Author + information
- Received October 11, 2017
- Revision received December 20, 2017
- Accepted December 26, 2017
- Published online March 5, 2018.
- Leslee J. Shaw, PhDa,∗ (, )
- Abhinav Goyal, MD, MHSa,
- Christina Mehta, PhDb,
- Joe Xie, MDa,
- Lawrence Phillips, MDc,
- Anita Kelkar, MDa,
- Joseph Knapper, MDa,
- Daniel S. Berman, MDd,
- Khurram Nasir, MD, MPHe,
- Emir Veledar, PhDe,
- Michael J. Blaha, MD, MPHf,
- Roger Blumenthal, MDf,
- James K. Min, MDg,
- Reza Fazel, MDa,
- Peter W.F. Wilson, MDa and
- Matthew J. Budoff, MDh
- aEmory University School of Medicine, Atlanta, Georgia
- bEmory University School of Public Health, Atlanta, Georgia
- cNew York University School of Medicine, New York, New York
- dCedars-Sinai Medical Center, Los Angeles, California
- eBaptist Health South Florida, South Miami, Florida
- fJohns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland
- gWeill Cornell Medical College, New York, New York
- hUniversity of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California
- ↵∗Address for correspondence:
Dr. Leslee J. Shaw, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, 1462 Clifton Road NE, Room 529, Atlanta, Georgia 30324.
Background Cardiovascular disease (CVD) imparts a heavy economic burden on the U.S. health care system. Evidence regarding the long-term costs after comprehensive CVD screening is limited.
Objectives This study calculated 10-year health care costs for 6,814 asymptomatic participants enrolled in MESA (Multi-Ethnic Study of Atherosclerosis), a registry sponsored by the National Heart, Lung, and Blood Institute, National Institutes of Health.
Methods Cumulative 10-year costs for CVD medications, office visits, diagnostic procedures, coronary revascularization, and hospitalizations were calculated from detailed follow-up data. Costs were derived by using Medicare nationwide and zip code–specific costs, inflation corrected, discounted at 3% per year, and presented in 2014 U.S. dollars.
Results Risk factor prevalence increased dramatically and, by 10 years, diabetes, hypertension, and dyslipidemia was reported in 19%, 57%, and 53%, respectively. Self-reported symptoms (i.e., chest pain or shortness of breath) were common (approximately 40% of enrollees). At 10 years, approximately one-third of enrollees reported having an echocardiogram or exercise test, whereas 7% underwent invasive coronary angiography. These utilization patterns resulted in 10-year health care costs of $23,142. The largest proportion of costs was associated with CVD medication use (78%). Approximately $2 of every $10 were spent for outpatient visits and diagnostic testing among the elderly, obese, those with a high-sensitivity C-reactive protein level >3 mg/l, or coronary artery calcium score (CACS) ≥400. Costs varied widely from <$7,700 for low-risk (Framingham risk score <6%, 0 CACS, and normal glucose measurements at baseline) to >$35,800 for high-risk (persons with diabetes, Framingham risk score ≥20%, or CACS ≥400) subgroups. Among high-risk enrollees, CVD costs accounted for $74 million of the $155 million consumed by MESA participants.
Conclusions Longitudinal patterns of health care resource use after screening revealed new evidence on the economic burden of treatment and testing patterns not previously reported. Maintenance of a healthy population has the potential to markedly reduce the economic burden of CVD among asymptomatic individuals.
