[Show abstract][Hide abstract] ABSTRACT: Purpose:
This study was designed to evaluate the feasibility of endovascular guidance by means of live fluoroscopy fusion with magnetic resonance angiography (MRA) and computed tomography angiography (CTA).
Fusion guidance was evaluated in 20 endovascular peripheral artery interventions in 17 patients. Fifteen patients had received preinterventional diagnostic MRA and two patients had undergone CTA. Time for fluoroscopy with MRA/CTA coregistration was recorded. Feasibility of fusion guidance was evaluated according to the following criteria: for every procedure the executing interventional radiologists recorded whether 3D road-mapping provided added value (yes vs. no) and whether PTA and/or stenting could be performed relying on the fusion road-map without need for diagnostic contrast-enhanced angiogram series (CEAS) (yes vs. no). Precision of the fusion road-map was evaluated by recording maximum differences between the position of the vasculature on the virtual CTA/MRA images and conventional angiography.
Average time needed for image coregistration was 5 ± 2 min. Three-dimensional road-map added value was experienced in 15 procedures in 12 patients. In half of the patients (8/17), intervention was performed relying on the fusion road-map only, without diagnostic CEAS. In two patients, MRA roadmap showed a false-positive lesion. Excluding three patients with inordinate movements, mean difference in position of vasculature on angiography and MRA/CTA road-map was 1.86 ± 0.95 mm, implying that approximately 95 % of differences were between 0 and 3.72 mm (2 ± 1.96 standard deviation).
Fluoroscopy with MRA/CTA fusion guidance for peripheral artery interventions is feasible. By reducing the number of CEAS, this technology may contribute to enhance procedural safety.
[Show abstract][Hide abstract] ABSTRACT: Purpose
Epicardial adipose tissue (EAT) is emerging as a risk factor for coronary artery disease (CAD). The aim of this study was to determine the applicability and efficiency of automated EAT quantification.
Methods and Materials
EAT volume was assessed both manually and automatically in 157 coronary CTA patients. Manual assessment consisted of a short axis-based manual measurement while automated assessment on both contrast and non-contrast enhanced datasets was achieved through novel prototype software (syngo.via, Siemens Healthcare). Duration of both quantification methods was recorded and EAT volumes were compared using paired samples t-test. Correlation of volumes was determined using intraclass correlation coefficient; agreement was tested using Bland-Altman analysis. The association between EAT and CAD was estimated using logistic regression.
Automated quantification was significantly less time consuming than automated quantification (17±2 vs. 280±78 seconds, p<0.0001). Although manual EAT volume differed significantly from automated EAT volume (75±33 cm³ vs. 95±45 cm³, p<0.001), a good correlation between both assessments was found (r=0.76, p<0.001). For all methods, EAT volume was positively associated with the presence of CAD. Stronger predictive value for the severity of CAD was achieved through automated quantification on both contrast enhanced and non-contrast enhanced datasets.
Automated EAT quantification is a quick method to estimate EAT and may serve as a predictor for CAD presence and severity.
[Show abstract][Hide abstract] ABSTRACT: The aim of this study was to evaluate the sensitivity and specificity of MR angiography (MRA) in the diagnosis of ruptured and unruptured intracranial aneurysms.
A systematic search was performed on 4 electronic databases on relevant articles that were published from January 1998 to October 2013. Inclusion criteria were met by 12 studies that compared MRA with digital subtraction angiography as reference standard. Two independent reviewers evaluated the methodological quality of the studies. Data from eligible studies were extracted and used to construct 2×2 contingency tables on a per-aneurysm level. Pooled estimates of sensitivity and specificity were calculated for all studies and subgroups of studies. Heterogeneity was tested, and risk for publication bias was assessed.
Included studies were of high methodological quality. Studies with larger sample size tended to have higher diagnostic performance. Most studies used time-of-flight MRA technique. Among the 960 patients assessed, 772 aneurysms were present. Heterogeneity with reference to sensitivity and specificity was moderate to high. Pooled sensitivity of MRA was 95% (95% confidence interval, 89%-98%), and pooled specificity was 89% (95% confidence interval, 80%-95%). False-negative and false-positive aneurysms detected on MRA were mainly located at the skull base and middle cerebral artery. Freehand 3-dimensional reconstructions performed by the radiologist significantly increased diagnostic performance. Studies performed on 3 Tesla showed a trend toward higher performance (P=0.054).
