Real world hospital costs following stress echocardiography in the UK: a costing study from the EVAREST/BSE-NSTEP multi-entre study

EVAREST/BSE-NSTEP Investigators; Casey L Johnson; William Woodward; Annabelle McCourt; Cameron Dockerill; Samuel Krasner; Mark Monaghan; Roxy Senior; Daniel X Augustine; Maria Paton; Jamie O'Driscoll; David Oxborough; Keith Pearce; Shaun Robinson; James Willis; Rajan Sharma; Apostolos Tsiachristas; Paul Leeson

doi:10.1186/s44156-023-00020-1

Real world hospital costs following stress echocardiography in the UK: a costing study from the EVAREST/BSE-NSTEP multi-entre study

EVAREST/BSE-NSTEP Investigators, Casey L Johnson, William Woodward, Annabelle McCourt, Cameron Dockerill, Samuel Krasner, Mark Monaghan, Roxy Senior, Daniel X Augustine, Maria Paton, Jamie O'Driscoll, David Oxborough, Keith Pearce, Shaun Robinson, James Willis, Rajan Sharma, Apostolos Tsiachristas, Paul Leeson

Biomedical Engineering Department

Research output: Contribution to journal › Article › peer-review

1 Citation (Scopus)

Abstract

BACKGROUND: Stress echocardiography is widely used to detect coronary artery disease, but little evidence on downstream hospital costs in real-world practice is available. We examined how stress echocardiography accuracy and downstream hospital costs vary across NHS hospitals and identified key factors that affect costs to help inform future clinical planning and guidelines.

METHODS: Data on 7636 patients recruited from 31 NHS hospitals within the UK between 2014 and 2020 as part of EVAREST/BSE-NSTEP clinical study, were used. Data included all diagnostic tests, procedures, and hospital admissions for 12 months after a stress echocardiogram and were costed using the NHS national unit costs. A decision tree was built to illustrate the clinical pathway and estimate average downstream hospital costs. Multi-level regression analysis was performed to identify variation in accuracy and costs at both patient, procedural, and hospital level. Linear regression and extrapolation were used to estimate annual hospital cost-savings associated with increasing predictive accuracy at hospital and national level.

RESULTS: Stress echocardiography accuracy varied with patient, hospital and operator characteristics. Hypertension, presence of wall motion abnormalities and higher number of hospital cardiology outpatient attendances annually reduced accuracy, adjusted odds ratio of 0.78 (95% CI 0.65 to 0.93), 0.27 (95% CI 0.15 to 0.48), 0.99 (95% CI 0.98 to 0.99) respectively, whereas a prior myocardial infarction, angiotensin receptor blocker medication, and greater operator experience increased accuracy, adjusted odds ratio of 1.77 (95% CI 1.34 to 2.33), 1.64 (95% CI 1.22 to 2.22), and 1.06 (95% CI 1.02 to 1.09) respectively. Average downstream costs were £646 per patient (SD 1796) with significant variation across hospitals. The average downstream costs between the 31 hospitals varied from £384-1730 per patient. False positive and false negative tests were associated with average downstream costs of £1446 (SD £601) and £4192 (SD 3332) respectively, driven by increased non-elective hospital admissions, adjusted odds ratio 2.48 (95% CI 1.08 to 5.66), 21.06 (95% CI 10.41 to 42.59) respectively. We estimated that an increase in accuracy by 1 percentage point could save the NHS in the UK £3.2 million annually.

CONCLUSION: This study provides real-world evidence of downstream costs associated with stress echocardiography practice in the UK and estimates how improvements in accuracy could impact healthcare expenditure in the NHS. A real-world downstream costing approach could be adopted more widely in evaluation of imaging tests and interventions to reflect actual value for money and support realistic planning.

Original language	English
Article number	8
Pages (from-to)	8
Journal	Echo Research and Practice
Volume	10
Issue number	1
Early online date	31 May 2023
DOIs	https://doi.org/10.1186/s44156-023-00020-1
Publication status	Published - Dec 2023

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EVAREST/BSE-NSTEP Investigators, Johnson, C. L., Woodward, W., McCourt, A., Dockerill, C., Krasner, S., Monaghan, M., Senior, R., Augustine, D. X., Paton, M., O'Driscoll, J., Oxborough, D., Pearce, K., Robinson, S., Willis, J., Sharma, R., Tsiachristas, A., & Leeson, P. (2023). Real world hospital costs following stress echocardiography in the UK: a costing study from the EVAREST/BSE-NSTEP multi-entre study. Echo Research and Practice, 10(1), 8. Article 8. https://doi.org/10.1186/s44156-023-00020-1

