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Cost-effectiveness in diagnosis of stable angina patients: a decision-analytical modelling approach

Muhummad Sohaib Nazir1, Yael Rodriguez-Guadarrama2,3, Tiago Rua4,3

  • 1Biomedical Engineering and Imaging Sciences, King's College London, London, UK sohaib.nazir@kcl.ac.uk.

Open Heart
|April 5, 2022
PubMed

Insights

For stable angina patients, combining SPECT or CMR with CTCA and invasive coronary angiography with fractional flow reserve (ICA-FFR) is most cost-effective for diagnosing coronary artery disease (CAD). ICA-FFR alone becomes cost-effective at higher thresholds.

Area of Science:

  • Cardiovascular Medicine
  • Health Economics
  • Diagnostic Imaging

Background:

  • Coronary artery disease (CAD) diagnosis in stable angina requires accurate and cost-effective strategies.
  • Published diagnostic accuracies vary, necessitating a comparative economic evaluation.
  • Invasive coronary angiography (ICA) with fractional flow reserve (FFR) serves as a gold standard for assessing significant CAD.

Purpose of the Study:

  • To determine the most cost-effective diagnostic strategy for significant CAD in stable angina patients.
  • To compare 17 different diagnostic pathways, including various imaging modalities and invasive procedures.
  • To establish cost-effectiveness thresholds for different diagnostic approaches.

Main Methods:

  • A probabilistic decision-analytical model was developed for a cohort of stable angina patients.
  • Seventeen diagnostic strategies were evaluated, ranging from no testing to combinations of CT coronary angiography (CTCA), stress echocardiography, CT-FFR, SPECT, CMR, PET, ICA, and ICA-FFR.
  • Incremental cost-effectiveness ratios (ICERs) were calculated as the additional cost per correct diagnosis.

Main Results:

  • SPECT followed by CTCA and ICA-FFR is the most cost-effective strategy for cost-effectiveness thresholds (CET) of £1000-£3000 per correct diagnosis.
  • Cardiovascular magnetic resonance (CMR) followed by CTCA and ICA-FFR is cost-effective within CETs of £3000-£17,000.
  • ICA-FFR as a first-line test becomes the most cost-effective strategy when CET exceeds £24,000.

Conclusions:

  • Functional imaging as a first-line strategy is cost-effective for patients with low to intermediate CAD risk and low to intermediate cost-effectiveness thresholds.
  • While ICA alone is not cost-effective, ICA-FFR can be cost-effective, particularly in patients with a high pre-test probability of CAD.
  • The optimal diagnostic strategy for CAD in stable angina is dependent on the available budget and patient risk profile.
Abstract

Keywords:
CORONARY ARTERY DISEASEHealth Care Economics and OrganizationsSTABLE ANGINA

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