Cost-Effectiveness of Diagnostic Strategies for Patients with Chest Pain

Cost-Effectiveness of Diagnostic Strategies for Patients with Chest Pain

From Brigham and Women's Hospital; Beth Israel Deaconess Medical Center, Harvard Medical School; and Harvard School of Public Health, Boston, Massachusetts; and the University of Groningen, Groningen, the Netherlands.

Abstract

Background: Many noninvasive tests exist to determine whether patients should undergo coronary angiography. The routine use of coronary angiography without previous noninvasive testing is typically not advocated.

Objective: To determine the cost-effectiveness of diagnostic strategies for patients with chest pain.

Design: Cost-effectiveness analysis.

Data Sources: Published data.

Target Population: Patients who present with chest pain, have no history of myocardial infarction, and are able to perform an exercise stress test.

Time Horizon: Lifetime.

Perspective: Societal.

Interventions: No testing, exercise electrocardiography, exercise echocardiography, exercise single-photon emission computed tomography (SPECT), and coronary angiography alone.

Outcome Measures: Quality-adjusted life expectancy, lifetime cost, and incremental cost-effectiveness.

Results of Base-Case Analysis: The incremental cost-effectiveness ratio of routine coronary angiography compared with exercise echocardiography was $36 400 per quality-adjusted life-year (QALY) saved for 55-year-old men with typical angina. For 55-year-old men with atypical angina, exercise echocardiography compared with exercise electrocardiography cost $41 900 per QALY saved. If adequate exercise echocardiography was not available, exercise SPECT cost $54 800 per QALY saved compared with exercise electrocardiography for these patients. For 55-year-old men with nonspecific chest pain, the incremental cost-effectiveness ratio of exercise electrocardiography compared with no testing was $57 700 per QALY saved.

Results of Sensitivity Analysis: On the basis of a probabilistic sensitivity analysis, there is a 75% chance that exercise echocardiography costs less than $50 900 per QALY saved for 55-year-old men with atypical angina.

Conclusions: Exercise electrocardiography or exercise echocardiography resulted in reasonable cost-effectiveness ratios for patients at mild to moderate risk for coronary artery disease in terms of age, sex, and type of chest pain. Coronary angiography without previous noninvasive testing resulted in reasonable cost-effectiveness ratios for patients with a high pretest probability of coronary artery disease.

Article and Author Information

Grant Support: By a project grant from the American Society of Echocardiography (Drs. Kuntz and Fleischmann); a Clinical Investigator Development Award (1K08Hl02964-01) from the National Heart, Lung, and Blood Institute (Dr. Fleischmann); and a PIONIER award from the Netherlands Organizations for Scientific Research (Dr. Hunink).
Requests for Reprints: Karen M. Kuntz, ScD, Center for Risk Analysis, Harvard School of Public Health, 718 Huntington Avenue, Boston, MA 02115-5924; e-mail, kmk{at}hsph.harvard.edu.
Current Author Addresses: Dr. Kuntz: Center for Risk Analysis, Harvard School of Public Health, 718 Huntington Avenue, Boston, MA 02115-5924.
Dr. Fleischmann: Division of Cardiology, University of California, San Francisco, Medical Center, 505 Parnassus Avenue, San Francisco, CA 94143-0214.
Dr. Hunink: Department of Radiology, Erasmus University Medical School, Room EE21-40a, P.O. Box 1738, 300 DR Rotterdam, The Netherlands.
Dr. Douglas: Cardiovascular Division, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215.