| BackgroundAcute myocardial infarction (AMI) is the most serious type of coronary atherosclerotic heart disease. AMI is a leading cause of death in China and the rest of the world, and imposes a substantial burden on national economies. New epidemiological studies showed an increase in the prevalence rates for diabetes mellitus (DM) in recent30years. The age-standardized prevalence of diabetes was9.7%among adults over the age of20, and the proportion of pre-diabetes was15.5%. Namely, one in four people has a high blood sugar-glucose level in the body. Moreover, people with diagnosed DM, on average, have medical expenditures that are2.3times higher than what expenditures would be in the absence of DM. And the largest component of medical expenditures is hospital inpatient care (43%of the total medical cost). Adults with DM have been reported to have a two to fourfold higher risk of myocardial infarction than those without DM. DM is an independent predictor of mortality in patients with AMI. Application of PCI in the treatment of patients with AMI makes in-hospital mortality rates decrease. However, the hospitalization cost increases obviously. However, few studies have examined the impact of type2diabetes on in-hospital mortality, incidence of in-hospital complications and effectiveness of inpatient treatment in patients with AMI. It is important to estimate the impact of DM on hospitalization economic in patients with AMI, which can strengthen people’s awareness of prevention and treatment of DM, which may be helpful for clinicist to evaluate therapeutic effect thereby making an appropriate treatment strategy, which will also assist policy makers in making informed decisions about future health policy and budgets.Objectives1) To evaluate the impact of type2diabetes mellitus co-morbidity on hospitalization costs in patients with AMI.2) To examine the impact of type2diabetes on in-hospital mortality, incidence of in-hospital complications and effectiveness of inpatient treatment in patients with AMI.Subjects and methodsIn this retrospective cohort study, we recruited733consecutive subjects with AMI for the period January1,2011to December31,2012. There were250patients with diabetes (157males,66.18±11.38yr of age), and483without diabetes (360males,63.28±13.37yr of age). The following criteria for inclusion were used:AMI was explicitly diagnosed in discharge diagnosis; when acute coronary syndrome (ACS) was diagnosed in discharge diagnosis, the patients with cTnl>0.06ng/ml were selected; the patients implemented emergency PCI in emergency room were selected. Patients with type2diabetes mellitus were identified using discharge diagnosis. In addition, patients who were automatically discharged were excluded from the present study. Univariate general linear model was used to estimate the interaction between diabetes and stent on affecting hospitalization cost. Multivariate linear regression model was used to find the factors affecting hospitalization cost. Binary logistic regression model was used to find the factors affecting the incidence of acute heart failure. Cost-effectiveness analysisCER:cost-effectiveness ratio P:the incidence of event C:the average costICER:incremental cost-effectiveness ratioPi:the incidence of event after implementing PCI Po:the incidence of event without implementing PCICi:the average cost after implementing PCI Co:the average cost without implementing PCIResults(1) Between January2011and December2012, a total of733hospitalizations due to AMI were studied. The250patients with diabetes were significantly older than non-diabetic patients (P<0.05). On the other hand, the483patients without diabetes were predominantly male (P<0.05). Diabetes group was higher than non-diabetes group in terms of SBP, HR, TG and LDL (all P<0.05). Non-diabetes group was higher than non-diabetes group in terms of height, HDL, RBC and PLT (all P<0.05). Diabetic patients had a greater incidence of multivessel disease than non-diabetic patients (P<0.05), but had a less incidence of implementing PCI (P<0.05). The AMI patients with diabetes used more nitrate esters, diuretic and CCB than those without diabetes (P<0.05). Insulin (38.4%), biguanides (39.2%), acarbose (27.2%) and sulfonylureas (24.4%) were used more, glinide (7.6%) and glitazones (2.4%) were used less in diabetic patients.(2) Comparison of hospitalization costs and hospital stay between the two groups: Non-diabetes group is higher than diabetes group in terms of total costs of hospital admission, total costs per hospital day, treatment costs and treatment costs per hospital day (P<0.05). However, the hospital stay is shorter than non-diabetes group (P<0.05). 