Long‐term Cost‐Effectiveness of Diagnostic Tests for Assessing Stable Chest Pain: Modeled Analysis of Anatomical and Functional Strategies

Abstract

Several tests exist for diagnosing coronary artery disease, with varying accuracy and cost. We sought to provide cost-effectiveness information to aid physicians and decision-makers in selecting the most appropriate testing strategy. We used the state-transitions (Markov) model from the Brazilian public health system perspective with a lifetime horizon. Diagnostic strategies were based on exercise electrocardiography (Ex-ECG), stress echocardiography (ECHO), single-photon emission computed tomography (SPECT), computed tomography coronary angiography (CTA), or stress cardiac magnetic resonance imaging (C-MRI) as the initial test. Systematic review provided input data for test accuracy and long-term prognosis. Cost data were derived from the Brazilian public health system. Diagnostic test strategy had a small but measurable impact in quality-adjusted life-years gained. Switching from Ex-ECG to CTA-based strategies improved outcomes at an incremental cost-effectiveness ratio of 3100 international dollars per quality-adjusted life-year. ECHO-based strategies resulted in cost and effectiveness almost identical to CTA, and SPECT-based strategies were dominated because of their much higher cost. Strategies based on stress C-MRI were most effective, but the incremental cost-effectiveness ratio vs CTA was higher than the proposed willingness-to-pay threshold. Invasive strategies were dominant in the high pretest probability setting. Sensitivity analysis showed that results were sensitive to costs of CTA, ECHO, and C-MRI. Coronary CT is cost-effective for the diagnosis of coronary artery disease and should be included in the Brazilian public health system. Stress ECHO has a similar performance and is an acceptable alternative for most patients, but invasive strategies should be reserved for patients at high risk.

Adoption of the Coronary Artery Disease-reporting and Data System: Reduced Downstream Testing and Cardiology Referral Rates in Patients with Non-obstructive Coronary Artery Disease

“…SCOT HEART notably did report higher rates of ICA and revascularization in the CCTA group initially, but overall rates were similar at five years. CCTA utilizing non-standardized reporting systems have been evaluated previously with prior analyses concluding that CCTA is likely a cost-effective alternative to functional testing [21]. In fact, an independent economic analysis performed for the NICE guidelines concluded that CCTA provided the lowest cost per correct diagnosis [10].…”

Cost-utility Analysis of Opportunistic and Systematic Diabetic Retinopathy Screening Strategies from the Perspective of the Brazilian Public Healthcare System

“…A variation of 10% in the discount rate was used as recommended by the Brazilian Economic Evaluation guideline [39]. A variation of 15% was adopted for the cost estimates based on the average variation used in other model-based economic evaluations performed in Brazil [45,46]. The 95% CI was used in the sensitivity analysis of utility values and RR of laser photocoagulation treatment (Table 1).…”

Can myocardial remodeling be a useful surrogate predictor of myocardial iron load? A 3D echocardiographic multicentric study

“…Screening of myocardial iron has long been relying on the costly CMR (cardiac magnetic resonance). The cost of CMR is at least five times equal to the cost of an echocardiographic study putting a real barrier toward optimization of iron screening and subsequent iron chelation techniques in patients with cardiac siderosis . This raises the need to validate new echocardiographic parameters of myocardial iron load in order to replace gradually the costly CMR.…”