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O112 How much does a non-physician healthcare worker based model of care for cardiovascular disease management cost?
ORAL ABSTRACTS
Conclusion: Myonecrosis secondary to other diseases is more frequent and associated with more than a 2-fold increased risk of new MI and late death compared to spontaneous MI. Whether established therapies for MI decrease this risk deserves to be evaluated in clinical trials. Disclosure of Interest: None Declared
O111 Assessment Of The Effectiveness Of Early Risk Stratification Using A New Cardiac Marker - Heart-Type Fatty Acid-Binding Protein In Patients With Suspected Non-StElevation Acute Coronary Syndromes Konstantin Y. Nikolaev*1,2, Mikhail Voevoda1,3, Natalia Yarokhno2, Alexander Balabushevich2 1 Internal Medicine, Novosibirsk State University, 2emergency treatment, 3Internal Medicine, Institute of Internal Medicine, Novosibirsk, Russian Federation Introduction: In patients with non-ST-elevation acute coronary syndrome (ACS), early risk stratification is of critical importance. Among others, the Thrombolysis in Myocardial Infarction (TIMI) risk score is the most validated and the most extensively used in patients with non-ST-elevation ACS. However, this score does not utilize results of evaluation of early markers of myocardial necrosis such as heart-type fatty acidbinding protein (hFABP). Objectives: The aim of this study was to estimate the effectiveness of new cardiac marker - hFABP in the protocol of early risk stratification during rendering emergency medical care for patients with suspected non-ST-elevation acute coronary syndromes (NSTEACS). Methods: The study included two groups of patients. The first group included 442 patients (6713 years) with suspected NSTEACS who underwent early risk stratification and the second (control group) consist of 491 patients (5916 years) with suspected NSTEACS but without pre-operative risk stratification. We stratificated patient from first group accordind Modified TIMI risk score which was constructed with included results of hFABP evaluation. This evaluation was provided by a novel, sensitive assay that is based on the immunochromatographic test-strip technique has been recently developed for rapid qualitative detection of hFABP in whole blood (BioTest Co., Novosibirsk, Russia). The procedure requires approximately 100 microliters of whole blood and can be completed within 20 min in any in-patient or out-patient settings without any special equipment. The analytical sensitivity of this test is 15 ng/ml. Results: A preliminary diagnosis of myocardial infarction (MI) was adjudged in 52 (11.8%) patients from the first group and 64 (13.0%) from the second, and a preliminary diagnosis of unstable angina was adjudged in 390 (88.2%) and 427 (87.0%) patients, respectively. The accuracy of diagnosis of myocardial infarction in the first group was higher in the first group than the second (86,5% and 60,9% respectively, p¼0,003). The sensitivity of the hFABP assay within the first 12 hours was 84% for the detection of MI and the corresponding specificity was 93%. Conclusion: Using of new cardiac marker - hFABP is effective in early risk stratification for patients with suspected non-ST-elevation acute coronary syndromes during rendering emergency medical care. Disclosure of Interest: None Declared
O112 How much does a non-physician healthcare worker based model of care for cardiovascular disease management cost? Rohina Joshi*1, Beverley Essue2, Krishnam Raju3, Stephen Jan2, Clara K. Chow1, on behalf of the APRHI Collaboration 1 Cardiovascular, 2Economics, The George Institute for Global Health, University of Sydney, Sydney, Australia, 3Cardiology, CARE Hospital, Hyderabad, India Introduction: Cardiovascular disease (CVD) is the leading cause of mortality and disability in rural India but few individuals have their risk assessed or appropriately managed. CVD management is a challenge in rural India because of the shortage of healthcare workforce and the costs of care. Objectives: To assess the costs of a task-shifting intervention for the treatment of cardiovascular disease in primary care settings in rural Andhra Pradesh, India Methods: The study was a cluster randomised control trial done in 44 villages in Andhra Pradesh. Villages were randomised to receive an intervention based on a clinical algorithm designed to enhance the identification and treatment of high risk individuals (previous history of CVD) compared to usual care. The algorithm was designed to be used by nonphysician healthcare workers (NPHWs) in the community and for opportunistic screening in the clinics with referral to physicians for prescription of medications. We adopted a topdown costing approach to cost three alternative NPHW-based models of care: a) NPHW only; b) NPHW and the provision of free drugs and c) NPHW, provision of free drugs and a part-time physician. Cost categories included: training and salaries, CVD risk assessment equipment, and secondary prevention medications. The assumptions made for costing, based on published studies, is that each village has an adult population (>30 years) of 1500 with 5% at high risk of CVD. Results: The annual costs for the basic model which included salary and training of NPHW and materials for physical measurements was 833 USD for the intervention villages. The annual cost of the basic model plus provision of drugs for CVD prevention was 906 USD. The third model which included the basic model, drugs, and physician time was estimated to cost 1029 USD. The total cost per high-risk individual in the village was 11 USD, 12 USD and 14 USD for the basic model, case 2 and case 3 respectively.
