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Implications of alternative strategies to diagnose coronary artery disease
Insights
Diagnosing coronary artery disease in asymptomatic men is cost-ineffective. For symptomatic patients, strategies using exercise stress testing (ETT) offer better value for detecting disease and improving life years gained.
Area of Science:
- Cardiology
- Health Economics
- Diagnostic Imaging
Background:
- Coronary artery disease (CAD) diagnosis requires cost-effective strategies.
- Evaluating diagnostic pathways for asymptomatic and symptomatic individuals is crucial.
Purpose of the Study:
- To assess the cost-effectiveness of various diagnostic strategies for coronary artery disease.
- To compare diagnostic approaches in asymptomatic men, those with atypical angina, and those with definite angina.
Main Methods:
- A hypothetical cohort of 55-year-old men was modeled.
- Diagnostic strategies included resting ECG, exercise stress test (ETT), radionuclide scanning (RNS), and coronary angiography.
- Cost-effectiveness was measured in dollars per year of life gained, considering direct procedure costs.
Main Results:
- Screening asymptomatic individuals for CAD is relatively cost-ineffective, with costs ranging from $22,600 to $60,000 per year of life gained.
- For atypical angina, strategies involving ETT (alone or with ECG/RNS) are preferable at approximately $9300 per year of life gained.
- For definite angina, cost-effectiveness is similar across strategies ($8800 per year of life gained), with direct angiography being a reasonable option.
Conclusions:
- Widespread screening for CAD in asymptomatic individuals is not cost-effective.
- For symptomatic patients, noninvasive testing strategies, particularly those involving ETT, are more cost-effective.
- The choice of diagnostic strategy should be tailored to patient presentation and clinical suspicion for CAD.
Abstract:
Strategies to diagnose coronary artery disease were examined for cost-effectiveness in a hypothetical population of 55-year-old men who, alternatively, are asymptomatic, have atypical angina or have definite angina. Strategies considered include various combinations of noninvasive tests (resting ECG, exercise stress test [ETT]. radionuclide scanning [RNS] and coronary angiography). Benefits are estimated in terms of the detection of multivessel disease and years of life gained from coronary artery bypass graft surgery (CABG). Only the direct costs (charges) for diagnostic or treatment procedures are considered. In asymptomatic persons, the average cost-effectiveness for different strategies ranges from $22,600 per year of life gained (ETT followed in positives by RNS) to $60,000 (angiography as primary screening test). Hence, screening is relatively cost-ineffective and would be extremely expensive if implemented widely. For patients with atypical angina, the cost-effectiveness ratio is about $9300 per year of life gained. Strategies involving use of ETT alone or in combination with the ECG or RNS appear to be preferable. For definite angina, the cost-effectiveness ratio is about $8800. Little difference is noted among various strategies for diagnosing definite angina, and the option to proceed directly to angiography appears reasonable.