In the United States, nearly 1 in 3 (approximately 80 million) adults have some form of cardiovascular disease (CVD), which imparts a heavy economic burden, including estimated direct costs of approximately $444 billion (1–4). The CVD costs of care are continuing to rise, with the current costs for treatment accounting for nearly $1 of every $6 spent on health care (2). The evidence to date on the economic implications of CVD screening is less well developed. Screening for CVD has the potential to improve clinical outcomes through effective detection of CVD risk and to intensify preventive efforts among asymptomatic individuals. Other forms of screening, such as for lung, breast, and colon cancer, form the basis for preventive health, with robust economic evidence and documentation of the expense of downstream disease states (5). Heretofore, the evidence base on the impact of CVD testing on long-term health care expenditures among asymptomatic, apparently healthy individuals is unknown. The aim of the present analysis was to estimate 10-year CVD costs based on detailed resource consumption patterns collected within MESA (Multi-Ethnic Study of Atherosclerosis), a registry sponsored by the National Heart, Lung, and Blood Institute, National Institutes of Health (6,7).
MESA enrollment criteria
Enrollment criteria and CVD testing procedures for MESA have been previously reported in detail (6,7). In brief, a total of 6,814 asymptomatic, apparently healthy individuals (age range: 45 to 84 years) were enrolled. This substudy was approved by the MESA policy and publications committee and undertaken with a data use agreement between Emory University and the University of Washington.
Collection of baseline traditional risk factors
During the baseline visit, participants were queried as to the history of cardiac risk factors. Also recorded were self-reported history of diabetes, hyperlipidemia, and hypertension; a family history of CVD; and smoking history. At this time, lipids, glucose, and blood pressure were measured; details of the methods have been published (6,8). A Framingham risk score (FRS) was calculated on each enrollee, including categories of 10-year predicted risk of <6%, 6% to 9.9%, 10% to 19.9%, and ≥20% (9). Use of a total of 46 drug classes, such as sulfonylurea, beta-blocker, and calcium-channel blocker therapies, were collected in MESA.
Nontraditional CVD testing
At the baseline visit, MESA enrollees had measurement of high-sensitivity C-reactive protein (hsCRP) according to standardized methods (10). High- and low-risk hsCRP was defined as >3 and ≤3 mg/dl, respectively (11). At the baseline visit, all participants underwent coronary artery calcium scoring (CACS). The protocol and methods for CACS were performed by using standardized methods (6,7,10). For the present analysis, CACS was categorized as 1 to 9, 10 to 99, 100 to 399, 400 to 999, and ≥1,000, respectively.
Data collection of socioeconomic factors
During the baseline visit, detailed data on socioeconomic status were collected, including marital status, employment status, highest level of education achieved, household income, and health insurance coverage. These variables were candidates for covariate adjustment in the cost models because they are established determinants of health care utilization.
MESA collected detailed follow-up hospitalization, medication usage, and varied patterns of resource consumption throughout follow-up. In total, MESA participants returned for a total of 4 additional clinic examinations every 2 years. During each follow-up visit, a detailed history of intercurrent office visits, CVD diagnostic (e.g., exercise stress testing) and invasive (diagnostic coronary angiography and coronary revascularization) procedures, and CVD hospitalizations, as well as current and revised prescribed CVD medications, were ascertained. Medicare nationwide mean payments for diagnostic procedures, coronary revascularization, and hospitalizations are provided in Online Table 1. CVD medications included medications for hypertension, diabetes, and dyslipidemia such as diuretic agents, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, insulin, and statins. Anti-ischemic and heart failure (HF) medication usage was also collected (e.g., nitrates, ACE inhibitors). In the years when an in-person clinic examination was not scheduled, participants completed follow-up information through a detailed telephone interview. Similar to the clinic visit data collection, data on medication, procedures, and hospitalizations were collected annually. Specific questions on changes in drug therapy and intensification or reduction in dosing were collected annually. During each follow-up contact, enrollees were queried as to whether a new diagnosis of hypertension, diabetes, or dyslipidemia was assigned by their overseeing health care provider. In year 1 of follow-up, participants were queried as to whether they had discussed their MESA test results with their primary care physician. MESA investigators did not provide treatment or procedural guidance based on test findings.
