Going beyond the mean: economic benefits of myocardial infarction secondary prevention

Viktor Von Wyl,Beat Brüngger,Agne Ulyte,Matthias Schwenkglenks,Wenjia Wei,Eva Blozik,Dragana Radovanovic,Caroline Bähler,Oliver Grübner,Holger Dressel

doi:10.1186/s12913-020-05985-x

Abstract

BackgroundUsing the example of secondary prophylaxis of myocardial infarction (MI), our aim was to establish a framework for assessing cost consequences of compliance with clinical guidelines; thereby taking cost trajectories and cost distributions into account.MethodsSwiss mandatory health insurance claims from 1840 persons with hospitalization for MI in 2014 were analysed. Included persons were predominantly male (74%), had a median age of 73 years, and 71% were pre-exposed to drugs for secondary prophylaxis, prior to index hospitalization. Guideline compliance was defined as being prescribed recommended 4-class drug prophylaxis including drugs from the following four classes: beta-blockers, statins, aspirin or P2Y12 inhibitors, and angiotension-converting enzyme inhibitors or angiotensin receptor blockers. Health care expenditures (HCE) accrued over 1 year after index hospitalization were compared by compliance status using two-part regression, trajectory analysis, and counterfactual decomposition analysis.ResultsOnly 32% of persons received recommended 4-class prophylaxis. Compliant persons had lower HCE (− 4865 Swiss Francs [95% confidence interval − 8027; − 1703]) and were more likely to belong to the most favorable HCE trajectory (with 6245 Swiss Francs average annual HCE and comprising 78% of all studied persons). Distributional analyses showed that compliance-associated HCE reductions were more pronounced among persons with HCE above the median.ConclusionsCompliance with recommended prophylaxis was robustly associated with lower HCE and more favorable cost trajectories, but mainly among persons with high health care expenditures. The analysis framework is easily transferrable to other diseases and provides more comprehensive information on HCE consequences of non-compliance than mean-based regressions alone.

Highlights

Using the example of secondary prophylaxis of myocardial infarction (MI), our aim was to establish a framework for assessing cost consequences of compliance with clinical guidelines; thereby taking cost trajectories and cost distributions into account
On the basis of health insurance claims data of persons who were hospitalized for an MI event, this study evaluated health and financial outcome differences between persons who were prescribed secondary prevention of MI as recommended by guidelines compared to others who were not
Overall approach This study evaluated the health care expenditures (HCE) implications of noncompliance to MI secondary prevention by applying recent methods from the causal inference framework to better control for healthy adherer bias (Fig. 1, analysis 1)

Summary

Introduction

Using the example of secondary prophylaxis of myocardial infarction (MI), our aim was to establish a framework for assessing cost consequences of compliance with clinical guidelines; thereby taking cost trajectories and cost distributions into account. Real-world studies of care provision are usually retrospective, observational, and relying on secondary data sources (that is, data initially collected for other purposes), which brings about risks of biases such as residual confounding [3]. Among the potential biases described in the literature the “healthy adherer bias” is of particular concern [4]. This bias circumscribes the effect that healthier persons tend to adhere better to prescribed treatments, for example because they are generally more health-conscious. Compliance may appear to exert beneficial effects on specific health outcomes when such benefits are driven by unmeasured comparator group differences

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