 |
 |
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4 May 1999 | Volume 130 Issue 9 | Pages 719-728
Background: The appropriate roles for several diagnostic tests for coronary disease are uncertain.
Objective: To evaluate the cost-effectiveness of alternative approaches to diagnosis of coronary disease.
Design: Meta-analysis of the accuracy of alternative diagnostic tests plus decision analysis to assess the health outcomes and costs of alternative diagnostic strategies for patients at intermediate pretest risk for coronary disease.
Data Sources: Studies of test accuracy that met inclusion criteria; published information on treatment effectiveness and disease prevalence.
Target Population: Men and women 45, 55, and 65 years of age with a 25% to 75% pretest risk for coronary disease.
Time Horizon: 30 years.
Perspective: Societal.
Interventions: Diagnostic strategies were initial angiography and initial testing with one of five noninvasive tests—exercise treadmill testing, planar thallium imaging, single-photon emission computed tomography (SPECT), stress echocardiography, and positron emission tomography (PET)—followed by coronary angiography if noninvasive test results were positive. Testing was followed by observation, medical treatment, or revascularization.
Outcome Measures: Life-years, quality-adjusted life-years (QALYs), costs, and costs per QALY.
Results of Base-Case Analysis: Life expectancy varied little with the initial diagnostic test; for a 55-year-old man, the best-performing test increased life expectancy by 7 more days than the worst-performing test. More sensitive tests increased QALYs more. Echocardiography improved health outcomes and reduced costs relative to stress testing and planar thallium imaging. The incremental cost-effectiveness ratio was $75 000/QALY for SPECT relative to echocardiography and was greater than $640 000 for PET relative to SPECT. Compared with SPECT, immediate angiography had an incremental cost-effectiveness ratio of $94 000/QALY.
Results of Sensitivity Analysis: Qualitative findings varied little with age, sex, pretest probability of disease, or the test indeterminacy rate. Results varied most with sensitivity to severe coronary disease.
Conclusions: Echocardiography, SPECT, and immediate angiography are cost-effective alternatives to PET and other diagnostic approaches. Test selection should reflect local variation in test accuracy.
Author and Article Information
From Veterans Affairs Palo Alto Health Care System, and Stanford University, Stanford, California; and Kaiser Permanente, Oakland, California.
Grant Support: This research grew out of a project supported by the Blue Cross and Blue Shield Association. Dr. Garber was a Health Services Research and Development Senior Research Associate of the Department of Veterans Affairs and Dr. Solomon was a Veterans Affairs-Robert Wood Johnson Clinical Scholar when much of the work was performed. Opinions expressed here are not necessarily those of the Blue Cross and Blue Shield Association, the Department of Veterans Affairs, or Kaiser Permanente.
Acknowledgments: The authors thank Douglas K. Owens, MD, MSc; David M. Eddy, MD, PhD; Earl P. Steinberg, MD, MPP; and Mark A. Hlatky, MD, for their comments and suggestions and Ann Hwang, Jin Yang, and Nikhil Chanani for helpful research assistance.
Requests for Reprints: Alan M. Garber, MD, PhD, Center for Primary Care and Outcomes Research, Stanford University School of Medicine, 30 Alta Road, Stanford, CA 94305-8006.
Current Author Addresses: Dr. Garber: Veterans Affairs Palo Alto Health Care System and Stanford University School of Medicine, 30 Alta Road, Stanford, CA 94305-8006.
Dr. Solomon: Care Management Institute, Kaiser Permanente, 1 Kaiser Plaza, 16th Floor, Oakland, CA 94612. ARTICLE
Cost-Effectiveness of Alternative Test Strategies for the Diagnosis of Coronary Artery Disease
Related articles in Annals:
This article has been cited by other articles:
|
|
 |
|
  J. A. Ladapo, U. Hoffmann, F. Bamberg, J. T. Nagurney, D. M. Cutler, M. C. Weinstein, and G. S. Gazelle Cost-Effectiveness of Coronary MDCT in the Triage of Patients with Acute Chest Pain Am. J. Roentgenol., August 1, 2008; 191(2): 455 - 463. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P. Y. Hsue, K. Squires, A. F. Bolger, B. Capili, G. A. Mensah, Z. Temesgen, C. A. Wanke, D. A. Wohl, and for Working Group 4 Screening and Assessment of Coronary Heart Disease in HIV-Infected Patients Circulation, July 8, 2008; 118(2): e41 - e47. [Full Text] [PDF]