Studies on diagnostic performance of MRA show high sensitivity with large variation in specificity in the detection of intracranial aneurysms.
[Show abstract][Hide abstract] ABSTRACT: Although electrocardiography is frequently used as an initial test to detect or rule out previous myocardial infarction (MI), the diagnostic performance of commonly used electrocardiographic scoring systems is not well described. We aimed to determine the diagnostic accuracy of (1) the Universal Definition, (2) Minnesota ECG Code (MC), (3) Selvester QRS Score, and (4) assessment by cardiologists using late gadolinium enhancement cardiovascular magnetic resonance imaging as the reference standard. Additionally, the effect of electrocardiographic patterns and infarct characteristics on detecting previous MI was evaluated. The 3-month follow-up electrocardiograms of 78 patients with first-time reperfused ST elevation MI were pooled with electrocardiograms of 36 healthy controls. All 114 electrocardiograms were randomly analyzed, blinded to clinical and LGE-CMR data. The sensitivity of the Universal Definition, MC, Selvester QRS Score, and cardiologists to detect previous MI was 33%, 79%, 90%, and 67%, respectively; specificity 97%, 72%, 31%, and 89%, respectively; diagnostic accuracy 54%, 77%, 71%, and 74%, respectively. Probability of detecting MI by cardiologists increased with an increasing number (odds ratio [OR] 2.00, 95% confidence interval [CI] 1.30 to 3.09), width (OR 1.02, 95% CI 1.01 to 1.03), and depth (OR 1.16, 95% CI 1.07 to 1.27) of Q waves as well as increasing infarct size (OR 1.15, 95% CI 1.06 to 1.25) and transmurality (OR 1.05, 95% CI 1.01 to 1.08; p <0.05 for all). The time-consuming MC and rapid visual assessment by cardiologists achieved the best and similar diagnostic accuracies to detect previous MI. The diagnostic performance of all 4 electrocardiographic scoring systems was modest and related to the number, depth, and width of Q waves as well as increasing infarct size and transmurality. In conclusion, the exclusion of a previous MI based solely on electrocardiographic findings should be done with caution. Future studies are needed to define which patients should be referred to additional diagnostic testing.
The American journal of cardiology 07/2013; 112(8). DOI:10.1016/j.amjcard.2013.05.048 · 3.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
As one of the primary etiologies of the post-thrombotic syndrome, chronic venous occlusion is a huge burden on patient quality of life and medical costs. In this study, we evaluate the short-term and midterm results of endovenous recanalization by angioplasty and stenting in chronic iliofemoral deep venous occlusions.
This is a retrospective observational study set in a tertiary medical referral center. Patients with venous claudication or C4-6 venous disease combined with duplex and magnetic resonance-confirmed iliofemoral or caval occlusion were included. Patients with recent deep vein thrombosis (<1 year) were excluded. The intervention was endovascular deep venous recanalization, followed by angioplasty and stenting. Safety and feasibility were clinically evaluated during the procedure and during follow-up. Reocclusions and other treatment failures were evaluated during a maximum follow-up of 31 months by ultrasound imaging and venography.
Seventy-five procedures were performed in 63 patients (average age, 44 years; range, 18-75 years), of whom 86% had a history of deep venous thrombosis. The mean time between the initial deep venous thrombosis and treatment with PTA and stenting was 12 years (maximum, 31 years). May-Thurner syndrome was present in 57%. Forty-two procedures were performed in the left, six in the right, and 11 in both lower extremities. The vena cava inferior was partially stented in 25 patients. An average of 2.6 stents (median, 2) were used per procedure. Primary patency was 74% after 1 year. Assisted primary and secondary patency rates were 81% and 96%, respectively, at 1 year. Secondary procedures included restenting, catheter-directed thrombolysis, endophlebectomy of the common femoral vein, and creation of an arteriovenous fistula. No clinically evident pulmonary emboli were noted. A bleeding complication occurred after six procedures and was deemed major in two. No patients died. Relief or significant improvement of symptoms of chronic venous occlusive disease was achieved in 81% of patients.
Endovenous recanalization by angioplasty and stenting of chronically occluded iliofemoral vein segments is a safe and effective treatment with good short-term results, even when treatment takes place decades after the initial deep venous thrombosis. Most reocclusions can be adequately treated by a secondary procedure.