Data on CVD hospitalization were collected similar to the procedural and visit data. Angina or HF hospitalization, coronary revascularization, acute myocardial infarction (MI), or stroke underwent a detailed event adjudication by the MESA morbidity and mortality committee, as detailed in an online manual (12). The timing for MI, HF, angina, coronary revascularization, and resuscitated cardiac arrest was collected. During follow-up, all enrollees were queried as to new-onset chest pain during the preceding year of follow-up, and adjudicated angina was defined as an episode of ischemic pain, tightness, pressure, or discomfort in the chest, arm, or jaw, when co-occurring with a prescribed anti-ischemic therapy, documented angiographic obstructive coronary artery disease, an ischemic electrocardiogram, or imaging abnormality. Each enrollee was also queried with regard to the presence of shortness of breath symptoms. The criteria for adjudicated, symptomatic HF were documented HF symptoms and receiving treatment (with diuretic agents, vasodilator agents, beta-blockers, or ACE inhibitors) or imaging evidence of a dilated left ventricle or reduced left ventricular ejection fraction.
CVD health care costs
The Centers for Medicare & Medicaid Services pharmacy charges (zip code specific for each site) and nationwide reimbursement rates for office visits, CVD procedures, and hospitalizations were collected. Common prescribing doses were examined and aggregated according to drug class (13). Based on the common prescribing doses, median drug pricing was derived by using the site- or zip code–specific, online drug pricing. Online Table 2 provides a range of costs for CVD medications across the participating sites. Generic pricing for antihypertensive (e.g., diuretic agents, ACE inhibitors, beta-blockers), cholesterol-lowering (e.g., statins), and diabetes (e.g., metformin) drugs were collected (Online Table 3). Costs for outpatient services were derived from the Outpatient Prospective Payment System amounts based on Healthcare Common Procedure Coding System codes using the Outpatient PC Pricer system for nationwide mean fees (14). A similar approach was applied to define in-hospital procedures (PC Pricer prospective payment system estimator) (15). Payment codes included the following: diagnosis-related groups 66 to 69, 222 to 223, 232, 236 to 238, 280 to 285, 293, 311, and 313; ambulatory payment classifications 96, 99, 336, 337, and 602; and Current Procedural Terminology codes 80053, 80061, 83519, 85380, 85384, 86140, 93015, 93350, and 93454 to 93459. An MI hospitalization that occurred within 1 week of a percutaneous coronary intervention or coronary artery bypass surgery was assigned the relevant Medicare payment. Hospital costs varied and were higher when associated with complications. We applied mean costs, for example, for acute MI. When a range of hospital costs for a given admission were applied, our results did not vary.
All costs were inflation adjusted by using the medical care component of the Consumer Price Index (16). The unit cost is given in 2014 U.S. dollars. Costs were discounted at 3% per year to reflect the lower economic value of deferred expenses. When a cost was assigned to a given year of follow-up, discounting was based on the remaining years of follow-up through 10 years. Because enrollment occurred from 2000 to 2002, patient-specific costs varied according to the year of follow-up (e.g., a year 1 cost may be from 2001 to 2003 for a given patient). Costs for medications, outpatient visits, procedures, coronary revascularization, and hospitalizations were summed for each MESA enrollee. Nonsurviving enrollees had costs accumulated until their deaths.
All analyses were performed on MESA-approved and locked SAS files. Descriptive statistics (mean ± 95% confidence interval or percentage for continuous and categorical variables) were recorded. Chi-square and Student’s t-tests were used to compare MESA subgroups. The cumulative (unadjusted) costs were plotted through 10 years of follow-up aggregated according to costs for CVD medications, outpatient visits, diagnostic procedures, coronary revascularization, and hospitalizations. Unadjusted costs for CVD medications, outpatient visits, diagnostic procedures, coronary revascularization, and hospitalizations were plotted for women and men according to age, FRS, CACS, and hsCRP subgroups, respectively.
