location: nan, 'Thailand 
year: 2009 source: HSRI 
title: การศึกษาผลลัพธ์ทางคลินิก คุณภาพชีวิต และต้นทุน – ประสิทธิผลของการผ่าตัดหัวใจแบบเปิดในโครงการบริหารจัดการโรค สำนักงานหลักประกันสุขภาพแห่งชาติ 
abstract:The disease management program of open heart surgery in Northeast of Thailand was the co-operation of National Health Security Office, Ministry of Public Health and Khon Kaen University. The program was aimed to promote the equality of accessibility for patients under the Universal Coverage Health Scheme who waited for an open heart surgery treatment. Four hospitals providing open heart surgery in this program were Queen Sirikit Heart Center of the Northeast, Khon Kaen, Sringarind Hospital, Khon Kaen, Sappasitthiprasong Hospital, Ubonratchathani, and Maharat Nakhon Ratchasima Hospital, Nakhon Ratchasima. The quality of care is an important factor that would result in the lower rate of mortality and complications, and the higher quality of life. This study was conducted to evaluate clinical outcomes, quality of life, and cost-effectiveness of the disease management program. This report was divided into three chapters: chapter I, clinical outcomes; chapter II, quality of life; and chapter III, cost-effectiveness of the disease management program. 
The mortality rate of 302 patients who undergone the open heart surgery was 6%. The mortality rates differed by types of surgery that the rates of CABG, valve, congenital heart disease, and more than one types of surgery were 3.6%, 6.9%, 1.7%, and 14.3%, respectively. The 28-day hospital re-admission rate in this study was 8.5%. The complication rate was 34%, and the common complications were arrhythmia (12.6%) and wound infection (12.3%). The significant factor associated with the overall mortality of open heart surgery was fever condition (> 39°C) when patients were in ICU/CCU (Hazard Ratio = 5.2, 95% CI 1.4 – 20.1). 
The study assessed quality of life of 225 patients in terms of physical activity using DASI, physical health and mental health using 9-THAI, cognitive function using RAND, chest pain after coronary artery bypass graft using SAQ, depression using CES-D, and overall quality of life using EQ-5D VAS. Patients were assessed their quality of life at baseline, 3 and 5 months after the operation. The patients under the disease management program had a significant improvement in physical activities, physical health and mental health, depression, cognitive function, chest pain for CABG patients and overall HRQoL at 3 and 5 months after open heart surgery. 
The cost effectiveness for open heart surgery in disease management program was compared with usual care. This study analyzed the cost effectiveness for two types of surgery including coronary bypass grafting (CABG) in the 60 years old patient and surgery for patients with valvular heart disease in 40 years old patients. Decision Analysis Model was used to calculate life expectancy, quality-adjusted- life- expectancy (QALY), lifetime cost and incremental cost-effectiveness ratio (ICER). Compared to usual care, CABG under the disease management program improved life expectancy and QALY, and was more costly. Life expectancy were 9.83 and 9.36 years which were equivalent to 6.29 and 5.82 QALYs for disease management program and usual care, respectively. An ICER of the disease management program as compared with that of the usual care was 17,276 Baht per QALY. For surgery in VHD, compared with the usual care, the disease management program also improved life expectancy and QALY, and was more costly. Life expectancy were 13.17 and 11.54 years which were equivalent to 11.54 and 7.35 QALYs for the disease management program and usual care, respectively. An ICER of the disease management program as compared with that of the usual care was 5,904 Baht per QALY. A cost effectiveness acceptability curve, based on Monte Carlo simulation suggests that at a willingness to pay threshold of more than 15,000 Baht per QALY, more than 50% of CABG in the disease management program will be cost effective. For the surgery for VHD, at a willingness to pay threshold of more than 10,000 Baht per QALY, more than 50% of surgery for VHD under the disease management program will be cost effective. Based on the WHO cost-effectiveness threshold, open heart surgery under the disease management program is considered the cost-effectiveness management when compared to the usual care.