[Show abstract][Hide abstract] ABSTRACT: Background
Although echocardiography is used as a first line imaging modality, its accuracy to detect acute and chronic myocardial infarction (MI) in relation to infarct characteristics as assessed with late gadolinium enhancement cardiovascular magnetic resonance (LGE-CMR) is not well described.
One-hundred-forty-one echocardiograms performed in 88 first acute ST-elevation MI (STEMI) patients, 2 (IQR1-4) days (n = 61) and 102 (IQR92-112) days post-MI (n = 80), were pooled with echocardiograms of 36 healthy controls. 61 acute and 80 chronic echocardiograms were available for analysis (53 patients had both acute and chronic echocardiograms). Two experienced echocardiographers, blinded to clinical and CMR data, randomly evaluated all 177 echocardiograms for segmental wall motion abnormalities (SWMA). This was compared with LGE-CMR determined infarct characteristics, performed 104 ± 11 days post-MI. Enhancement on LGE-CMR matched the infarct-related artery territory in all patients (LAD 31%, LCx 12% and RCA 57%).
The sensitivity of echocardiography to detect acute MI was 78.7% and 61.3% for chronic MI; specificity was 80.6%. Undetected MI were smaller, less transmural, and less extensive (6% [IQR3-12] vs. 15% [IQR9-24], 50 ± 14% vs. 61 ± 15%, 7 ± 3 vs. 9 ± 3 segments, p < 0.001 for all) and associated with higher left ventricular ejection fraction (LVEF) and non-anterior location as compared to detected MI (58 ± 5% vs. 46 ± 7%, p < 0.001 and 82% vs. 63%, p = 0.03). After multivariate analysis, LVEF and infarct size were the strongest independent predictors of detecting chronic MI (OR 0.78 [95%CI 0.68-0.88], p < 0.001 and OR 1.22 [95%CI0.99-1.51], p = 0.06, respectively). Increasing infarct transmurality was associated with increasing SWMA (p < 0.001).
In patients presenting with STEMI, and thus a high likelihood of SWMA, the sensitivity of echocardiography to detect SWMA was higher in the acute than the chronic phase. Undetected MI were smaller, less extensive and less transmural, and associated with non-anterior localization and higher LVEF. Further work is needed to assess the diagnostic accuracy in patients with non-STEMI.
Journal of Cardiovascular Magnetic Resonance 01/2013; 15(1):5. DOI:10.1186/1532-429X-15-5 · 4.56 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Both end-stage and milder stages of chronic kidney disease (CKD) are associated with an increased risk of adverse cardiovascular events. Several studies found an association between decreasing renal function and increasing coronary artery calcification, but it remains unclear if this association is independent from traditional cardiovascular risk factors. Therefore, the aim of this study was to investigate whether mild to moderate CKD is independently associated with coronary plaque burden beyond traditional cardiovascular risk factors.
A total of 2,038 patients with symptoms of chest discomfort suspected for coronary artery disease underwent coronary CT-angiography. We assessed traditional risk factors, coronary calcium score and coronary plaque characteristics (morphology and degree of luminal stenosis). Patients were subdivided in three groups, based on their estimated glomerular filtration rate (eGFR) Normal renal function (eGFR ≥90 mL/min/1.73 m(2)); mild CKD (eGFR 60-89 mL/min/1.73 m(2)); and moderate CKD (eGFR 30-59 mL/min/1.73 m(2)).
Coronary calcium score increased significantly with decreasing renal function (P<0.001). Coronary plaque prevalence was higher in patients with mild CKD (OR 1.83, 95%CI 1.52-2.21) and moderate CKD (OR 2.46, 95%CI 1.69-3.59), compared to patients with normal renal function (both P<0.001). Coronary plaques with >70% luminal stenosis were found significantly more often in patients with mild CKD (OR 1.67 (95%CI 1.16-2.40) and moderate CKD (OR2.36, 95%CI 1.35-4.13), compared to patients with normal renal function (both P<0.01). After adjustment for traditional cardiovascular risk factors, the association between renal function and the presence of any coronary plaque as well as the association between renal function and the presence of coronary plaques with >70% luminal stenosis becomes weaker and were no longer statistically significant.
Although decreasing renal function is associated with increasing extent and severity of coronary artery disease, mild to moderately CKD is not independently associated with coronary plaque burden after adjustment for traditional cardiovascular risk factors.