A multivariate linear regression model was calculated to identify predictors of elevated 10-year health care costs. The 10-year cost was log transformed to normalize the distribution of the values. The primary analysis was undertaken by using the log-transformed cost variable for evaluation of statistical significance. An additional linear regression model using (nontransformed) cost as the dependent measure was used to derive adjusted cost values from the unstandardized beta coefficients. Socioeconomic covariates in the model were education, income, and health insurance coverage. From the linear regression model, the model r2 was calculated. Predicted costs were then compared across MESA subgroups (i.e., according to CACS, FRS, age, BMI, hsCRP, hypertension, and diabetes). We then defined the following: a low-risk subgroup as those with a low-risk FRS, CACS = 0, and normal glucose values (n = 1,182); a high-risk subgroup as those with a high-risk FRS, CACS ≥400, or diabetes (n = 2,520); and a very-high-risk subgroup with a high-risk FRS, CACS ≥400, and diabetes (n = 126). Among these subgroups, cumulative costs and 95% confidence intervals were plotted for women and men. We then calculated the proportion of total costs for CVD medications, diagnostic procedures, outpatient visits, coronary revascularization, and hospitalizations. In a secondary analysis, the lowest cost, generic pricing was applied for hypertension, dyslipidemia, and diabetic medication costs (Online Table 3). Cost savings were calculated as the difference between brand name and generic pricing.
Statistical analysis was performed by using SAS version 9.4 (SAS Institute, Inc., Cary, North Carolina) and IBM SPSS version 24.0 (IBM Corporation, Armonk, New York).
Socioeconomic characteristics of MESA Participants
Among the 6,814 MESA enrollees, the median age was 62 years, and 53% were women, with 10 years of follow-up data reported (Table 1). Enrollment included diverse representation of African-American (28%), Chinese (12%), and Hispanic (22%) individuals. Only 35% of MESA participants completed a college education with a bachelor’s degree or higher, and only 38% were employed full-time. Approximately one-half of MESA enrollees had a family income <$40,000 per year. Of the MESA participants, 69% had private health insurance and 93% reported a physician’s office or clinic as their regular source of medical care.
Risk factor diagnosis and treatment at the baseline visit
At the baseline examination, 39%, 37%, and 11% of enrollees, respectively, reported a history of hypertension, dyslipidemia, and diabetes (Table 2). An abnormal fasting glucose level or diabetes was reported in 26% of MESA enrollees. Similarly, 45% of enrollees met criteria for hypertension at the baseline examination. Approximately 60% of MESA participants were taking a CVD-preventive medication for hypertension, dyslipidemia, or diabetes at the baseline visit. Of the MESA enrollees, 55% reported that they discussed findings from their baseline examination with their primary care physician. Nearly 60% of enrollees had an intermediate to high FRS. A high-risk hsCRP >3 mg/l occurred in 36% of participants, and 10% had a CACS ≥400.
10-Year cumulative diagnoses of diabetes, hypertension, and dyslipidemia
At the index examination, 10%, 45%, and 37%, respectively, of MESA participants had diabetes, hypertension, and dyslipidemia (Table 3). During follow-up, there was a graded increase in the cumulative incidence of diabetes, hypertension, and dyslipidemia. Cumulative 10-year rates of diabetes, hypertension, and dyslipidemia were 19%, 57%, and 53%.
10-Year procedural utilization data
By 10 years of follow-up, approximately one-third of MESA enrollees underwent an echocardiogram or exercise test (Table 4). At the end of follow-up, 70% of MESA participant had one or more noninvasive diagnostic procedures. The cumulative 10-year rate of invasive angiography was 6.9%.
10-Year self-reported chest pain or dyspnea symptoms
The cumulative rate of self-reported chest pain at 10 years was 39%, whereas the 10-year rate of adjudicated angina was 9.6% (Table 5). Of note, 79% and 39% of MESA enrollees with and without angina, respectively, underwent exercise testing (p < 0.0001). Similarly, 55% and 4% of MESA enrollees with and without angina underwent invasive coronary angiography during 10 years of follow-up (p < 0.0001). The odds of invasive angiography were 8-fold higher (95% confidence interval: 5.8 to 11.4) among patients experiencing an acute MI or resuscitated cardiac arrest during follow-up (p < 0.0001). Nearly one-third of individuals undergoing invasive coronary angiography also had documented coronary revascularization (including 54 coronary bypass surgeries and 79 percutaneous coronary interventions).