3) Multivariate linear regression model:Multivariate linear regression model showed that stent, twice vascular reconstruction, atrial arrhythmia and ventricular arrhythmia are factors affecting total costs. Stent, FIB and UA are factors affecting total costs per hospital day. Stent, twice vascular reconstruction, FIB and TT are factors affecting total treatment costs. Stent, FIB, TT and UA are factors affecting treatment costs per hospital day. Univariate general linear model showed diabetes does not make an impact on hospitalization cost and hospital stay of AMI patients (P>0.05), and stent is an important factor affecting hospitalization cost and hospital stay (P<0.05). In addition, diabetes and stent are not interaction terms (P>0.05).4) Comparison of clinical complications between the two groups:Diabetes group’s in-hospital incidence of acute heart failure (AHF) is higher than non-diabetes group’s (P<0.05). There is no major difference between the two groups in terms of in-hospital mortality, the incidence of atrial and ventricular arrhythmia and the percentage of patients who suffered rescue and twice vascular reconstruction (all P>0.05).5) Binary logistic regression model:Binary logistic regression model showed stent and β-blockers are protective factors to prevent AHF. HR and age are risk factors. Application of PCI makes in-hospital incidence of AHF decrease among diabetic and non-diabetic patients (P<0.05), and also makes in-hospital mortality of non-diabetic patients decrease (P<0.05). Stent does not make an impact on the incidence of atrial and ventricular arrhythmia (both P>0.05).6) Cost effectiveness analysis:1) When cost-effectiveness ratio (CER) was calculated, the in-hospital incidence of clinical complications and in-hospital mortality of patients implemented PCI were lower than those without implementing PCI.2) From the perspective of reduction in the in-hospital incidence of AHF after implementing PCI, diabetic patients’incremental cost-effectiveness ratio (ICER) estimate for implementing PCI was higher than non-diabetic patients’.3) From the perspective of increased in-hospital incidence of event-free survival after implementing PCI, diabetic patients’ incremental cost-effectiveness ratio (ICER) estimate for implementing PCI was higher than non-diabetic patients’.Conclusions1. Diabetes does not make an impact on hospitalization cost of AMI patients, and stent is an important factor affecting hospitalization cost.2. Stent and P-blockers are protective factors to prevent AHF. Implementation of PCI can reduce in-hospital incidence of AHF of diabetic and non-diabetic patients, and elevate in-hospital incidence of event-free survival of diabetic and non-diabetic patients.3. From the perspective of reduction in the in-hospital incidence of AHF and increased in-hospital incidence of event-free survival after implementing PCI, implementation of PCI after an AMI in patients with diabetes mellitus has a higher level of cost-effectiveness than those without diabetes mellitus. BackgroundChina has become a country with an aging population, and the aging population is growing rapidly and by the middle of this century will peak. Changes in the age structure will have a major impact on the overall health of a country’s population and its healthcare system. In China and the rest of the world, the high prevalence of acute myocardial infarction (AMI) places an enormous economic burden upon societies, and the largest component of medical expenditures is hospital inpatient care. Despite a significant reduction in mortality rates due to cardiovascular disease in the percutaneous coronary intervention (PCI) era, AMI continues to be a leading cause of hospital admission and death in older adults, because the risk of experiencing an AMI increases with age.Diabetes mellitus (DM) is a growing national epidemic and is an independent predictor of mortality in patients with AMI. The incidence of diabetes with AMI has already shown a gradual upward trend. Primary PCI can reduce early and late adverse events for diabetic patients with AMI, and diabetic patients hospitalized for AMI are more costly than non-diabetic patients. Older populations with diabetes have double the risk of dying from AMI. However, few studies have examined the matching relation between hospitalization cost and clinical treatment and prognosis at present. Thus, the aim of this study is to evaluate the impact of type2diabetes mellitus on hospitalization economic in older AMI patients.The aging population of China is growing rapidly and older populations are facing an increase in demand for primary care. So, it is important to estimate the impact of diabetes on hospitalization economic in older patients with AMI, which can aroused people’s attention of taking care of elderly people, which may be helpful for clinicist to evaluate therapeutic effect thereby making an appropriate treatment strategy, which will also assist policy makers in making informed decisions about future health policy and budgets.Objectives1) To evaluate the impact of type2diabetes mellitus co-morbidity on hospitalization costs in older AMI patients.2) To examine the impact of type2diabetes on in-hospital