Cardiovascular magnetic resonance in emergency patients with multivessel disease or unobstructed coronary arteries: a cost-effectiveness analysis in the UK

Abstract

ObjectiveTo identify the key drivers of cost-effectiveness for cardiovascular magnetic resonance (CMR) when patients activate the primary percutaneous coronary intervention (PPCI) pathway.DesignEconomic decision models for two patient subgroups populated from secondary sources, each with a 1 year time horizon from the perspective of the National Health Service (NHS) and personal social services in the UK.SettingUsual care (with or without CMR) in the NHS.ParticipantsPatients who activated the PPCI pathway, and for Model 1: underwent an emergency coronary angiogram and PPCI, and were found to have multivessel coronary artery disease. For Model 2: underwent an emergency coronary angiogram and were found to have unobstructed coronary arteries.InterventionsModel 1 (multivessel disease) compared two different ischaemia testing methods, CMR or fractional flow reserve (FFR), versus stress echocardiography. Model 2 (unobstructed arteries) compared CMR with standard echocardiography versus standard echocardiography alone.Main outcome measuresKey drivers of cost-effectiveness for CMR, incremental costs and quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios.ResultsIn both models, the incremental costs and QALYs between CMR (or FFR, Model 1) versus no CMR (stress echocardiography, Model 1 and standard echocardiography, Model 2) were small (CMR: −£64 (95% CI −£232 to £187)/FFR: £360 (95% CI −£116 to £844) and CMR/FFR: 0.0012 QALYs (95% CI −0.0076 to 0.0093)) and (£98 (95% CI −£199 to £488) and 0.0005 QALYs (95% CI −0.0050 to 0.0077)), respectively. The diagnostic accuracy of the tests was the key driver of cost-effectiveness for both patient groups.ConclusionsIf CMR were introduced for all subgroups of patients who activate the PPCI pathway, it is likely that diagnostic accuracy would be a key determinant of its cost-effectiveness. Further research is needed to definitively answer whether revascularisation guided by CMR or FFR leads to different clinical outcomes in acute coronary syndrome patients with multivessel disease.

The Merits, Limitations, and Future Directions of Cost-Effectiveness Analysis in Cardiac MRI with a Focus on Coronary Artery Disease: A Literature Review

“…The diagnostic accuracy of CMR for cardiac diseases drives its cost-effectiveness. One study aimed to identify key determinants for the cost-effectiveness of CMR in the United Kingdom in patients with multivessel CAD and unobstructive coronary arteries [ 25 ]. The patients were divided into two models of multivessel CAD and unobstructed coronary arteries using an index angiogram and underwent initial percutaneous coronary intervention.…”

A national registry to assess the value of cardiovascular magnetic resonance imaging after primary percutaneous coronary intervention pathway activation: a feasibility cohort study

“…c For further information on how estimates of sensitivity and specificity for standard ECHO were obtained, please see the final paragraph in Probabilities for the normal coronaries model. Reproduced with permission from Stokes et al 36 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.…”

“…According to Davies et al 45 58% of strokes are disabling; this percentage was used to weigh the two continuing care costs for stroke. Additional costs to 1 year associated with MACE were calculated by weighting estimates of the annual costs of MI and stroke by the number of patients with these complications across the number of patients with MACE, from Pathik et al 52 Reproduced with permission from Stokes et al 36…”

“…See: https://creativecommons.org/licenses/by/4.0/. plot of the 1000 simulated cost and QALY differences from the PSA for CMR vs. stress ECHO.Reproduced with permission from Stokes et al36 © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY.…”

“…d These probabilities are not required in the base-case analysis (since the probability in the preceding branch is zero), but are included here as they are required in sensitivity analyses. Reproduced with permission from Stokes et al36 © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY.…”