The cumulative rate of self-reported shortness of breath at 10 years was 43%, whereas the 10-year rate of adjudicated HF was 6.9%. For those with and without HF symptoms, 77% and 35% of enrollees, respectively, reported having an echocardiogram performed during follow-up (p < 0.0001).
10-Year CVD costs
All costs presented in Figures 1 and 2 are unadjusted. The mean cumulative 10-year health care costs were $23,142 and summed to >$155 million for all enrollees. Cumulative health care costs ranged from $0 to $274,582; the 10th, 25th, 50th, 75th, and 90th percentile costs, respectively, were $592, $2,026, $13,349, $33,026, and $56,824. Over time, CVD medication costs represented a growing proportion of cumulative costs. At 10 years of follow-up, 78% of cumulative costs were associated with CVD medication usage. When generic pricing was applied to treatment for diabetes, hypertension, and dyslipidemia, total costs for CVD medications were reduced by approximately $45 million, representing a 36.3% cost savings. By applying generic pricing, the proportional costs for CVD medications would be reduced to 71% of the total CVD health care costs. The proportion of cumulative costs was 4.3%, 8.6%, 5.4%, and 3.3% for outpatient visits, diagnostic procedures, coronary revascularization, and CVD hospitalizations.
Costs varied widely and increased with advancing age for women and men (Figure 2A). MESA participants <65 years of age had much lower health care costs. Similarly, costs increased from low- to high-risk FRS subgroups (Figure 2B). Across the FRS subgroups, women had higher cumulative costs. Women were older across FRS subgroups by 6, 9, 7, and 2 years for low, average, intermediate, and high FRS enrollees, respectively (p < 0.0001).
A similar pattern of health care costs was noted across low- to high-risk CACS (Figure 2C), and hsCRP (Figure 2D) subgroups. Among those with a high-risk hsCRP, new diagnoses for dyslipidemia, hypertension, and diabetes contributed to higher CVD medication costs. For those with a high-risk hsCRP, the rate of diagnosis for hypertension, diabetes, and dyslipidemia increased 1.7-, 2.9-, and 4.9-fold, respectively, over the 10 years of follow-up.
Multivariate linear regression model estimating 10-year health care costs
We then performed multivariate linear regression modeling to identify significant estimators of 10-year CVD health care costs. The results from a multivariate linear regression using log-transformed and nontransformed cost as the dependent variable reveal similar findings (Online Table 4). The Central Illustration plots show adjusted costs. Cumulative costs were high for those with impaired fasting glucose or diabetes. For those with impaired fasting glucose, adjusted costs were $11,449, whereas those with untreated and treated diabetes had 10-year CVD costs of $5,567 and $12,274, respectively. Using this analysis, a CACS of 400 to 999 contributed $15,511 in higher costs, and an additional $3,668 in higher costs was estimated for those with a CACS ≥1,000. By comparison, a high-risk hsCRP >3 mg/l added $4,948 to cumulative health care costs.
Proportional costs for CVD medications, visits, procedures, and hospitalizations
Table 6 reports the proportion of 10-year health care costs associated with CVD medications, diagnostic procedures, outpatient visits, coronary revascularization, and CVD hospitalization. For all MESA enrollees, CVD medications accounted for the highest proportion of 10-year costs of care, especially for persons with diabetes (87%) and dyslipidemia (90%). The elderly, obese, and those with a high-risk hsCRP >3 mg/l and a CACS ≥400 had higher proportional costs related to diagnostic procedures and outpatient visits. Approximately 5% of costs for MESA enrollees with a CACS ≥400 were attributed to coronary revascularization. Less than 5% of 10-year health care costs were attributable to CVD hospitalization.
