat Exclusion: CAD, EF < 45%, AF, CR >1.5, BMI 39,...
30 Freqüência de CAT e RVM baseado na estratégia fase aguda Qual o custo? Goldstein J Am Coll Cardiol, 2007;49:
31 Freqüência de CAT e RVM baseado na estratégia 6 meses + custo de acompanhamento dos 8 achados incidentais em pulmão? estratégia adequada? Custo efetiva? Goldstein J Am Coll Cardiol, 2007;49:
32 Potenciais Procedimentos Invasivos Desnecessários
33 SOURCE OF RADIATION USA 1987 Medical 15% USA 2006 Medical 47%
34 ECONOMIC IMPLICATIONS OF REVASCULARISATION CONSIDERING SELECTION BASED ON ISCHEMIA Leslee Shaw et al. JACC 1999;33:
35 Shaw JACC 1999;33:
36
37 Frequency of Abnormal SPECT Depending on Each Variable Below Average Average Above Average Athletes Low Duke Exercise Test Female Gender Phy Active Mean Abnormal Rate Sedentary Cholesterol Male Gender Diabetes Typical Pain Dipyridamole Known CAD Hx PCI Hx CABG High Duke 6.00% 22.60% 26.90% 30.50% 32.80% 35.40% 38.30% 39.20% 39.80% 52.30% 53.20% 60.30% 63.60% 64% 75% 76% Vitola JV et al, Quanta Database Curitiba - Brazil
38 61 yo, male, stress, obese Dyspnea on exertion / atypical pain Should we revascularize? Cortes Tomográficos-Referência Eixo Curto Eixo Longo Vertical Eixo Longo Horizontal Habibian R, Delbeke D, Martin W, Sandler M, Vitola JV Cardiovascular Imaging, in Nuclear Medicine Teaching File, 2009
39 61 yo, male, stress, obese Dyspnea on exertion / atypical pain Post Revasc SPECT Habibian R, Delbeke D, Martin W, Sandler M, Vitola JV Cardiovascular Imaging, in Nuclear Medicine Teaching File, 2009
40 WHAT ARE THE ECONOMIC COSTS OF CARDIOVASCULAR DISEASES? 1. CVDs affect many people in middle age, very often severely limiting the income and savings of affected individuals and their families. 2. Lost earnings and out of pocket health care payments undermine the socioeconomic development of communities and nations. 3. CVDs place a heavy burden on the economies of countries. 4. Lower socioeconomic groups in high income countries generally have a greater prevalence of risks factors, diseases and mortality, a similar pattern is emerging as the CVD epidemic evolves in low and middle income countries. Rationale for Nuclear Cardiology projects at the UN - IAEA...
41 What is the utilization of Nuclear Cardiology in India? Only about 20 thousand SPECT / year / entire India 100 MPI/mo
42 High Moderate High Moderate Moderate Low Low Inexistente Vitola JV, Shaw L, Allam A et al JNC, 2009
WHO data on Cardiovascular Disease and Nuclear Cardiology Utilization Worldwide
WHO data on Cardiovascular Disease and Nuclear Cardiology Utilization Worldwide João V. Vitola, MD, PhD Cardiologist and Nuclear Medicine Physician Quanta Diagnostico Nuclear Curitiba - Brazil DISCLOSURES
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