PLoS ONE 10/2012; 7(10):e47267. DOI:10.1371/journal.pone.0047267 · 3.23 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This study aimed to determine the diagnostic accuracy of the 3 most commonly used noninvasive myocardial perfusion imaging modalities, single-photon emission computed tomography (SPECT), cardiac magnetic resonance (CMR), and positron emission tomography (PET) perfusion imaging for the diagnosis of obstructive coronary artery disease (CAD). Additionally, the effect of test and study characteristics was explored.
Accurate detection of obstructive CAD is important for effective therapy. Noninvasive myocardial perfusion imaging is increasingly being applied to gauge the severity of CAD.
Studies published between 1990 and 2010 identified by PubMed search and citation tracking were examined. A study was included if a perfusion imaging modality was used as a diagnostic test for the detection of obstructive CAD and coronary angiography as the reference standard (≥50% diameter stenosis).
Of the 3,635 citations, 166 articles (n = 17,901) met the inclusion criteria: 114 SPECT, 37 CMR, and 15 PET articles. There were not enough publications on other perfusion techniques such as perfusion echocardiography and computed tomography to include these modalities into the study. The patient-based analysis per imaging modality demonstrated a pooled sensitivity of 88% (95% confidence interval [CI]: 88% to 89%), 89% (95% CI: 88% to 91%), and 84% (95% CI: 81% to 87%) for SPECT, CMR, and PET, respectively; with a pooled specificity of 61% (95% CI: 59% to 62%), 76% (95% CI: 73% to 78%), and 81% (95% CI: 74% to 87%). This resulted in a pooled diagnostic odds ratio (DOR) of 15.31 (95% CI: 12.66 to 18.52; I(2) 63.6%), 26.42 (95% CI: 17.69 to 39.47; I(2) 58.3%), and 36.47 (95% CI: 21.48 to 61.92; I(2) 0%). Most of the evaluated test and study characteristics did not affect the ranking of diagnostic performances.
SPECT, CMR, and PET all yielded a high sensitivity, while a broad range of specificity was observed. SPECT is widely available and most extensively validated; PET achieved the highest diagnostic performance; CMR may provide an alternative without ionizing radiation and a similar diagnostic accuracy as PET. We suggest that referring physicians consider these findings in the context of local expertise and infrastructure.
Journal of the American College of Cardiology 05/2012; 59(19):1719-28. DOI:10.1016/j.jacc.2011.12.040 · 16.50 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Epicardial adipose tissue (EAT) volume has been associated with coronary artery disease (CAD). As diabetes mellitus type 2 (DM2) patients have higher EAT volumes, it has been suggested that EAT may play a role in promoting CAD in these patients. The aim of this study was to examine the association between EAT and CAD in DM2, impaired fasting glucose (IFG) and control patients presenting with stable chest pain.
A total of 410 stable chest pain patients underwent multidetector cardiac computed tomography angiography (CCTA) to assess the presence of CAD. The extent of CAD was expressed as the number of affected segments. The EAT volume was measured using three-dimensional volumetric quantification. The EAT was compared using ANOVA, logistic and linear regression models were used to assess its predictive value. Multivariable regression analysis corrected for traditional risk factors was performed. Eighty-three patients had DM2, 118 IFG and there were 209 controls. DM2 as well as IFG patients had higher EAT volumes compared with controls (98 ± 41, 92 ± 39, and 75 ± 34 cm(3), respectively; P < 0.001). EAT predicted the presence (OR: 1.01; P < 0.001) and the extent of CAD (B: 0.01; P < 0.001). The associations were equal in all subgroups. However, in a multivariable regression model corrected for traditional cardiovascular risk factors, EAT was not an independent predictor for the presence or extent of CAD (OR: 1.00; P = 0.88 and B: -0.11; P = 0.68, respectively).
The EAT volume is associated with CAD in DM2, IFG, and control patients. However, EAT is not an independent predictor for CAD in patients presenting with stable chest pain.
[Show abstract][Hide abstract] ABSTRACT: Poor adherence to treatment is one of the major problems in the treatment of hypertension. Self blood pressure measurement may help patients to improve their adherence to treatment.
In this prospective, randomized, controlled study coordinated by a university hospital, a total of 228 mild-to-moderate hypertensive patients were randomized to either a group that performed self-measurements at home in addition to office blood pressure measurements [the self-pressure group (n = 114)] or a group that only underwent office blood pressure measurement [the office pressure group (n = 114)]. Patients were followed for 1 year in which treatment was adjusted, if necessary, at each visit to the physician's office according to the achieved blood pressure. Adherence to treatment was assessed by means of medication event monitoring system TrackCaps.