Low- and high-cost subgroups
A total of 1,182 MESA enrollees were categorized as low risk (0 CACS, a low FRS, and normal glucose values at baseline) with cumulative 10-year (mean) costs of $7,008, albeit higher in women due to their older age and elevated costs for outpatient visits and CVD medications (Figure 3). Total costs associated with low-risk status were $8.3 million or 5.2% of the total $155 million for all MESA enrollees. By comparison, among the 2,520 high-risk participants (CACS ≥400, diabetes, or a high-risk FRS), 10-year costs of health care were $37,732 for women and $35,814 for men. Total costs associated with high-risk status were $74 million or 48% of the $155 million total for all MESA enrollees.
MESA, sponsored by the National Heart, Lung, and Blood Institute, National Institutes of Health, is a landmark investigation reporting on the long-term effectiveness of traditional and nontraditional risk markers for prediction of major CVD events (7,10). Although many risk markers have proven effectiveness at stratifying populations, estimating risk alone is insufficient to describe the clinical burden of diagnosis and treatment for high-risk subsets. Limited information is available on the follow-up resource consumption and cost patterns among asymptomatic individuals following a detailed screening examination collecting measurements of CVD risk factors and nontraditional risk markers, such as with hsCRP and CACS (17–20). Our findings are consistent with previous estimates that there is an increasing economic burden of CVD over time, which is projected to increase to $1.1 trillion in the United States by 2035 (21). This pattern of accelerating health care costs within MESA reveals that individuals who are screened today will experience suspected coronary artery disease symptoms and new diagnoses, prompting more intensive treatment and frequent use of diagnostic procedures.
Cost findings among MESA subgroups
Our MESA analysis examining resource consumption patterns revealed dramatic and surprising differences in CVD costs across the varied MESA subgroups. We identified a high-risk population cohort with a high FRS, CACS ≥400, or diabetes that consumed nearly one-half of the estimated $155 million for CVD health care costs during the 10 years of follow-up. By comparison, a low-risk population cohort (with normal glucose values, no detectable CACS, and a low risk FRS) consumed only 5% of the CVD health care costs over 10 years. These results are similar to recent findings from the Chicago Heart Association Detection Project noting that individuals with low CVD risk had decidedly lower 5-year Medicare costs (22).
Moreover, women often had higher CVD costs, in large part related to their risk factor burden and advanced age compared with men. This relationship between women and men was most apparent when comparing across FRS subgroups: in the low to intermediate FRS subgroups, 10-year costs were approximately $10,000 higher among women with average to intermediate risk. Numerous reports have challenged the accuracy of the FRS and proposed an underestimation of risk, particularly associated with aging for women. This factor led to comparisons across any FRS subgroup of women having higher CVD costs and more intensive resource consumption patterns compared with men (23).
We also reported a lack of association between race and ethnicity as a primary driver of increased CVD costs. Many reports note the high burden of CVD risk factors and comorbidities that increase CVD event risk among racial and ethnically diverse patient populations (24). Our analysis revealed that the addition of income, insurance, and education attenuated the impact of race and ethnicity as a significant driver of health care. These data further support that socioeconomic factors influence resource consumption patterns for many priority populations, including MESA enrollees of diverse race and ethnicity (23). Moreover, policies focusing on equitable access to preventive management not only reduce health care disparities but may also influence the economic burden of CVD care among at-risk minority populations.
Another surprising finding is the high costs (approximately $5,000) associated with high-risk hsCRP. Certainly, the epidemiological data support an elevated CVD risk that would increase hospitalization and revascularization costs (25–27). Analyses also detailed higher costs for CVD medications among those with hsCRP >3 mg/l, which was likely influenced by trial evidence of therapeutic risk reduction with statin therapy (28).