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Conclusion: The cRCT trial results demonstrated that the clinical algorithm (corresponding to the first case scenario) is an effective model of care for CVD screening and management. This is the first study from rural India that provides a detailed explanation of the costs required to implement and run a NPHW based CVD management model of care in this setting. These results demonstrate that this model of care is an effective and low cost alternative to current practice which at present, does not routinely incorporate NPHWs in CVD management. Disclosure of Interest: None Declared O113 Is Transcatheter Closure Better Than Medical Therapy For Cryptogenic Stroke With Patent Foramen Ovale? A Meta-Analysis Of Randomized Trials Vinayak Nagaraja*1, Jwalant Raval2, Guy D. Eslick3, David Burgess2, A. Robert Denniss2 1 Cardiology, Prince of Wales Hospital, University of Sydney, 2Blacktown Hospital, 3Cardiology, The University of Sydney, Sydney, Australia Introduction: The prevalence of patent foramen ovale among patients with cryptogenic stroke is higher than that in the general population. Closure with a percutaneous device is often recommended in such patients, but it is not known whether this intervention reduces the risk of recurrent stroke. Objectives: Recently three randomized trials have reviewed the benefit of closure over optimal medical therapy. We synthesized the available evidence from the randomized trials on secondary stroke prevention in patients with patent foramen ovale and cryptogenic stroke and primarily focus on the comparison of the 2 strategies. Methods: A systematic search was conducted using MEDLINE, PubMed, EMBASE, Current Contents Connect, Cochrane library, Google Scholar, Science Direct, and Web of Science. Original data was abstracted from each study and used to calculate a pooled event rate (ER), odd ratio (OR) and 95% confidence interval (95% CI). Results: Only 3 randomized trials comprising of 2303 patients met full criteria for analysis. Procedural success (ER: 94.20%, 95% CI: 87.6%>97.4%) and effective closure (ER: 92.70%, 95% CI: 85.9%>96.4%) of closure therapy were good. The odds ratio for stroke (OR: 0.654, 95% CI: 0.358-1.193) and transient ischemic attack (OR: 0.768, 95% CI: 0.413-1.429) did not confer a benefit of PFO closure over medical therapy. Age {<45 years (OR: 0.449, 95% CI: 0.117-1.722), >45 years(OR:0.707 , 95% CI:0.27-1.856)}, gender {males (OR: 0.498, 95% CI: 0.247-1.004), females (OR: 1.16, 95% CI:0.597-2.255)},substantial shunt size (OR: 0.354, 95% CI: 0.089-1.406) and the presence of atrial septal aneurysm (OR: 0.7, 95% CI:0.21-2.33) did not influence the treatment effect of PFO closure. However, the adverse events like major vascular complication (OR: 10.905, 95% CI: 1.997-59.562) and atrial fibrillation (OR: 3.297, 95% CI: 0.874-12.432) were significantly higher in the closure group. Conclusion: In patients with cryptogenic stroke or TIA who had a patent foramen ovale, closure with a device does not confer an advantage over medical therapy and is associated with adverse events like major vascular complication and atrial fibrillat. Disclosure of Interest: None Declared O114 The cost-of-illness of rheumatic heart disease: a national estimation in Fiji Rachel C. Heenan*1, Till Bärnighausen2, Jennifer O’Brien2, Tom Parks3, Joseph H. Kado4, David E. Bloom2, Andrew C. Steer1,5 1 Centre for International Child Health, University of Melbourne, Melbourne, Australia, 2 Department of Global Health and Population, Harvard School of Public Health, Boston, United States, 3University of Oxford, Oxford, United Kingdom, 4Paediatrics Department, Colonial War Memorial Hospital, Suva, Fiji, 5Royal Children’s Hospital, Melbourne, Australia Introduction: Rheumatic heart disease (RHD) is an important cause of morbidity and mortality in the Pacific region. Notwithstanding its sizable health burden, little is known about the full economic impact of the disease, which includes costs of diagnosis, treatment, and care as well as lost income. RHD is likely a high-cost disease, given its premature mortality and morbidity, its associated complications, and the frequent requirement for cardiac surgery. Because RHD typically leads to heart failure in middle age, when productivity and earnings normally peak, the lost income associated with RHD is also likely high.