Median adherence was slightly greater in patients from the self-pressure group than in those from the office pressure group (92.3 vs. 90.9%; P = 0.043). Although identical among both groups, in the week directly after each visit to the physician's office, adherence [71.4% (interquartile range 71-79%)] was significantly lower (P < 0.001) than that at the last 7 days prior to each visit [100% (interquartile range 90-100%)]. On the remaining days between the visits, patients from the self-pressure group displayed a modestly better adherence than patients from the office pressure group (97.6 vs. 97.0%; P = 0.024).
Although self-blood pressure measurement as an adjunct to office blood pressure measurement led to somewhat better adherence to treatment in this study, the difference was only small and not clinically significant. The time relative to a visit to the doctor seems to be a more important predictor of adherence.
Journal of Hypertension 11/2009; 28(3):622-7. DOI:10.1097/HJH.0b013e328334f36b · 4.72 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This article investigates whether differences in utility scores based on the EQ-5D and the SF-6D have impact on the incremental cost-utility ratios in five distinct patient groups.
We used five empirical data sets of trial-based cost-utility studies that included patients with different disease conditions and severity (musculoskeletal disease, cardiovascular pulmonary disease, and psychological disorders) to calculate differences in quality-adjusted life-years (QALYs) based on EQ-5D and SF-6D utility scores. We compared incremental QALYs, incremental cost-utility ratios, and the probability that the incremental cost-utility ratio was acceptable within and across the data sets.
We observed small differences in incremental QALYs, but large differences in the incremental cost-utility ratios and in the probability that these ratios were acceptable at a given threshold, in the majority of the presented cost-utility analyses. More specifically, in the patient groups with relatively mild health conditions the probability of acceptance of the incremental cost-utility ratio was considerably larger when using the EQ-5D to estimate utility. While in the patient groups with worse health conditions the probability of acceptance of the incremental cost-utility ratio was considerably larger when using the SF-6D to estimate utility.
Much of the appeal in using QALYs as measure of effectiveness in economic evaluations is in the comparability across conditions and interventions. The incomparability of the results of cost-utility analyses using different instruments to estimate a single index value for health severely undermines this aspect and reduces the credibility of the use of incremental cost-utility ratios for decision-making.
Value in Health 10/2009; 13(2):222-9. DOI:10.1111/j.1524-4733.2009.00669.x · 3.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Het doel van deze literatuurstudie is om de effectiviteit na te gaan van intensieve huisbezoekenprogramma's aan ouderen met gezondheidsproblemen of functionele beperkingen. Het doorzoeken van de literatuur was gebaseerd op de ingesloten experimenten van vier literatuurstudies over de effectiviteit van huisbezoeken, gepubliceerd vanaf 2000, en de databestanden van Cinahl, Cochrane, Embase, Medline en PsycINFO vanaf 2001. De zoekstrategie identificeerde 844 studies, waarvan acht voldeden aan de inclusiecriteria. Zeven experimenten waren van voldoende methodologische kwaliteit; geen van deze experimenten hadden, op basis van de belangrijkste analyses, een significant gunstig effect voor de interventiegroep in vergelijking met de controlegroep op mortaliteit, gezondheid, zorggebruik of kosten. De inclusie van minder intensieve programma's voor kwetsbare ouderen zou weinig invloed uitgeoefend hebben op de conclusies van onze literatuurstudie. We concluderen dat huisbezoekenprogramma's niet zinvol lijken voor oudere personen met (ervaren) gezondheidsproblemen binnen het gezondheidszorgsysteem van westerse landen.
Tijdschrift voor Verpleeghuisgeneeskunde 04/2009; 33(5):148-154. DOI:10.1007/BF03078542
[Show abstract][Hide abstract] ABSTRACT: The objective of this study was to assess compliance with a 10-day treatment of antibiotics or placebo once-daily (OD) and three-times-daily (TD) for lower respiratory tract infections (LRTIs) using electronic monitoring, and to evaluate whether compliance depends on time since the start of treatment and weekday. Taking compliance, timing compliance, correct dosing compliance and mean interdose intervals were assessed using data from 155 LRTI patients who received either a 10-day treatment of amoxicillin TD and placebo OD or roxithromycin OD and placebo TD using a double-dummy technique. Compliance was assessed by electronic monitoring. Taking compliance was 98.0% for the OD regimen and 91.0% for the TD regimen. Correct dosing was 98.1% for the OD regimen and 91.1% for the TD regimen and timing compliance was 48.2% and 10.9%, respectively. The mean interdose interval before the first daily dose for the TD group was particularly prolonged to >13h. Correct dosing over time showed fewer patients with correct dosing compliance, reaching a low of 79% for the TD group towards the end of the 10-day treatment. Compliance was not influenced by weekday. This study adds important information to the limited evidence on compliance with antibiotics for LRTI, one of the most common reasons for consultation in primary care. Taking compliance was high for both regimens, yet timing compliance was poor. The prolonged mean interdose intervals provide striking new insights into understanding non-compliance with more-than-once-daily regimens. These findings require consideration when exploring ways to improve future compliance in short-term antibiotic treatment for respiratory tract infections.