A final example is the high rate of self-reported chest pain and shortness of breath in this initially apparently healthy, asymptomatic population. Nearly 1 in 10 MESA enrollees reported symptoms that prompted a high rate of diagnostic procedural use compared with those without such symptoms. This association suggests a heavy burden of suspected symptoms, which may underlie the high rates of diagnostic procedures observed over the past several decades (29).
Policy implications for investing in screening of apparently healthy populations
As health care systems embark on population health strategies, the cost estimates from MESA may provide insight into the cost implications of early screening and targeted preventive programs. From our analysis, we captured a low-risk subgroup with decidedly lower long-term CVD costs compared with higher risk MESA subgroups. It is possible that an investment in preventive health programs could be economically advantageous if a sizeable proportion of enrollees maintain their low-risk status for many years. Moreover, depending on the success of preventive programs, investments could be balanced by reduced health care costs for the low-risk patients who require minimal clinical care. As CVD medications encumbered the highest proportional costs, a focus on behavioral or community-wide policies and programs to enhance lifestyle changes may reduce the need (and thus the costs) for CVD medications. There should also be an aim for more widespread use of lower cost treatments, such as aspirin, to reduce CVD risk while adding minimally to CVD costs (30).
Moreover, implementation of community or health system policies may become more palatable if economic advantages, such as that estimated within MESA, were realized in long-term CVD costs of care. In a recent example, New York City health policy initiatives on improving healthy eating behaviors and tobacco control were associated with reductions in CVD mortality (31). The dramatic differences in cost among MESA subgroups provide insight into the substantive health care costs that could be averted by reducing the burden of risk factors (i.e., CACS) and preventing atherosclerotic disease development.
Importantly, contractual agreements with private payers generally have higher payment rates than that of Medicare. Thus, for the nearly one-quarter of MESA enrollees who are not yet eligible for Medicare, costs were underestimated. Although rigorously collected data were ascertained on utilization of health care services, only Medicare data were used in our analyses. Limited diagnostic test results were available. The MESA adjudication process was detailed and provided for ascertainment of CVD hospitalizations and events, as well as symptom data. Data are not available to compare the effectiveness of various screening strategies, as all enrollees underwent a battery of laboratory and imaging procedures.
The longitudinal patterns of health care resource use after traditional and nontraditional CVD testing within MESA reveal new evidence on the long-term economic burden of follow-up treatment and testing patterns. The economic needs of the adult population with traditional and nontraditional CVD risk markers exceeded $155 million in MESA. These data illustrate the unique contributions to elevated cost, as well as the targeted economic burden of various risk factors and markers on total health care costs. Identification of low-risk populations that maintain healthy weight, glucose, blood pressure, and cholesterol levels has markedly reduced health care costs. High-risk subgroups with diabetes, a high FRS, or a CACS ≥400 have up to 15-fold higher costs for health care, and targeted early screening and intervention programs could offset the elevated long-term costs for asymptomatic populations.
COMPETENCY IN SYSTEMS-BASED PRACTICE: Among patients screened for CVD, those in high-risk subgroups have up to 15-fold greater costs for health care over the following decade.
TRANSLATIONAL OUTLOOK: Further studies are needed to confirm whether more carefully targeted screening and intervention programs for asymptomatic populations could reduce the elevated resource utilization and costs during long-term follow-up.
Support was provided by the National Heart, Lung, and Blood Institute, National Institutes of Health (grant RC1 HL100915-01). Dr. Min has served as a member of the scientific advisory board of Arineta; has ownership in MDDX; and has a research agreement with GE Healthcare. Dr. Budoff has received grants from the National Institutes of Health and GE. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Abbreviations and Acronyms
- angiotensin-converting enzyme
- coronary artery calcium score
- cardiovascular disease
- Framingham risk score
- heart failure
- high-sensitivity C-reactive protein
- myocardial infarction
- Received October 11, 2017.
- Revision received December 20, 2017.
- Accepted December 26, 2017.
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