Cardiac sarcoidosis is a disease of young adults. In most cases it presents with sudden death, arrhythmias, conduction disorders, heart failure or cardiomyopathy. The authors describe two cases of myocardial involvement by sarcoidosis that lead to death of the patients. Case one was a 26-year-old Indian man who was previously well and presented with sudden death. Autopsy showed nodules of sarcoid granuloma involving the heart, lungs and lymph nodes. Case two was a 47-year-old Indian lady who complained of reduced effort tolerance. Echocardiography showed that she had restrictive hypertrophic cardiomyopathy with heart failure. Seven months after initial presentation, she developed worsening of heart failure and died. Autopsy revealed involvement of the heart, lungs and liver by sarcoidosis.
Autopsy ; Cardiac sarcoidosis ; Sarcoidosis ; Heart failure, NOS ; seconds

BACKGROUND

Coronary artery disease is the leading cause of death in the Philippines and can present as acute coronary syndrome. Hospitalization for ACS has epidemiologic and economic burden. In fact, last 2017, there were 1.52% or 152 admissions for every 10,000 hospitalized patients for medical conditions in PhilHealth-accredited hospitals locally. However, coronary angioplasty was performed in only less than 1% of these cases mainly because of its cost and the out-of-pocket expense that the treatment entail, when primary percutaneous intervention has been proven to be effective in reducing mortality in STEMI and early invasive intervention performed during index hospitalization for NSTEMI is likewise recommended. Moreover, there is a big disparity between the current case rates for ACS for medical therapy alone and for invasive intervention compared to the actual ACS hospitalization cost.

1) To propose revisions to the current PhilHealth case rates for acute coronary syndrome (ACS); and 2) To determine the budget impact of the proposed ACS case rates.

The Philippine Heart Association with the assistance of a technical working group undertook the study. A panel of experts composed of general and invasive cardiologists from Luzon, Visayas, and Mindanao was formed. The ACS hospitalization costs based on the recent study by Mendoza were presented and discussed during the focus group discussions with the panelists. Issues pertinent to their localities that may affect the costs were discussed. The proposed revised costs on the particular ACS conditions and therapeutic regimens were then voted and agreed upon. A budget impact analysis of the proposed case rates was then performed.

The proposed case rates for ACS ranged from Php 80,000 (for low risk unstable angina given medical treatment) to Php 530,000 (for ST-elevation myocardial infarction initially given a thrombolytic agent then underwent PCI which necessitated the use of three stents). The budget impact analysis showed that the proposed ACS rates would require an additional PHP 1.5 billion to 2.3 billion during the first year of a 3- versus 5-year implementation period, respectively. The period of implementation will be affected by budgetary constraints as well as the availability of cardiac catheterization facilities in the country.

The proposed revised PhilHealth hospitalization coverage for ACS is more reflective or realistic of the ACS hospitalization costs in contrast with the current PhilHealth case rates. The corresponding budget impact analysis of these proposed case rates showed that PHP 7.6 billion is needed for full implementation. However, given the budget constraints, the percentage of the total costs for the first and subsequent years of implementation may be modified.

BACKGROUND

Hospitalization for acute coronary syndrome (ACS) has epidemiologic and economic burden. The coverage for hospitalization in the local setting is much less than the actual costs. Many patients do not consent to or avail of the optimal and timely management because of financial challenges.

The paper aimed to propose revised PhilHealth case rates/packages for ACS, namely: 1) unstable angina (UA), 2) non-ST-elevation myocardial infarction (NSTEMI), and 3) STelevation myocardial infarction (STEMI).

A consensus panel was organized to provide inputs such as cost and other matters pertaining to the revision of the PhilHealth ACS case rates/packages. The results of the cost of hospitalization of the different ACS conditions derived from a study on hospitalization cost for ACS were presented to the panel. Several focused group discussions were held afterward for propositioning new case rates through votation and by nominal group technique, using the costs from the study as the bases of rate adjustment.

Final costs agreed upon by the consensus panel for medical management alone for UA, NSTEMI, and STEMI were adjusted or amended in increments of Php 20,000, (80,000, 100,000, and 120,000, respectively). Thrombolysis of a patient admitted for STEMI increased the cost to Php 140,000. An additional cost of Php 150,000 was added on top of the cost for medical management and coronary angiogram for NSTE- ACS for PCI with use of a single stent. For STEMI, the same category had an additional cost of Php 180,000. For each additional stent used for all clinical scenarios undergoing PCI, Php 65,000 was added, to cover up to a total of 3 stents.

Based on the consensus process with Philippine Heart Association ACS panelists, the cost proposed ranges from 80,000 pesos to 530,000 pesos depending on the clinical scenarios.

OBJECTIVE

This study aimed to determine the budget impact of the proposed revised PhilHealth case rate packages for acute coronary syndrome (ACS).

This budget impact analysis used the static approach or cost calculator modeling method. The prevalence of hospitalization for coronary artery disease in all PhilHealth-accredited hospitals in the country in 2017 and the data from the ACS registry project of the Philippine Heart Association were used in this study. The study multiplied the present PhilHealth coverage with the number of ACS hospitalization claims to come up with the total cost of ACS hospitalization in the next three years with the assumptions that the eligible population and the ACS PhilHealth case rates will remain constant for these years. The future ACS hospitalization costs were also determined if the proposed case rates were used rather than the current PhilHealth case rates. The cost of re-admissions was considered as savings in hospitalization cost (due to prevention of admissions if the appropriate interventions were given) and were deducted from the future total cost of ACS hospitalizations.

The annual total ACS hospitalization cost using the current case rates was Php 1,134,683,000. Using the proposed case rates, the total hospitalization costs over five years was Php 2,653,019,000 in the first year (proposed case rates implemented to only 20% of the ACS patients) and increased to Php 8,726,364,000 by year 5 (full implementation of the proposed case rates or to 100% of ACS patients). This resulted in a lower incremental cost in the first year of implementation compared with a less gradual implementation over 3 years. The total incremental costs would amount to PHP7.6 billion for full implementation.

The study provided the budget impact of the proposed revised ACS case rates. The incremental cost is relatively huge, however the benefits of providing coverage of guidelinedirected therapy including invasive strategies for ACS must be considered.