International Journal of Antimicrobial Agents 06/2008; 31(6):531-6. DOI:10.1016/j.ijantimicag.2008.01.029 · 4.30 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Home visiting programs have been developed aimed at improving the health and independent functioning of older people. Also, they intend to reduce hospital and nursing home admission and associated cost. A substantial number of studies have examined the effects of preventive home visiting programs on older people living in the community; the findings have been inconsistent. The objective of this review was to assess the effectiveness of intensive home visiting programs targeting older people with poor health or otherwise with functional impairments.
A search for literature was based on included trials from four reviews on the effectiveness of home visits published after 2000 and on a database search of Cinahl, the Cochrane Central Register of Controlled Trials, Embase, Medline and PsycINFO from 2001 onwards. We also manually searched reference lists from potentially relevant papers. Randomized controlled trials were included assessing the effectiveness of intervention programs consisting of at least four home visits per year, an intervention duration of 12 months or more, and targeting older people (aged 65 years and over) with poor health. Two reviewers independently abstracted data from full papers on program characteristics and outcome measures; they also evaluated the methodological quality.
The search identified 844 abstracts; eight papers met the inclusion criteria. Seven trials were of sufficient methodological quality; none of the trials showed a significant favorable effect for the main analysis comparing the intervention group with the control group on mortality, health status, service use or cost. The inclusion of less-intensive intervention programs for frail older persons would not have exerted a great influence on the findings of our review.
We conclude that home visiting programs appear not to be beneficial for older people with poor health within the health care setting of Western countries.
BMC Health Services Research 02/2008; 8(1):74. DOI:10.1186/1472-6963-8-74 · 1.71 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: It is still uncertain whether one can safely base treatment decisions on self-measurement of blood pressure. In the present study, we investigated whether antihypertensive treatment based on self-measurement of blood pressure leads to the use of less medication without the loss of blood pressure control. We randomly assigned 430 hypertensive patients to receive treatment either on the basis of self-measured pressures (n=216) or office pressures (OPs; n=214). During 1-year follow-up, blood pressure was measured by office measurement (10 visits), ambulatory monitoring (start and end), and self-measurement (8 times, self-pressure group only). In addition, drug use, associated costs, and degree of target organ damage (echocardiography and microalbuminuria) were assessed. The self-pressure group used less medication than the OP group (1.47 versus 2.48 drug steps; P<0.001) with lower costs ($3222 versus $4420 per 100 patients per month; P<0.001) but without significant differences in systolic and diastolic OP values (1.6/1.0 mm Hg; P=0.25/0.20), in changes in left ventricular mass index (-6.5 g/m(2) versus -5.6 g/m(2); P=0.72), or in median urinary microalbumin concentration (-1.7 versus -1.5 mg per 24 hours; P=0.87). Nevertheless, 24-hour ambulatory blood pressure values at the end of the trial were higher in the self-pressure than in the OP group: 125.9 versus 123.8 mm Hg (P<0.05) for systolic and 77.2 versus 76.1 mm Hg (P<0.05) for diastolic blood pressure. These data show that self-measurement leads to less medication use than office blood pressure measurement without leading to significant differences in OP values or target organ damage. Ambulatory values, however, remain slightly elevated for the self-pressure group.
[Show abstract][Hide abstract] ABSTRACT: To use a decision analytic model to determine the cost-effectiveness of performing diagnostic digital subtraction angiography (DSA), computed tomographic (CT) angiography, or magnetic resonance (MR) angiography or proceeding immediately to tentative percutaneous revascularization in patients suspected of having renovascular hypertension.