@article{154e8fc1e8304b989e52891b0d59be20,

title = "Real world hospital costs following stress echocardiography in the UK: a costing study from the EVAREST/BSE-NSTEP multi-entre study",

abstract = "BACKGROUND: Stress echocardiography is widely used to detect coronary artery disease, but little evidence on downstream hospital costs in real-world practice is available. We examined how stress echocardiography accuracy and downstream hospital costs vary across NHS hospitals and identified key factors that affect costs to help inform future clinical planning and guidelines.METHODS: Data on 7636 patients recruited from 31 NHS hospitals within the UK between 2014 and 2020 as part of EVAREST/BSE-NSTEP clinical study, were used. Data included all diagnostic tests, procedures, and hospital admissions for 12 months after a stress echocardiogram and were costed using the NHS national unit costs. A decision tree was built to illustrate the clinical pathway and estimate average downstream hospital costs. Multi-level regression analysis was performed to identify variation in accuracy and costs at both patient, procedural, and hospital level. Linear regression and extrapolation were used to estimate annual hospital cost-savings associated with increasing predictive accuracy at hospital and national level.RESULTS: Stress echocardiography accuracy varied with patient, hospital and operator characteristics. Hypertension, presence of wall motion abnormalities and higher number of hospital cardiology outpatient attendances annually reduced accuracy, adjusted odds ratio of 0.78 (95% CI 0.65 to 0.93), 0.27 (95% CI 0.15 to 0.48), 0.99 (95% CI 0.98 to 0.99) respectively, whereas a prior myocardial infarction, angiotensin receptor blocker medication, and greater operator experience increased accuracy, adjusted odds ratio of 1.77 (95% CI 1.34 to 2.33), 1.64 (95% CI 1.22 to 2.22), and 1.06 (95% CI 1.02 to 1.09) respectively. Average downstream costs were £646 per patient (SD 1796) with significant variation across hospitals. The average downstream costs between the 31 hospitals varied from £384-1730 per patient. False positive and false negative tests were associated with average downstream costs of £1446 (SD £601) and £4192 (SD 3332) respectively, driven by increased non-elective hospital admissions, adjusted odds ratio 2.48 (95% CI 1.08 to 5.66), 21.06 (95% CI 10.41 to 42.59) respectively. We estimated that an increase in accuracy by 1 percentage point could save the NHS in the UK £3.2 million annually.CONCLUSION: This study provides real-world evidence of downstream costs associated with stress echocardiography practice in the UK and estimates how improvements in accuracy could impact healthcare expenditure in the NHS. A real-world downstream costing approach could be adopted more widely in evaluation of imaging tests and interventions to reflect actual value for money and support realistic planning.",

author = "{EVAREST/BSE-NSTEP Investigators} and Johnson, {Casey L} and William Woodward and Annabelle McCourt and Cameron Dockerill and Samuel Krasner and Mark Monaghan and Roxy Senior and Augustine, {Daniel X} and Maria Paton and Jamie O'Driscoll and David Oxborough and Keith Pearce and Shaun Robinson and James Willis and Rajan Sharma and Apostolos Tsiachristas and Paul Leeson",

