Noninvasive Imaging for the Diagnosis of Coronary Artery Disease: Focusing the Development of New Diagnostic Technology

Noninvasive Imaging for the Diagnosis of Coronary Artery Disease: Focusing the Development of New Diagnostic Technology

From Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands; Harvard School of Public Health, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts; and University of California, San Francisco, School of Medicine, San Francisco, California.

Abstract

Background: New tests, such as magnetic resonance imaging (MRI) and electron-beam computed tomography (CT), are being developed for the diagnosis of coronary artery disease.

Objective: To determine the conditions that a new test must meet to be a cost-effective alternative to established imaging tests.

Design: Decision model and cost-effectiveness analysis.

Data Sources: Literature review and meta-analysis.

Target Population: 55-year-old men and 65-year-old women presenting with chest pain.

Time Horizon: Lifetime of the patient.

Perspective: Health care policy.

Interventions: MRI, electron-beam CT, exercise echocardiography, exercise single-photon emission CT, and coronary angiography.

Outcome Measures: Target sensitivity and specificity values for a new noninvasive test.

Results of Base-Case Analysis: Assuming that society is willing to pay $75 000 per quality-adjusted life-year (QALY) gained, a new test that costs $1000 would need a sensitivity of 94% and a specificity of 90% to be cost-effective.

Results of Sensitivity Analysis: Assuming that society is willing to pay $50 000 per QALY gained, a new test that costs $1000 or more would never be cost-effective. For a test that costs $500, the sensitivity and specificity must each be 95%.

Conclusions: New imaging techniques, such as MRI and electron-beam CT, must be relatively inexpensive and have excellent sensitivity and specificity to be cost-effective compared with other techniques for the diagnosis of coronary artery disease. Similar analyses in other areas of health care may help to focus the development of new diagnostic technology.

Article and Author Information

Acknowledgments: Dr. Hunink was supported in part by a Persoongerichte Impuls voor Onderzoeksgroepen met Nieuwe Ideëen voor Excellente Research (PIONIER 900-92-146) award from the Netherlands Organization for Scientific Research. Drs. Fleischmann and Kuntz were supported by a project grant from the American Society of Echocardiography. Dr. Fleischmann is the recipient of a Clinical Investigator Development Award (1K08HL02964-01) from the National Heart, Lung, and Blood Institute.
Requests for Reprints: Maria G.M. Hunink, MD, PhD, Department of Epidemiology and Biostatistics and Department of Radiology, Erasmus Medical Center Rotterdam, Room EE21-40a, Box 1738, 3000 DR Rotterdam, the Netherlands; e-mail, hunink{at}epib.fgg.eur.nl. For reprint orders in quantities exceeding 100, please contact the Reprints Coordinator; phone, 215-351-2657; e-mail, reprints{at}mail.acponline.org.
Current Author Addresses: Dr. Hunink: Department of Epidemiology and Biostatistics and Department of Radiology, Erasmus Medical Center Rotterdam, Room EE21-40a, Box 1738, 3000 DR Rotterdam, the Netherlands.
Dr. Kuntz: Center for Risk Analysis, Harvard School of Public Health, 718 Huntington Avenue, Boston, MA 02115-5924.
Dr. Fleischmann: School of Medicine Division of Cardiology, University of California, San Francisco, 505 Parnassus Avenue, M 326, San Francisco, CA 94143-0214.
Dr. Brady: Center for Innovative Minimally Invasive Therapy, Partners Healthcare System, Massachusetts General Hospital, 55 Fruit Street, BAR 703, Boston, MA 02114-2696.