mortality, incidence of in-hospital complications and effectiveness of inpatient treatment in older AMI patients.Subjects and methodsIn this retrospective cohort study, we recruited733consecutive subjects with AMI for the period January1,2011to December31,2012. The study subjects were divided into two different age groups (<65,≥65).137older patients with diabetes (71men, mean age74.77±5.66years),113younger patients with diabetes (87men, mean age55.77±7.03years),227older patients without diabetes (132men, mean age74.84±6.47years) and256younger patients without diabetes (228men, mean age53.03±8.73years) were retrospectively evaluated.The following criteria for inclusion were used:AMI was explicitly diagnosed in discharge diagnosis; when acute coronary syndrome (ACS) was diagnosed in discharge diagnosis, the patients with cTnl>0.06ng/ml were selected; the patients implemented emergency PCI in emergency room were selected. Patients with type2diabetes mellitus were identified using discharge diagnosis. In addition, patients who were automatically discharged were excluded from the present study.Univariate general linear model was used to estimate the interaction between diabetes and stent on affecting hospitalization cost. Multivariate linear regression model was used to find the factors affecting hospitalization cost. Binary logistic regression model was used to find the factors affecting the incidence of acute heart failure.Cost-effectiveness analysis CER=c/pCER:cost-effectiveness ratio P:the incidence of event C:the average costICER:incremental cost-effectiveness ratioP1:the incidence of event after implementing PCI Po:the incidence of event without implementing PCIC1:the average cost after implementing PCI Co:the average cost without implementing PCIResults(1) Clinical characteristics of the four groups:The four groups’age and gender did not match each other (P<0.05). And the four groups’height, weight, BMI, systolic blood pressure (SBP), heart rate, TG, HDL-C, red blood cell, Hb, percentage of stenting, and the use of nitrate esters, diuretic and CCB did not match each other (P<0.05). There were no difference in diastolic blood pressure (DBP), Ch0, LDL-C, white blood cell, PLT and the use of p-blockers, ACEI, ARB and acetylsalicylic acid among the four groups (P>0.05).(2) Comparison of hospitalization costs and hospital stay:Older patients spent less total costs, treatment costs, laboratory testing fee, consultation fee and bed fee than younger ones (P<0.05), and the hospital stay of older patients was shorter than younger ones (P<0.05). There was no difference in total costs, treatment costs, total drug costs, inspection fee, bed fee, nursing fee and hospital stay between diabetic and non-diabetic patients (P>0.05). For older patients, laboratory testing fee of diabetic patients was higher than non-diabetic patients (P<0.05). In addition, older patients with diabetes spent less total costs, treatment costs, total drug costs, inspection fee, consultation fee and bed fee than younger patients without diabetes(P<0.05), and the hospital stay of older patients with diabetes was shorter than younger ones without diabetes (P<0.05).3) Multivariate linear regression model:Multivariate linear regression model showed that stent (β=0.685, P=0.000), WBC (β=0.152, P=0.000), twice vascular reconstruction (β=0.130, P-0.003), atrial arrhythmia (β=0.116, P=0.006) and weight (β=0.109, P=0.011) are factors affecting total costs of older AMI patients. Stent (β=0.508, P=0.000), FIB (β=0.176, P=0.000) and twice vascular reconstruction (β=0.145, P=0.002) are factors affecting treatment costs of older AMI patients. Univariate general linear model showed diabetes does not make an impact on hospitalization cost and hospital stay of older AMI patients, and stent is an important factor affecting hospitalization cost and hospital stay. In addition, diabetes and stent are not interaction terms.4) Comparison of clinical complications:Older patients’in-hospital incidence of AHF is higher than younger patients’in both diabetic (19.7%vs.7.1%, P<0.05) and non-diabetic patients (11.5%vs.2.7%, P<0.05). For older patients, diabetic patients’in-hospital incidence of AHF is higher than non-diabetic patients’(19.7%vs.11.5%, P<0.05), and in-hospital incidence of event-free survival is lower (80.3%vs.88.5%, P<0.05). In addition, the in-hospital incidence of event-free survival of younger patients without diabetes is higher than older patients with diabetes (92.2%vs.80.3%, P<0.05). For non-diabetic patients, older patients’in-hospital incidence of atrial arrhythmia is higher than younger patients’(P<0.05). For diabetic patients, older patients’in-hospital incidence of ventricular arrhythmia is higher than younger patients’(P<0.05), but the incidence of twice vascular reconstruction is lower (P<0.05).5) Binary logistic regression model:Binary logistic regression model showed stent (OR=0.189,95%CI:0.059-0.602, P=0.005) and weight (OR=0.957,95%CI:0.918-0.998, P=0.038) are protective factors to prevent AHF of older AMI patients, HR (OR=1.045,95%CI:1.020-1.072, P=0.000) and UA (OR=1.006,95%CI:1.002-1.009, P=0.003) are risk factors.