With use of a Markov-Monte Carlo decision model, cost-effectiveness analysis was performed from a societal perspective. Data were derived from the Renal Artery Diagnostic Imaging Study in Hypertension and from published literature. The base-case analyses were used to evaluate a 50-year-old patient with a diastolic blood pressure higher than 95 mm Hg and one or more clinical clues suggestive of renovascular hypertension. Outcome measures were quality-adjusted life-year (QALY), lifetime costs, and incremental cost-effectiveness.
For a 50-year-old male patient, immediate tentative revascularization was the least costly (euro54 415) and most effective (12.265 QALYs) strategy. For the other strategies, costs and QALYs, respectively, were euro55 570 and 12.195 for DSA, euro55 191 and 12.163 for CT angiography, and euro56 890 and 12.088 for MR angiography. For a 50-year-old female patient, costs and QALYs, respectively, were euro66 731 and 13.731 for MR angiography, euro63 970 and 13.749 for CT angiography, and euro63 079 and 13.902 for DSA. Immediate tentative revascularization yielded more QALYs (13.937) and was more costly (euro63 329) than DSA. The incremental cost-effectiveness ratio was euro7143 per QALY. As the prior probability increased, use of a more invasive diagnostic imaging strategy became justified. Also, the sensitivities of CT angiography and MR angiography and the costs of DSA influenced the results.
Given currently accepted incremental cost-effectiveness ratios, immediate tentative percutaneous revascularization is a cost-effective strategy for the diagnosis of renal artery stenosis. Management decisions should be conditional on the prior probability.
[Show abstract][Hide abstract] ABSTRACT: Objective Previous studies suggest that for moderate and poor health states SF6D utilities are higher than EQ-5D utilities. As a result, the range of utility scores for different health conditions is considerably larger when using the EQ-5D to derive the utilities, than when the SF-6D is used. The objective of this study was to investigate whether these differences translate into larger utility gain after intervention, and thus more acceptable cost-effectiveness ratios, when using the EQ-5D. Methods The data set was taken from five separate studies (920 cases in total). Both the EuroQol and the SF36 were completed at baseline and at final follow up. The EQ-5D and the SF-6D utilities were derived using previously described algorithms (Dolan, 1995; Brazier et al, 2002, respectively). One year incremental cost-effectiveness ratios (ICERs) were calculated based on both the EQ-5D and the SF-6D utility scores. Ten ICERs could be calculated: home versus office blood pressure management for hypertensive outpatients (1); nurse led telemonitoring versus usual care for asthmatics (2); spa treatment in Austria, versus spa treatment in the Netherlands (3), and both spa treatments versus home treatment for ankylosing spondylitis (4 & 5); Sertraline versus usual care for panic disorder (6); joint recovery versus usual care after hip (7) and knee replacement surgery (9) in osteoarthritis; and before and after knee (9) and hip (10) replacement surgery in osteoarthritis. Results Based on the EQ-5D the incremental one year QALY ranged from -0.06 (ICER 7) to 0.39 (ICER 10). Based on the SF-6D the range was from -0.02 (ICER 7) to 0.13 (ICER 10). The incremental QALY was smaller according to the EQ-5D for ICERs number 1 (difference -0.004) and 7 (difference -0.04). For the other 8 comparisons the EQ-5D resulted in a larger incremental QALY; with the largest differences observed in ICERs 9 (0.18) and 10 (0.27). The point estimates of four ICERs (1, 3, 6 and 8) indicated dominance, regardless the utility instrument used. ICER 7 was more cost-effective based on the SF-6D utility (difference 36k per QALY lost). The other ICERs were more cost-effective when using EQ-5D utilities. For ICERs 2 and 5 the ICERs based on the SF-6D indicated inferiority, while based on the EQ-5D the ICERs were 37k and 50k per QALY gained, respectively. ICERs 4, 9 and 10 were respectively 126k, 157k and 60k per QALY gained lower when using EQ-5D utilities. When appling a cost-effectiveness threshold of 80k per additional QALY, based on EQ-5D utilities nine ICERs were acceptable, while based on SF-6D utilities four ICERs were acceptable (ICERS 1, 3, 6, 8). In addition to these results, cost-effectivess acceptability curves will be presented at the conference. Conclusions Based on ten incremental comparisons of the costs and effects of interventions it can be concluded that ICERs based on EQ-5D utilities tend to be more acceptable than ICERs based on SF-6D utilities. In five out of the ten comparisons the observed difference in ICER is of a magnitude that would alter policy recommendations.