Increasing the costs of having an on-call catheterization team at hospitals during the weekends to perform coronary angiography and other interventions in patients suffering from non-ST-segment elevation acute coronary syndromes (NSTE-ACS) is cost effective, given the decrease of the expenses associated to hospital stays. Those were the conclusions of a study conducted at the Population Health Research Institute of McMaster University in Canada and published at the Canadian Journal of Cardiology.
NSTE-ACS is a condition that requires a fast and invasive intervention, and requires access to procedures such as coronary angiography, which helps both high and low risk patients. Despite this, necessary interventions currently tend to be unavailable during the weekends due to lack of professionals. Therefore, a group of researchers studied the costs related to early intervention in comparison with delayed invasive intervention strategy, and concluded that early invasive strategy for Canadian NTSE-ACS patients reduced healthcare expenses, even during the weekends, as it reduced hospitalization times.
“Hospitals that currently tend to delay stable patients in favor of weekday catheterization instead of mobilizing the on-call team for an earlier invasive management of NSTE-ACS patients should consider the latter as the savings from adhering to the timing of an early intervention approach would outweigh additional costs,” explained lead investigator Andre Lamy, MD, MHSc, from the Population Health Research Institute, and professor in the Department of Surgery and Department of Clinical Epidemiology at McMaster University, in a press release.
The scientists examined information from 479 patients being treated in Canada, from the Timing of Intervention in Acute Coronary Syndromes (TIMACS) multinational trial. From the total, 238 were included in the early strategy group and 241 in the delayed strategy group, which enabled the evaluation of the impact from the point of view of the Canadian healthcare system.
The study, entitled “Cost Implication of an Early Invasive Strategy on Weekdays and Weekends in Patients with Acute Coronary Syndromes” revealed that each patient that receives early coronary angiography and intervention registers CAN $2,938 less costs compared to the ones receiving delayed treatments. The overall savings is related to a $9,761 reduced expense for shorter length of hospital stays, compared to $12,569 for delayed, totaling a $2,808 saving. The results were even more significant in ICU/CCU and ward units, while it was registered no significant difference in cost for study percutaneous coronary interventions, drugs, procedures or diagnostic procedures.
“The results of our Canadian-led multinational trial shows that early intervention is a cost saving strategy for all patients with acute coronary syndromes. In higher risk patients, early intervention also appears to improve clinical outcomes,” added TIMACS lead investigator Shamir R. Mehta, MD, MSc, Professor of Medicine at McMaster University, and director of Interventional Cardiology at Hamilton Health Sciences.
In addition, the researchers demonstrated that the early invasive intervention group spent 2.3 days less in the hospital, since those patients spent an average of 8.6 days admitted, while the delayed intervention patients spent 10.9 days. However, the authors also noted that several cardiac catheterization labs (CCLs) do not handle non-emergent cases on weekends, which can reduce the ability to save.
“Early invasive intervention is similar to a delayed invasive approach for prevention of cardiovascular death, myocardial infarction, or stroke, but in low or high risk patients, it is a dominant economic strategy,” said Lamy. “Given many high-risk NSTE-ACS patients receive delayed intervention due to weekend catheterization lab status, these findings support opening catheterization labs on weekends to facilitate the use of early invasive intervention.”
Despite the results, the study has sparked a debate, as Stéphane Rinfret, MD, SM, Clinical and Interventional Cardiology, Multidisciplinary Cardiology Department, Quebec Heart and Lung Institute, and Associate Professor, Laval University, and Brian J. Potter, MDCM, SM, Interventional Cardiology and Healthcare Services Research Centre Hospital, University of Montreal wrote in an editorial commenting on stable NSTE-ACS patients that, “while the evidence for cost savings utilizing an earlier catheterization strategy certainly appears robust, the authors’ conclusions about the need to mobilize the CCL team during weekends for patients with NSTE-ACS merit further discussion.”
In addition, the authors of the comment questioned the design of the study, as they believe it was not consistent with the reality practiced at Canadian hospitals, which privilege the reduction of delays. Ultimately, any economic benefit (which remains an open question) of performing these cases on weekends must be weighed against its potential negative impact on already-stretched weekend call teams, including on “morale, healthcare workers’ physical or mental health, and, possibly and most importantly, patients’ safety,” they added.