note = "Funding Information: The authors would like to express gratitude to the funders of this study. Additionally, the authors would like to thank all EVAREST/BSE-NSTEP investigators as well as participating patients without whom this work would not be possible. EVAREST/BSE-NSTEP Investigators: Paul Leeson1, Roxy Senior3, Jacob Easaw4, Daniel X. Augustine4, Keith Pearce8, Rajan Sharma10, Abraheem Abraheem13, Sanjay Banypersad14, Christopher Boos15, Sudantha Bulugahapitiya16, Jeremy Butts17, Duncan Coles18, Thuraia Nageh18, Haytham Hamdan19, Ayyaz Sultan19, Shahnaz Jamil-Copley20, Gajen Kanaganayagam21, Tom Mwambingu22, Antonis Pantazis23, Alexandros Papachristidis24, Ronak Rajani25, Muhammad Amer Rasheed26, Naveed A. Razvi27, Sushma Rekhraj20, David P. Ripley28, Kathleen Rose29, Michaela Scheuermann-Freestone30, Rebecca Schofield31, Spyridon Zidros32, Kenneth Wong33, Sarah Fairbarin34, Badrinathan Chandrasekaran35, Maria Paton36, Patrick Gibson37, Attila Kardos38, Henry Boardman38, Joanna d{\textquoteright}Arcy38, Katrin Balkhausen39, Ioannis Moukas40, Joban S. Sehmi41, Soroosh Firoozan4213Tameside and Glossop Integrated Care NHS Foundation Trust, Ashton-under-Lyne, UK.14East Lancashire Hospitals NHS Trust, Burnley, UK.15Poole Hospital NHS Foundation Trust, Poole, UK.16Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK.17Calderdale and Huddersfield NHS Foundation Trust, Calderdale, UK.18Mid and South Essex NHS Foundation Trust, UK.19Wrightington, Wigan and Leigh NHS Foundation Trust, UK.20Nottingham University Hospitals NHS Trust, UK.21Chelsea and Westminster Hospital NHS Foundation Trust, UK.22The Mid Yorkshire Hospitals NHS Trust, UK.23North Middlesex University Hospital NHS Trust, UK.24King's College Hospital NHS Foundation Trust, UK.25Guy{\textquoteright}s and St Thomas{\textquoteright} NHS Foundation Trust, UK.26Yeovil District Hospital NHS Foundation Trust, UK.27East Suffolk and North Essex NHS Foundation Trust, UK.28Northumbria Healthcare NHS Foundation Trust, UK.29Northampton General Hospital NHS Trust, UK.30Hampshire Hospitals NHS Foundation Trust, UK.31North West Anglia NHS Foundation Trust, UK.32Bedford Hospital NHS Trust, UK.33Blackpool Teaching Hospitals NHS Foundation Trust, UK.34University Hospitals Bristol and Weston NHS Foundation Trust, UK.35Great Western Hospitals NHS Foundation Trust, UK.36Leeds Teaching Hospitals NHS Trust, UK.37NHS Lothian, UK.38Milton Keynes University Hospital NHS Foundation Trust, UK.39Royal Berkshire NHS Foundation Trust, UK.40Warrington and Halton Teaching Hospitals NHS Foundation Trust, UK.41West Hertfordshire Hospitals NHS Trust, UK.42Buckinghamshire Healthcare NHS Trust, UK. Funding Information: This work was supported by National Institute for Health Research Health Education England Healthcare Science Research Fellowship [NIHR-HCS-P13-04–001]; Cardiovascular Clinical Research Facility, University of Oxford; Ultromics Ltd.; Lantheus Medical Imaging Inc. and National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford. The funders of the study had no role in study design, data collection, analysis, interpretation, or writing of the report. Publisher Copyright: {\textcopyright} 2023, The Author(s).",

year = "2023",

month = dec,

doi = "10.1186/s44156-023-00020-1",

language = "English",

volume = "10",

pages = "8",

journal = "Echo Research and Practice",

issn = "2055-0464",

publisher = "BioScientifica Ltd.",

number = "1",

}

EVAREST/BSE-NSTEP Investigators, Johnson, CL, Woodward, W, McCourt, A, Dockerill, C, Krasner, S, Monaghan, M, Senior, R, Augustine, DX, Paton, M, O'Driscoll, J, Oxborough, D, Pearce, K, Robinson, S, Willis, J, Sharma, R, Tsiachristas, A & Leeson, P 2023, 'Real world hospital costs following stress echocardiography in the UK: a costing study from the EVAREST/BSE-NSTEP multi-entre study', Echo Research and Practice, vol. 10, no. 1, 8, pp. 8. https://doi.org/10.1186/s44156-023-00020-1

