Impact of New Cardiovascular Events on Quality of Life and Hospital Costs in People With Cardiovascular Disease in the United Kingdom and United States

Abstract

Background: Despite optimized risk factor control, people with prior cardiovascular disease remain at high cardiovascular disease risk. We assess the immediate- and longer-term impacts of new vascular and nonvascular events on quality of life (QoL) and hospital costs among participants in the REVEAL (Randomized Evaluation of the Effects of Anacetrapib Through Lipid Modification) trial in secondary prevention.

Methods and results: Data on demographic and clinical characteristics, health-related quality of life (QoL: EuroQoL 5-Dimension-5-Level), adverse events, and hospital admissions during the 4-year follow-up of the 21 820 participants recruited in Europe and North America informed assessments of the impacts of new adverse events on QoL and hospital costs from the UK and US health systems' perspectives using generalized linear regression models. Reductions in QoL were estimated in the years of event occurrence for nonhemorrhagic stroke (-0.067 [United Kingdom], -0.069 [US]), heart failure admission (-0.072 [United Kingdom], -0.103 [US]), incident cancer (-0.064 [United Kingdom], -0.068 [US]), and noncoronary revascularization (-0.071 [United Kingdom], -0.061 [US]), as well as in subsequent years following these events. Myocardial infarction and coronary revascularization (CRV) procedures were not found to affect QoL. All adverse events were associated with additional hospital costs in the years of events and in subsequent years, with the highest additional costs in the years of noncoronary revascularization (£5830 [United Kingdom], $14 133 [US Medicare]), of myocardial infarction with urgent CRV procedure (£5614, $24722), and of urgent/nonurgent CRV procedure without myocardial infarction (£4674/£4651 and $15 251/$17 539).

Conclusions: Stroke, heart failure, and noncoronary revascularization procedures substantially reduce QoL, and all cardiovascular disease events increase hospital costs. These estimates are useful in informing cost-effectiveness of interventions to reduce cardiovascular disease risk in secondary prevention.

Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01252953; https://www.Isrctn.com. Unique identifier: ISRCTN48678192; https://www.clinicaltrialsregister.eu. Unique identifier: 2010-023467-18.

Keywords: United Kingdom; United States; cardiovascular diseases; health care costs; quality of life; secondary prevention.

Figure 1. Quality of life utility of participants by category of new adverse event and time since event occurrence.

UK (A) and US (B) perspectives. EQ‐5D is a standardized instrument used to measure health‐related QoL across 5 domains (mobility, self‐care, usual activities, pain/discomfort, anxiety/depression). By combining the scores of each dimension, the EQ‐5D generates a health state profile, which can be converted into a single summary QoL utility value. The QoL utility represents an individual's overall health status on a scale where 1.0 denotes perfect health, 0.0 represents death, and negative values indicate health states considered worse than death. UK or US EQ‐5D QoL utility tariffs were used, respectively. Each participant completed the EQ‐5D questionnaire at baseline and at the end of the trial. The numbers in parentheses indicate the total number of participants who experienced the particular adverse events before EQ‐5D questionnaire completion at the end of the trial. The figure presents QoL for participants who had experienced new relevant events during the trial. QoL utility before new event uses EQ‐5D questionnaires completed at entry into the study and QoL utilities within a year of event and in later years based on EQ‐5D questionnaires completed at end of trial. Participants contributed to categories of Years since new event occurrence, depending on the number of years from their latest relevant event to EQ‐5D measurement at end of study. EQ‐5D indicates EuroQol‐5 Dimensions; QoL, quality of life; UK, United Kingdom; and US, United States.

Figure 2. Mean annual hospital costs before, in year of, and in subsequent years of first new adverse event occurrence.

UK (A) and US (Medicare) (B) health care perspectives. UK hospital care costed using Healthcare Resource Group reference costs. US hospital care costed using Medicare diagnosis‐related group costs plus professional fees. The numbers of participants who experienced the adverse events during study follow‐up are presented in parentheses. Participants contributed years of cost data to categories of Years since new event occurrence, depending on time since their first relevant event. Their annual cost data in years before event occurrence contributed to the Before first new event category. All hospital costs at 2019 prices. UK indicates United Kingdom; and US, United States.

Figure 3. Quality of life (QoL) reductions associated with new adverse events in secondary prevention of CVD, UK and US perspectives.

Data of the 19 321 REVEAL participants randomized in Europe and North America was used in both analyses from the UK and US perspectives. EQ‐5D utility values for all 19 321 contributing participants were calculated using the UK or US EQ‐5D value sets, respectively. EQ‐5D is a standardized instrument used to measure health‐related QoL across 5 domains (mobility, self‐care, usual activities, pain/discomfort, anxiety/depression). By combining the scores of each dimension, the EQ‐5D generates a health state profile, which can be converted into a single summary index score. The index score represents an individual's overall health status on a scale where 1.0 denotes perfect health, 0.0 represents death, and negative values indicate health states considered worse than death. QoL reductions associated with adverse events, by duration of time between latest adverse event from each category and EQ‐5D QoL measure at the end of the trial (≤1 year, 1–2 years, and >1 or >2 years), were estimated using a linear regression model with adjustments for sociodemographic and clinical characteristics. We were unable to detect QoL reductions associated with myocardial infarction, coronary revascularization (urgent, nonurgent), and incident diabetes, so these events were not included in the model. CVD indicates cardiovascular disease; EQ‐5D, EuroQol‐5 Dimensions; N, number of people who experienced the event in the study before QoL measure at final follow‐up in the study; QoL, quality of life; REVEAL, Randomized Evaluation of the Effects of Anacetrapib Through Lipid Modification; UK, United Kingdom; and US, United States.