Date on Master's Thesis/Doctoral Dissertation

12-2011

Document Type

Master's Thesis

Degree Name

M.S.

Department

Bioinformatics and Biostatistics

Committee Chair

Myers, John Allen

Author's Keywords

Cost-effectiveness; NIS; PCI; CABG; KY pilot project; Onsite

Subject

Coronary heart disease--Treatment--Cost effectiveness; Angioplasty; Medical laws and legislation--Kentucky

Abstract

A myocardial infarction (MI) occurs when blood supply to the heart is cut off by a blockage in one of the coronary arteries. Most hospitals treat a patient with thrombolysis or a percutaneous coronary intervention (PC I). The latter has been established as the preferred revascularization method. However, the American College of Cardiologists and the American Heart Association strongly recommend that a hospital performing PCI must also have coronary artery bypass graft capabilities (CABG). By following these recommendations, the state of Kentucky has limited the number of hospitals allowed to perform PCI and thereby limiting access to such a life-saving procedure. Recently, the state of Kentucky has begun evaluating if hospitals without such capabilities should be allowed to perform primary PCI, and data from this evaluation allowed the establishment of the medical soundness of allowing such hospitals to perform primary PCI. To have the most comprehensive understanding of the effects of allowing hospitals without surgical-backup performing primary PCI, the effects and costs must be evaluated simultaneously. The current study aims to study the financial feasibility of allowing these hospitals to do emergency PCI in addition to hospitals with onsite open-heart surgery capabilities. The estimates have been derived from a systematic literature review of national studies based on PCI registries as well as our earlier study - KENTUCKY PILOT PROJECT FOR PRIMARY PCI WITHOUT ONSITE CABG. Costs estimates were derived from the National Inpatient Sample, which approximates a twenty percent sample of the U.S. community hospitals. In determining costs, the sample was extracted by filtering using ICD-9 codes. A deterministic model was developed so that more uncertainty would not be introduced. The economic evaluation focused on estimating the incremental cost effectiveness ratio (ICER) of allowing regional hospitals to perform primary PCI from a payer's perspective. Uncertainty about the model parameters was investigated through employing sensitivity analysis techniques. The study found that there were no statistically significant differences in outcomes between hospitals with and without CABG capabilities. The only characteristic, which was significantly different between these two groups, was total charges. The alternative to allow Regional Hospitals as well to perform primary PCI dominated the other alternative of Only Allowing Hospitals with Onsite CABG to perform PCI. That is, allowing regional hospitals to perform primary PCI both incur fewer costs while also averting more deaths. However, sensitivity to the cost of PC I at regional hospitals was observed in the model. The study suggests that by allowing primary PCI to be performed at selected facilities without onsite CABG, the state of Kentucky can expand access to PCI and reduce geographical health disparities, one of its main healthcare initiatives.

Download

Share

COinS