Cost-effectiveness of anatomical and functional test strategies for stable chest pain: public health perspective from a middle-income country. Issue 4 (4th May 2017)

• Record Type: Journal Article
• Authors: Bertoldi, Eduardo G; Stella, Steffen F; Rohde, Luis Eduardo P; Polanczyk, Carisi A
• Is Part Of: BMJ open. Volume 7:Issue 4(2017)
• Publication Date: 2017-05-04
• Subjects: cost-benefit analysis -- coronary disease -- diagnosis -- cardiovascular imaging; Medicine -- Research -- Periodicals; 610.72
• DOI: 10.1136/bmjopen-2016-012652
• Languages: English
• ISSNs: 2044-6055

Abstract

Abstract : Objectives: The aim of this research is to evaluate the relative cost-effectiveness of functional and anatomical strategies for diagnosing stable coronary artery disease (CAD), using exercise (Ex)-ECG, stress echocardiogram (ECHO), single-photon emission CT (SPECT), coronary CT angiography (CTA) or stress cardiacmagnetic resonance (C-MRI). Setting: Decision-analytical model, comparing strategies of sequential tests for evaluating patients with possible stable angina in low, intermediate and high pretest probability of CAD, from the perspective of a developing nation's public healthcare system. Participants: Hypothetical cohort of patients with pretest probability of CAD between 20% and 70%. Primary and secondary outcome measures: The primary outcome is cost per correct diagnosis of CAD. Proportion of false-positive or false-negative tests and number of unnecessary tests performed were also evaluated. Results: Strategies using Ex-ECG as initial test were the least costly alternatives but generated more frequent false-positive initial tests and false-negative final diagnosis. Strategies based on CTA or ECHO as initial test were the most attractive and resulted in similar cost-effectiveness ratios (I$ 286 and I$ 305 per correct diagnosis, respectively). A strategy based on C-MRI was highly effective for diagnosing stable CAD, but its high cost resulted in unfavourable incremental cost-effectiveness (ICER) in moderate-risk and high-risk scenarios. Non-invasive strategies based on SPECT have been dominated. Conclusions: An anatomical diagnostic strategy based on CTA is a cost-effective option for CAD diagnosis. Functional strategies performed equally well when based on ECHO. C-MRI yielded acceptable ICER only at low pretest probability, and SPECT was not cost-effective in our analysis.