GHEART Vol 9/1S/2014
j
March, 2014
j
ORAL/2014 WCC Orals
Conclusion: Myonecrosis secondary to other diseases is more frequent and associated with more than a 2-fold increased risk of new MI and late death compared to spontaneous MI. Whether established therapies for MI decrease this risk deserves to be evaluated in clinical trials. Disclosure of Interest: None Declared
O111 Assessment Of The Effectiveness Of Early Risk Stratification Using A New Cardiac Marker - Heart-Type Fatty Acid-Binding Protein In Patients With Suspected Non-StElevation Acute Coronary Syndromes Konstantin Y. Nikolaev*1,2, Mikhail Voevoda1,3, Natalia Yarokhno2, Alexander Balabushevich2 1 Internal Medicine, Novosibirsk State University, 2emergency treatment, 3Internal Medicine, Institute of Internal Medicine, Novosibirsk, Russian Federation Introduction: In patients with non-ST-elevation acute coronary syndrome (ACS), early risk stratification is of critical importance. Among others, the Thrombolysis in Myocardial Infarction (TIMI) risk score is the most validated and the most extensively used in patients with non-ST-elevation ACS. However, this score does not utilize results of evaluation of early markers of myocardial necrosis such as heart-type fatty acidbinding protein (hFABP). Objectives: The aim of this study was to estimate the effectiveness of new cardiac marker - hFABP in the protocol of early risk stratification during rendering emergency medical care for patients with suspected non-ST-elevation acute coronary syndromes (NSTEACS). Methods: The study included two groups of patients. The first group included 442 patients (6713 years) with suspected NSTEACS who underwent early risk stratification and the second (control group) consist of 491 patients (5916 years) with suspected NSTEACS but without pre-operative risk stratification. We stratificated patient from first group accordind Modified TIMI risk score which was constructed with included results of hFABP evaluation. This evaluation was provided by a novel, sensitive assay that is based on the immunochromatographic test-strip technique has been recently developed for rapid qualitative detection of hFABP in whole blood (BioTest Co., Novosibirsk, Russia). The procedure requires approximately 100 microliters of whole blood and can be completed within 20 min in any in-patient or out-patient settings without any special equipment. The analytical sensitivity of this test is 15 ng/ml. Results: A preliminary diagnosis of myocardial infarction (MI) was adjudged in 52 (11.8%) patients from the first group and 64 (13.0%) from the second, and a preliminary diagnosis of unstable angina was adjudged in 390 (88.2%) and 427 (87.0%) patients, respectively. The accuracy of diagnosis of myocardial infarction in the first group was higher in the first group than the second (86,5% and 60,9% respectively, p¼0,003). The sensitivity of the hFABP assay within the first 12 hours was 84% for the detection of MI and the corresponding specificity was 93%. Conclusion: Using of new cardiac marker - hFABP is effective in early risk stratification for patients with suspected non-ST-elevation acute coronary syndromes during rendering emergency medical care. Disclosure of Interest: None Declared
O112 How much does a non-physician healthcare worker based model of care for cardiovascular disease management cost? Rohina Joshi*1, Beverley Essue2, Krishnam Raju3, Stephen Jan2, Clara K. Chow1, on behalf of the APRHI Collaboration 1 Cardiovascular, 2Economics, The George Institute for Global Health, University of Sydney, Sydney, Australia, 3Cardiology, CARE Hospital, Hyderabad, India Introduction: Cardiovascular disease (CVD) is the leading cause of mortality and disability in rural India but few individuals have their risk assessed or appropriately managed. CVD management is a challenge in rural India because of the shortage of healthcare workforce and the costs of care. Objectives: To assess the costs of a task-shifting intervention for the treatment of cardiovascular disease in primary care settings in rural Andhra Pradesh, India Methods: The study was a cluster randomised control trial done in 44 villages in Andhra Pradesh. Villages were randomised to receive an intervention based on a clinical algorithm designed to enhance the identification and treatment of high risk individuals (previous history of CVD) compared to usual care. The algorithm was designed to be used by nonphysician healthcare workers (NPHWs) in the community and for opportunistic screening in the clinics with referral to physicians for prescription of medications. We adopted a topdown costing approach to cost three alternative NPHW-based models of care: a) NPHW only; b) NPHW and the provision of free drugs and c) NPHW, provision of free drugs and a part-time physician. Cost categories included: training and salaries, CVD risk assessment equipment, and secondary prevention medications. The assumptions made for costing, based on published studies, is that each village has an adult population (>30 years) of 1500 with 5% at high risk of CVD. Results: The annual costs for the basic model which included salary and training of NPHW and materials for physical measurements was 833 USD for the intervention villages. The annual cost of the basic model plus provision of drugs for CVD prevention was 906 USD. The third model which included the basic model, drugs, and physician time was estimated to cost 1029 USD. The total cost per high-risk individual in the village was 11 USD, 12 USD and 14 USD for the basic model, case 2 and case 3 respectively.
