Stress echocardiography in the district hospital setting: a cost-saving analysis

Wennike, Nic; Shah, Benoy N.; Boger, Emma; Senior, Roxy; Greaves, Kim

doi:10.1093/ejechocard/jep223

Cited by 8 publications

(7 citation statements)

References 24 publications

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“…CAD indicates coronary artery disease; cath, cardiac catheterization; ECHO, echocardiography; MI, myocardial infarction; MPI, myocardial perfusion imaging; NA, not available from article.*Jang et al, 35 Charvat et al, 39 and Hannoush et al 36 reported prior coronary artery bypass graft surgery only and did not report prior percutaneous coronary intervention.*Diamond et al 38 reported prevalence only in patients with normal exercise test result.*Wennike et al, 31 Charvat et al, 39 Koistinen et al, 25 and Roeters van Lennep et al 33 reported prevalence only in patients with abnormal exercise test result.…”

Section: Resultsmentioning

confidence: 99%

Clinical Implications of Referral Bias in the Diagnostic Performance of Exercise Testing for Coronary Artery Disease

Ladapo

Blecker

Elashoff

et al. 2013

JAHA

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BackgroundExercise testing with echocardiography or myocardial perfusion imaging is widely used to risk‐stratify patients with suspected coronary artery disease. However, reports of diagnostic performance rarely adjust for referral bias, and this practice may adversely influence patient care. Therefore, we evaluated the potential impact of referral bias on diagnostic effectiveness and clinical decision‐making.Methods and ResultsSearching PubMed and EMBASE (1990–2012), 2 investigators independently evaluated eligibility and abstracted data on study characteristics and referral patterns. Diagnostic performance reported in 4 previously published meta‐analyses of exercise echocardiography and myocardial perfusion imaging was adjusted using pooled referral rates and Bayesian methods. Twenty‐one studies reported referral patterns in 49 006 patients (mean age 60.7 years, 39.6% women, and 0.8% prior history of myocardial infarction). Catheterization referral rates after normal and abnormal exercise tests were 4.0% (95% CI, 2.9% to 5.0%) and 42.5% (36.2% to 48.9%), respectively, with odds ratio for referral after an abnormal test of 14.6 (10.7 to 19.9). After adjustment for referral, exercise echocardiography sensitivity fell from 84% (80% to 89%) to 34% (27% to 41%), and specificity rose from 77% (69% to 86%) to 99% (99% to 100%). Similarly, exercise myocardial perfusion imaging sensitivity fell from 85% (81% to 88%) to 38% (31% to 44%), and specificity rose from 69% (61% to 78%) to 99% (99% to 100%). Summary receiver operating curve analysis demonstrated only modest changes in overall discriminatory power but adjusting for referral increased positive‐predictive value and reduced negative‐predictive value.ConclusionsExercise echocardiography and myocardial perfusion imaging are considerably less sensitive and more specific for coronary artery disease after adjustment for referral. Given these findings, future work should assess the comparative ability of these and other tests to rule‐in versus rule‐out coronary artery disease.

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Section: Resultsmentioning

confidence: 99%

Clinical Implications of Referral Bias in the Diagnostic Performance of Exercise Testing for Coronary Artery Disease

Ladapo

Blecker

Elashoff

et al. 2013

JAHA

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“…The PTPs were not reported, or expressed as prevalence of CAD, in two publications [40,49]. A further study reported PTP as low to CCA n = 1 CCA [48] n = 1 CCA [40]* n = 0 n = 0 n= 0 n= 2 CCA [40,48] The cost-effectiveness of a screening strategy involving SPECT versus direct referral to ICA was evaluated in five studies with SPECT resulting to be costeffective in almost all these studies (four out of five) despite the different populations considered. SPECT was a cost-saving approach either in one study involving patients with high PTP (>85%) [25] and in a study involving patients with low PTP [37].…”

Section: Resultsmentioning

confidence: 94%

“…Two studies both undertaking a cost-consequence analysis were also found [40,48]. Of all CEAs, many were US based (9 of 31, 29%; see SUPPLEMENTARY TABLE S2) and a further 8 (26%) studies were UK based.…”

Section: Resultsmentioning

confidence: 99%

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The cost–effectiveness of diagnostic cardiac imaging for stable coronary artery disease

Turchetti

Kroes

Lorenzoni

et al. 2015

Expert Review of Pharmacoeconomics & Outcomes Research

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Early and accurate diagnosis of stable coronary artery disease (CAD) is crucial to reduce morbidity, mortality and healthcare costs. This critical appraisal of health-economic literature concerning non-invasive diagnostic cardiac imaging aims to summarize current approaches to economic evaluation of diagnostic cardiac imaging and associated procedural risks, inform cardiologists how to use economic analyses for decision-making, highlight areas where new information could strengthen the economic evaluation and shed light on cost-effective approaches to diagnose stable CAD. Economic analysis can support cardiologists' decision-making. Current economic evidence in the field does not provide sufficient information to guide the choice among different imaging modalities or strategies for each patient. Available economic analyses suggest that computed tomography coronary angiography (CTCA) is a cost-effective approach to rule out CAD prior to invasive coronary angiography in patients with low to intermediate pre-test probability of disease and that stress imaging modalities may be cost-effective at variable pre-test probabilities.

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“…As ever cost effectiveness is a major aspect of all work performed in the national health service and stress echocardiography has been shown to a very cost effective way of reducing the need for invasive angiography [15] and now it is clear that money saved is not likely to be wasted when there are late events in follow up.…”

Section: Discussionmentioning

confidence: 99%

Long Term Outcomes in Stress Echocardiography: Ten Year Follow up of a Cohort in a Single Centre

et al. 2012

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BackgroudThe high service burden for acute admissions and referrals via rapid access chest pain clinics for evaluation of possible coronary artery disease means that many patients are now undergoing an investigation such as stress echocardiography as part of their evaluation. We aimed to see if the reassurance provided by negative stress echocardiography correlates with long-term event free survival.MethodsA cohort of all patients who were referred at a single centre for stress echocardiography for diagnosis of coronary artery disease between January 1st 1999 and December 31st 2000 were followed up at least 10 years following theirs stress echocardiogram for further major cardiovascular events and mortality.ResultsA total of 64 patients were identified where records could be obtained for analysis. There were 16 positive scans, 37 negative scans and 11 inconclusive scans. The indeterminacy rate of scans was 17%, the sensitivity rate for detecting significant disease as indexed to invasive angiography was 88 % and the specificity rate compared with angiography was 75%. There were no myocardial infarctions or new diagnoses of heart failure in the negative echocardiogram group. There were seven deaths in the total population and only one death from cardiovascular causes in the negative echocardiogram group.ConclusionStress echocardiography even in this small group predicts long-term outcomes as well as invasive coronary angiography.

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Stress echocardiography in the district hospital setting: a cost-saving analysis

Abstract: Stress echocardiography is a cost saving method for the investigation of chest pain in patients with low-intermediate risk of flow limiting coronary artery disease in the district hospital setting.

Cited by 8 publications

References 24 publications

Clinical Implications of Referral Bias in the Diagnostic Performance of Exercise Testing for Coronary Artery Disease

Clinical Implications of Referral Bias in the Diagnostic Performance of Exercise Testing for Coronary Artery Disease

The cost–effectiveness of diagnostic cardiac imaging for stable coronary artery disease

Long Term Outcomes in Stress Echocardiography: Ten Year Follow up of a Cohort in a Single Centre

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