TY - JOUR

T1 - Real world hospital costs following stress echocardiography in the UK

T2 - a costing study from the EVAREST/BSE-NSTEP multi-entre study

AU - EVAREST/BSE-NSTEP Investigators

AU - Johnson, Casey L

AU - Woodward, William

AU - McCourt, Annabelle

AU - Dockerill, Cameron

AU - Krasner, Samuel

AU - Monaghan, Mark

AU - Senior, Roxy

AU - Augustine, Daniel X

AU - Paton, Maria

AU - O'Driscoll, Jamie

AU - Oxborough, David

AU - Pearce, Keith

AU - Robinson, Shaun

AU - Willis, James

AU - Sharma, Rajan

AU - Tsiachristas, Apostolos

AU - Leeson, Paul

N1 - Funding Information: The authors would like to express gratitude to the funders of this study. Additionally, the authors would like to thank all EVAREST/BSE-NSTEP investigators as well as participating patients without whom this work would not be possible. EVAREST/BSE-NSTEP Investigators: Paul Leeson1, Roxy Senior3, Jacob Easaw4, Daniel X. Augustine4, Keith Pearce8, Rajan Sharma10, Abraheem Abraheem13, Sanjay Banypersad14, Christopher Boos15, Sudantha Bulugahapitiya16, Jeremy Butts17, Duncan Coles18, Thuraia Nageh18, Haytham Hamdan19, Ayyaz Sultan19, Shahnaz Jamil-Copley20, Gajen Kanaganayagam21, Tom Mwambingu22, Antonis Pantazis23, Alexandros Papachristidis24, Ronak Rajani25, Muhammad Amer Rasheed26, Naveed A. Razvi27, Sushma Rekhraj20, David P. Ripley28, Kathleen Rose29, Michaela Scheuermann-Freestone30, Rebecca Schofield31, Spyridon Zidros32, Kenneth Wong33, Sarah Fairbarin34, Badrinathan Chandrasekaran35, Maria Paton36, Patrick Gibson37, Attila Kardos38, Henry Boardman38, Joanna d’Arcy38, Katrin Balkhausen39, Ioannis Moukas40, Joban S. Sehmi41, Soroosh Firoozan4213Tameside and Glossop Integrated Care NHS Foundation Trust, Ashton-under-Lyne, UK.14East Lancashire Hospitals NHS Trust, Burnley, UK.15Poole Hospital NHS Foundation Trust, Poole, UK.16Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK.17Calderdale and Huddersfield NHS Foundation Trust, Calderdale, UK.18Mid and South Essex NHS Foundation Trust, UK.19Wrightington, Wigan and Leigh NHS Foundation Trust, UK.20Nottingham University Hospitals NHS Trust, UK.21Chelsea and Westminster Hospital NHS Foundation Trust, UK.22The Mid Yorkshire Hospitals NHS Trust, UK.23North Middlesex University Hospital NHS Trust, UK.24King's College Hospital NHS Foundation Trust, UK.25Guy’s and St Thomas’ NHS Foundation Trust, UK.26Yeovil District Hospital NHS Foundation Trust, UK.27East Suffolk and North Essex NHS Foundation Trust, UK.28Northumbria Healthcare NHS Foundation Trust, UK.29Northampton General Hospital NHS Trust, UK.30Hampshire Hospitals NHS Foundation Trust, UK.31North West Anglia NHS Foundation Trust, UK.32Bedford Hospital NHS Trust, UK.33Blackpool Teaching Hospitals NHS Foundation Trust, UK.34University Hospitals Bristol and Weston NHS Foundation Trust, UK.35Great Western Hospitals NHS Foundation Trust, UK.36Leeds Teaching Hospitals NHS Trust, UK.37NHS Lothian, UK.38Milton Keynes University Hospital NHS Foundation Trust, UK.39Royal Berkshire NHS Foundation Trust, UK.40Warrington and Halton Teaching Hospitals NHS Foundation Trust, UK.41West Hertfordshire Hospitals NHS Trust, UK.42Buckinghamshire Healthcare NHS Trust, UK. Funding Information: This work was supported by National Institute for Health Research Health Education England Healthcare Science Research Fellowship [NIHR-HCS-P13-04–001]; Cardiovascular Clinical Research Facility, University of Oxford; Ultromics Ltd.; Lantheus Medical Imaging Inc. and National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford. The funders of the study had no role in study design, data collection, analysis, interpretation, or writing of the report. Publisher Copyright: © 2023, The Author(s).

