The cost implications of an early versus delayed invasive strategy in acute coronary syndromes: the TIMACS study

Abstract

Background:

The Timing of Intervention in Acute Coronary Syndromes (TIMACS) trial demonstrated that early invasive intervention (within 24 hours) was similar to a delayed approach (after 36 hours) overall but improved outcomes were seen in patients at high risk. However, the cost implications of an early versus delayed invasive strategy are unknown.

Methods and results:

A third-party perspective of direct cost was chosen and United States Medicare costs were calculated using average diagnosis related grouping (DRG) units. Direct medical costs included those of the index hospitalization (including clinical, procedural and hospital stay costs) as well as major adverse cardiac events during 6 months of follow-up. Sensitivity and sub-group analyses were performed. The average total cost per patient in the early intervention group was lower compared with the delayed intervention group (−$1170; 95% CI −$2542 to $202). From the bootstrap analysis (5000 replications), the early invasive approach was associated with both lower costs and better clinical outcomes regarding death/myocardial infarction (MI)/stroke in 95.1% of the cases (dominant strategy). In high-risk patients (GRACE score ≥141), the net reduction in cost was greatest (−$3720; 95% CI −$6270 to −$1170). Bootstrap analysis revealed 99.8% of cases were associated with both lower costs and better clinical outcomes (death/MI/stroke).

Limitations:

We were unable to evaluate the effect of community care and investigations without hospitalization (office visits, non-invasive testing, etc). Medication costs were not captured. Indirect costs such as loss of productivity and family care were not included.

Conclusions:

An early invasive management strategy is as effective as a delayed approach and is likely to be less costly in most patients with acute coronary syndromes.

Keywords::

• Coronary intervention
• Cost analysis
• Economic evaluation

Transparency

Declaration of funding

Supported by the Canadian Institutes of Health Research; by the sponsors of the OASIS-5 study, which included GlaxoSmithKline, Sanofi-Aventis, and Organon NV; by a New Investigator Award from the Canadian Institutes of Health Research (to S.R.M.); and by the Heart and Stroke Foundation of Ontario. They have not been involved in the design, conduct, interpretation, analysis or writing of this study.

Author contributions: S.R.M., as principal investigator, and K.R.B. as co-principal investigator of this economic study have full access to all the data and attest to the accuracy and validity of the economic analysis.

Declaration of financial/other relationships

P.G.S. has disclosed that he received grant support from Sanofi-Aventis and consulting or lecture fees from Astellas, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Endotis, GlaxoSmithKline, Merck, Nycomed, Sanofi-Aventis, Servier, Takeda, and the Medicines Company. D.P.F. has disclosed that he received consulting fees from Johnson & Johnson and grant support from Boston Scientific. C.B.G. has disclosed that he received grant support from Sanofi-Aventis, AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb, GlaxoSmithKline, the Medicines Company, Novartis, and Merck, and consulting or speaking fees from Sanofi-Aventis, GlaxoSmithKline, the Medicines Company, Novartis, Fibrex, and AstraZeneca. S.Y. has disclosed that he received grant support from Bristol-Myers Squibb, Sanofi-Aventis, and GlaxoSmithKline and consulting and lecture fees from AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb, GlaxoSmithKline, Sanofi-Aventis, and Servier. S.R.M. has disclosed that he received grant support from Bristol-Myers Squibb, GlaxoSmithKline, and Sanofi-Aventis and consulting or lecture fees from Abbott Vascular, Astellas, AstraZeneca, Boston Scientific, Bristol-Myers Squibb, Eli Lilly, GlaxoSmithKline, Pfizer and Sanofi-Aventis. K.R.B., A.G., P.R.-M., W.T. and A.L. have disclosed that they have no significant relationships with or financial interests in any commercial companies related to this study or article.

JME peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Acknowledgments

No assistance in the preparation of this article is to be declared.