(6) Cost effectiveness analysis:1) For older AMI patients, when CER was calculated based on the average total costs and treatment costs, the in-hospital incidence of AHF of AMI patients after implementing PCI was lower than those without implementing PCI.2) For older AMI patients, diabetic patients’incremental cost-effectiveness ratio (ICER) estimate for implementing PCI was higher than non-diabetic patients’ when ICER was calculated based on the average total costs and average treatment costs from the perspective of reduction in the in-hospital incidence of AHF after implementing PCI.Conclusions1. Older patients spend less total costs and treatment costs than younger ones, and diabetes does not make an impact on hospitalization cost of AMI patients. Stent is an important factor affecting older patients’hospitalization cost.2. Stent is a protective factor to prevent acute heart failure (AHF) of older AMI patients. Implementation of PCI can reduce in-hospital incidence of AHF of older AMI patients with and without diabetes, but cannot reduce younger ones’.3. Among the elderly only, from the perspective of reduction in the in-hospital incidence of AHF, diabetic patients’incremental cost-effectiveness ratio (ICER) estimate for implementing PCI is higher than non-diabetic patients’. Objectives:To evaluate the impact of type2diabetes mellitus co-morbidity on hospitalization economic in patients with acute myocardial infarction (AMI).Methods:Retrospective analysis of case retrieval system data was conducted in patients with AMI in the year2011-2012.Results:Non-diabetes group is higher than diabetes group in terms of total costs of hospital admission (￥52888[28222-71013] vs.￥43028[19968-66506], P=0.006), total costs per hospital day (￥4643[2356-7098] vs.￥3245[1583-5914], P=0.000), treatment costs (￥7028[4748-35875] vs.￥5848[2401-11064], P=0.000) and treatment costs per hospital day (￥687[365-3181] vs.￥492[194-1141], P=0.000). Stent is an important factor affecting total costs of hospital admission (β=0.663, P=0.000), total costs per hospital day (β=0.561, P=0.000), treatment costs (β=0.418, P=0.000) and treatment costs per hospital day (β=0.378, P=0.000). Diabetes group’s in-hospital incidence of acute heart failure (AHF) is higher than non-diabetes group’s (14.0%vs.6.8%; P=0.002). Stent (OR=0.247,95%CI:0.125-0.487, P=0.000) and β-blockers (OR=0.386,95%CI:0.222-0.669, P=0.001) are protective factors to prevent AHF. Implementation of PCI can reduce in-hospital incidence of AHF of diabetic (23.3%vs.4.1%, P=0.000) and non-diabetic (14.5%vs.2.8%, P=0.000) patients, and elevate in-hospital incidence of event-free survival of diabetic (77%vs.94%, P=0.000) and non-diabetic (86%vs.94%, P=0.002) patients. Diabetic patients’ incremental cost-effectiveness ratio (ICER) estimate for implementing PCI is higher than non-diabetic patients’.Conclusions:Diabetes does not make an impact on total hospitalization costs and treatment costs of AMI patients, and stent is an important factor affecting hospitalization cost. From the perspective of reduction in the in-hospital incidence of AHF and increased in-hospital incidence of event-free survival after implementing PCI, implementation of PCI after an AMI in patients with diabetes mellitus has a higher level of cost-effectiveness than those without diabetes mellitus. Objectives:To evaluate the impact of type2diabetes mellitus on hospitalization costs in older acute myocardial infarction (AMI) patients.Methods:Retrospective analysis of data from the case retrieval system of Qilu Hospital of Shandong University located in Jinan city of Shandong Province was conducted in patients with AMI from January1,2011to December31,2012.Results Stent is an important factor affecting older patients’total hospitalization costs (β=0.685, P=0.000) and treatment costs over follow-up period (duration of hospital stay only)(β=0.508, P=0.000). Stent is also a protective factor to prevent acute heart failure (AHF) of older AMI patients over follow-up period (OR=0.189,95%CI:0.059-0.602, P=0.005). Implementation of PCI can reduce inpatient incidence of AHF of older AMI patients with (27.8%vs.4.3%, P=0.001) and without diabetes (18.2%vs.3.8%, P=0.001). Moreover, among the elderly only, diabetic patients’incremental cost-effectiveness ratio (ICER) estimate for implementing PCI is higher than non-diabetic patients’.Conclusions:Among the elderly only, stent is a protective factor to prevent AHF over follow-up period. From the perspective of reduction in the inpatient incidence of AHF, implementation of PCI after an AMI in older patients with diabetes mellitus (DM) has a higher level of cost-effectiveness than those without DM. |
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