|
|
|
|
 |
|
 R. Hernandez and L. Vale The Value of Myocardial Perfusion Scintigraphy in the Diagnosis and Management of Angina and Myocardial Infarction: A Probabilistic Economic Analysis Med Decis Making, December 1, 2007; 27(6): 772 - 788. [Abstract] [PDF]
|
|
|
|
 |
|
 J. L. Anderson, C. D. Adams, E. M. Antman, C. R. Bridges, R. M. Califf, D. E. Casey Jr, W. E. Chavey II, F. M. Fesmire, J. S. Hochman, T. N. Levin, et al. ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) Developed in Collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine J. Am. Coll. Cardiol., August 14, 2007; 50(7): e1 - e157. [Full Text] [PDF]
|
|
|
|
 |
|
 L. J. Shaw, T. H. Marwick, D. S. Berman, S. Sawada, G. V. Heller, C. Vasey, and D. D. Miller Incremental cost-effectiveness of exercise echocardiography vs. SPECT imaging for the evaluation of stable chest pain Eur. Heart J., October 2, 2006; 27(20): 2448 - 2458. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. A. Geluk and F. Zijlstra Gatekeeper for coronary angiography Eur. Heart J., May 1, 2006; 27(9): 1127 - 1128. [Full Text] [PDF]
|
|
|
|
 |
|
 T. Funk, D. L. Kirch, J. E. Koss, E. Botvinick, and B. H. Hasegawa A Novel Approach to Multipinhole SPECT for Myocardial Perfusion Imaging J. Nucl. Med., April 1, 2006; 47(4): 595 - 602. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. Pisu, N. James, S. Sampsel, and K. G. Saag The cost of glucocorticoid-associated adverse events in rheumatoid arthritis Rheumatology, June 1, 2005; 44(6): 781 - 788. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S R Underwood and L J Shaw Myocardial perfusion scintigraphy and cost effectiveness of diagnosis and management of coronary heart disease Heart, August 1, 2004; 90(suppl_5): v34 - v36. [Full Text] [PDF]
|
|
|
|
|
|
L. J. Shaw, J. F. Lewis, M. A. Hlatky, W. A. Hsueh, S. F. Kelsey, R. Klein, T. A. Manolio, A. R. Sharrett, R. P. Tracy, and Endorsed by the American College of Cardiology Fou Women's Ischemic Syndrome Evaluation: Current Status and Future Research Directions: Report of the National Heart, Lung and Blood Institute Workshop: October 2-4, 2002: Section 5: Gender-Related Risk Factors for Ischemic Heart Disease Circulation, February 17, 2004; 109 (6): e56 - e58. [Full Text] [PDF]
|
|
|
|
|
|
D. B. Mark, L. J. Shaw, M. S. Lauer, P. G. O'Malley, and P. Heidenreich Task force #5--is atherosclerosis imaging cost effective? J. Am. Coll. Cardiol., June 4, 2003; 41(11): 1906 - 1917. [Full Text] [PDF]
|
|
|
|
 |
|
 M N Maisey Overview of clinical PET Br. J. Radiol., November 1, 2002; 75(90009): S1 - 5. [Full Text] [PDF]
|
|
|
|
 |
|
 S. V. Williams, S. D. Fihn, and R. J. Gibbons Guidelines for the Management of Patients with Chronic Stable Angina: Diagnosis and Risk Stratification Ann Intern Med, October 2, 2001; 135(7): 530 - 547. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 T. H. Lee and C. A. Boucher Noninvasive Tests in Patients with Stable Coronary Artery Disease N. Engl. J. Med., June 14, 2001; 344(24): 1840 - 1845. [Full Text] [PDF]
|
|
|
|
|
|
E. Braunwald, E. M. Antman, J. W. Beasley, R. M. Califf, M. D. Cheitlin, J. S. Hochman, R. H. Jones, D. Kereiakes, J. Kupersmith, T. N. Levin, et al. ACC/AHA guidelines for the management of patients with unstable angina and non-st-segment elevation myocardial infarction: A report of the american college of cardiology/ american heart association task force on practice guidelines (committee on the management of patients with unstable angina) J. Am. Coll. Cardiol., September 1, 2000; 36(3): 970 - 1062. [Full Text] [PDF]
|
|
|
|
|
|
T. H. Lee and L. Goldman Evaluation of the Patient with Acute Chest Pain N. Engl. J. Med., April 20, 2000; 342(16): 1187 - 1195. [Full Text] [PDF]
|
|
|
|
 |
|
 J. F. Polak MR Coronary Angiography: Are We There Yet? Radiology, March 1, 2000; 214(3): 649 - 650. [Full Text]
|
|
|
|
|
|
L. Broemeling and C.H. Mielke Jr. Tests for Coronary Artery Disease Ann Intern Med, December 21, 1999; 131(12): 980 - 980. [Full Text] [PDF]
|
|
|
|
|
|
T. H. Lee Reducing Cardiac Risk in Noncardiac Surgery N. Engl. J. Med., December 9, 1999; 341(24): 1838 - 1840. [Full Text]
|
|
|
|
 |
|
 A. L Hersh, W. C Black, and A. N. Tosteson Estimating the population impact of an intervention: a decision-analytic approach Statistical Methods in Medical Research, August 1, 1999; 8(4): 311 - 330. [Abstract] [PDF]
|
|
|
|
 |
|
 Cost-Effective Strategies for Evaluating Chest Pain Journal Watch Cardiology, June 11, 1999; 1999(611): 11 - 11. [Full Text]
|
|
Article
