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Nonparametric Bayesian Instrumental Variable Analysis: Evaluating Heterogeneous Effects of Coronary Arterial Access
Samrachana Adhikari1, Sherri Rose2, Sharon-Lise Normand2,3
1Department of Population Health, New York University School of Medicine.
Insights
Percutaneous coronary interventions (PCIs) using wrist artery access reduce hospitalization costs compared to groin access. This approach offers greater cost savings for male patients undergoing PCI procedures.
Area of Science:
- Cardiovascular Medicine
- Health Economics
- Biostatistics
Background:
- Percutaneous coronary interventions (PCIs) are common nonsurgical treatments for blocked heart arteries.
- Arterial access for PCI is typically achieved via the groin or wrist.
- Wrist access is encouraged due to potential benefits in reduced complications, shorter hospital stays, and lower costs.
Purpose of the Study:
- To evaluate the effectiveness of wrist versus groin artery access on hospitalization charges in patients undergoing PCI.
- To investigate potential differences in effectiveness between males and females.
- To address unmeasured factors influencing access site selection.
Main Methods:
- Utilized data from a state-mandated clinical registry of 7,963 patients undergoing PCI.
- Employed a hierarchical Bayesian likelihood-based instrumental variable analysis.
- Incorporated a latent index modeling framework to jointly model outcomes and treatment status, accounting for unobserved heterogeneity and using Dirichlet process mixture models for nonparametric error distributions.
Main Results:
- Wrist artery access was found to reduce hospitalization charges compared to groin access.
- A higher mean reduction in hospitalization charges was observed for male patients utilizing wrist access.
- The study accounted for unobserved patient and physician factors influencing access site choice.
Conclusions:
- Wrist artery access is a cost-effective strategy for PCI compared to groin access.
- Sex-specific differences in cost savings exist, with males benefiting more from wrist access.
- Advanced statistical methods confirmed the benefits of wrist access while controlling for confounding factors.
Abstract:
Percutaneous coronary interventions (PCIs) are nonsurgical procedures to open blocked blood vessels to the heart, frequently using a catheter to place a stent. The catheter can be inserted into the blood vessels using an artery in the groin or an artery in the wrist. Because clinical trials have indicated that access via the wrist may result in fewer post procedure complications, shortening the length of stay, and ultimately cost less than groin access, adoption of access via the wrist has been encouraged. However, patients treated in usual care are likely to differ from those participating in clinical trials, and there is reason to believe that the effectiveness of wrist access may differ between males and females. Moreover, the choice of artery access strategy is likely to be influenced by patient or physician unmeasured factors. To study the effectiveness of the two artery access site strategies on hospitalization charges, we use data from a state-mandated clinical registry including 7,963 patients undergoing PCI. A hierarchical Bayesian likelihood-based instrumental variable analysis under a latent index modeling framework is introduced to jointly model outcomes and treatment status. Our approach accounts for unobserved heterogeneity via a latent factor structure, and permits nonparametric error distributions with Dirichlet process mixture models. Our results demonstrate that artery access in the wrist reduces hospitalization charges compared to access in the groin, with a higher mean reduction for male patients.
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