PY - 2023/12

Y1 - 2023/12

N2 - BACKGROUND: Stress echocardiography is widely used to detect coronary artery disease, but little evidence on downstream hospital costs in real-world practice is available. We examined how stress echocardiography accuracy and downstream hospital costs vary across NHS hospitals and identified key factors that affect costs to help inform future clinical planning and guidelines.METHODS: Data on 7636 patients recruited from 31 NHS hospitals within the UK between 2014 and 2020 as part of EVAREST/BSE-NSTEP clinical study, were used. Data included all diagnostic tests, procedures, and hospital admissions for 12 months after a stress echocardiogram and were costed using the NHS national unit costs. A decision tree was built to illustrate the clinical pathway and estimate average downstream hospital costs. Multi-level regression analysis was performed to identify variation in accuracy and costs at both patient, procedural, and hospital level. Linear regression and extrapolation were used to estimate annual hospital cost-savings associated with increasing predictive accuracy at hospital and national level.RESULTS: Stress echocardiography accuracy varied with patient, hospital and operator characteristics. Hypertension, presence of wall motion abnormalities and higher number of hospital cardiology outpatient attendances annually reduced accuracy, adjusted odds ratio of 0.78 (95% CI 0.65 to 0.93), 0.27 (95% CI 0.15 to 0.48), 0.99 (95% CI 0.98 to 0.99) respectively, whereas a prior myocardial infarction, angiotensin receptor blocker medication, and greater operator experience increased accuracy, adjusted odds ratio of 1.77 (95% CI 1.34 to 2.33), 1.64 (95% CI 1.22 to 2.22), and 1.06 (95% CI 1.02 to 1.09) respectively. Average downstream costs were £646 per patient (SD 1796) with significant variation across hospitals. The average downstream costs between the 31 hospitals varied from £384-1730 per patient. False positive and false negative tests were associated with average downstream costs of £1446 (SD £601) and £4192 (SD 3332) respectively, driven by increased non-elective hospital admissions, adjusted odds ratio 2.48 (95% CI 1.08 to 5.66), 21.06 (95% CI 10.41 to 42.59) respectively. We estimated that an increase in accuracy by 1 percentage point could save the NHS in the UK £3.2 million annually.CONCLUSION: This study provides real-world evidence of downstream costs associated with stress echocardiography practice in the UK and estimates how improvements in accuracy could impact healthcare expenditure in the NHS. A real-world downstream costing approach could be adopted more widely in evaluation of imaging tests and interventions to reflect actual value for money and support realistic planning.

AB - BACKGROUND: Stress echocardiography is widely used to detect coronary artery disease, but little evidence on downstream hospital costs in real-world practice is available. We examined how stress echocardiography accuracy and downstream hospital costs vary across NHS hospitals and identified key factors that affect costs to help inform future clinical planning and guidelines.METHODS: Data on 7636 patients recruited from 31 NHS hospitals within the UK between 2014 and 2020 as part of EVAREST/BSE-NSTEP clinical study, were used. Data included all diagnostic tests, procedures, and hospital admissions for 12 months after a stress echocardiogram and were costed using the NHS national unit costs. A decision tree was built to illustrate the clinical pathway and estimate average downstream hospital costs. Multi-level regression analysis was performed to identify variation in accuracy and costs at both patient, procedural, and hospital level. Linear regression and extrapolation were used to estimate annual hospital cost-savings associated with increasing predictive accuracy at hospital and national level.RESULTS: Stress echocardiography accuracy varied with patient, hospital and operator characteristics. Hypertension, presence of wall motion abnormalities and higher number of hospital cardiology outpatient attendances annually reduced accuracy, adjusted odds ratio of 0.78 (95% CI 0.65 to 0.93), 0.27 (95% CI 0.15 to 0.48), 0.99 (95% CI 0.98 to 0.99) respectively, whereas a prior myocardial infarction, angiotensin receptor blocker medication, and greater operator experience increased accuracy, adjusted odds ratio of 1.77 (95% CI 1.34 to 2.33), 1.64 (95% CI 1.22 to 2.22), and 1.06 (95% CI 1.02 to 1.09) respectively. Average downstream costs were £646 per patient (SD 1796) with significant variation across hospitals. The average downstream costs between the 31 hospitals varied from £384-1730 per patient. False positive and false negative tests were associated with average downstream costs of £1446 (SD £601) and £4192 (SD 3332) respectively, driven by increased non-elective hospital admissions, adjusted odds ratio 2.48 (95% CI 1.08 to 5.66), 21.06 (95% CI 10.41 to 42.59) respectively. We estimated that an increase in accuracy by 1 percentage point could save the NHS in the UK £3.2 million annually.CONCLUSION: This study provides real-world evidence of downstream costs associated with stress echocardiography practice in the UK and estimates how improvements in accuracy could impact healthcare expenditure in the NHS. A real-world downstream costing approach could be adopted more widely in evaluation of imaging tests and interventions to reflect actual value for money and support realistic planning.

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U2 - 10.1186/s44156-023-00020-1

DO - 10.1186/s44156-023-00020-1

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C2 - 37254216

SN - 2055-0464

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JO - Echo Research and Practice

JF - Echo Research and Practice

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M1 - 8

ER -

Real world hospital costs following stress echocardiography in the UK: a costing study from the EVAREST/BSE-NSTEP multi-entre study

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