e30
Conclusion: The cRCT trial results demonstrated that the clinical algorithm (corresponding to the first case scenario) is an effective model of care for CVD screening and management. This is the first study from rural India that provides a detailed explanation of the costs required to implement and run a NPHW based CVD management model of care in this setting. These results demonstrate that this model of care is an effective and low cost alternative to current practice which at present, does not routinely incorporate NPHWs in CVD management. Disclosure of Interest: None Declared O113 Is Transcatheter Closure Better Than Medical Therapy For Cryptogenic Stroke With Patent Foramen Ovale? A Meta-Analysis Of Randomized Trials Vinayak Nagaraja*1, Jwalant Raval2, Guy D. Eslick3, David Burgess2, A. Robert Denniss2 1 Cardiology, Prince of Wales Hospital, University of Sydney, 2Blacktown Hospital, 3Cardiology, The University of Sydney, Sydney, Australia Introduction: The prevalence of patent foramen ovale among patients with cryptogenic stroke is higher than that in the general population. Closure with a percutaneous device is often recommended in such patients, but it is not known whether this intervention reduces the risk of recurrent stroke. Objectives: Recently three randomized trials have reviewed the benefit of closure over optimal medical therapy. We synthesized the available evidence from the randomized trials on secondary stroke prevention in patients with patent foramen ovale and cryptogenic stroke and primarily focus on the comparison of the 2 strategies. Methods: A systematic search was conducted using MEDLINE, PubMed, EMBASE, Current Contents Connect, Cochrane library, Google Scholar, Science Direct, and Web of Science. Original data was abstracted from each study and used to calculate a pooled event rate (ER), odd ratio (OR) and 95% confidence interval (95% CI). Results: Only 3 randomized trials comprising of 2303 patients met full criteria for analysis. Procedural success (ER: 94.20%, 95% CI: 87.6%>97.4%) and effective closure (ER: 92.70%, 95% CI: 85.9%>96.4%) of closure therapy were good. The odds ratio for stroke (OR: 0.654, 95% CI: 0.358-1.193) and transient ischemic attack (OR: 0.768, 95% CI: 0.413-1.429) did not confer a benefit of PFO closure over medical therapy. Age {<45 years (OR: 0.449, 95% CI: 0.117-1.722), >45 years(OR:0.707 , 95% CI:0.27-1.856)}, gender {males (OR: 0.498, 95% CI: 0.247-1.004), females (OR: 1.16, 95% CI:0.597-2.255)},substantial shunt size (OR: 0.354, 95% CI: 0.089-1.406) and the presence of atrial septal aneurysm (OR: 0.7, 95% CI:0.21-2.33) did not influence the treatment effect of PFO closure. However, the adverse events like major vascular complication (OR: 10.905, 95% CI: 1.997-59.562) and atrial fibrillation (OR: 3.297, 95% CI: 0.874-12.432) were significantly higher in the closure group. Conclusion: In patients with cryptogenic stroke or TIA who had a patent foramen ovale, closure with a device does not confer an advantage over medical therapy and is associated with adverse events like major vascular complication and atrial fibrillat. Disclosure of Interest: None Declared O114 The cost-of-illness of rheumatic heart disease: a national estimation in Fiji Rachel C. Heenan*1, Till Bärnighausen2, Jennifer O’Brien2, Tom Parks3, Joseph H. Kado4, David E. Bloom2, Andrew C. Steer1,5 1 Centre for International Child Health, University of Melbourne, Melbourne, Australia, 2 Department of Global Health and Population, Harvard School of Public Health, Boston, United States, 3University of Oxford, Oxford, United Kingdom, 4Paediatrics Department, Colonial War Memorial Hospital, Suva, Fiji, 5Royal Children’s Hospital, Melbourne, Australia Introduction: Rheumatic heart disease (RHD) is an important cause of morbidity and mortality in the Pacific region. Notwithstanding its sizable health burden, little is known about the full economic impact of the disease, which includes costs of diagnosis, treatment, and care as well as lost income. RHD is likely a high-cost disease, given its premature mortality and morbidity, its associated complications, and the frequent requirement for cardiac surgery. Because RHD typically leads to heart failure in middle age, when productivity and earnings normally peak, the lost income associated with RHD is also likely high.
GHEART Vol 9/1S/2014
j
March, 2014
j
ORAL/2014 WCC Orals