Computer Simulation Shows CT May Be Cost-Effective Option for Chest Pain

Reed Miller

December 16, 2009

December 16, 2009 (Boston, Massachusetts) — Coronary CT angiography (CCTA) for the evaluation of ambulatory patients with stable chest pain should be evaluated in large randomized trials, according to the creators of a computer simulation that shows CCTA is as cost-effective as other testing modalities [1].

The results of the study, by Dr Joseph Ladapo (Beth Israel Deaconess Medical Center, Boston, MA) and colleagues, are published in the December 15–22, 2009 issue of the Journal of the American College of Cardiology.

Ladapo et al input data from published studies into a Monte Carlo microsimulation model to predict the clinical outcomes, costs, and cost-effectiveness of CCTA and other standard testing modalities for the diagnosis of coronary artery disease in patients 45 to 65 who presented to their primary-care physician with chest pain. The model tracked patient outcomes, including medical and surgical interventions, MIs, strokes, mortality, healthcare costs, and cost-effectiveness.

The study looked at eight diagnostic strategies: CCTA followed by stress ECG, stress ECG followed by CCTA, CCTA alone, stress ECG alone, stress echocardiography alone, stress single-photon emission computed tomography (SPECT) alone, cardiac catheterization, and no diagnostic testing.

For patients with stable chest pain and suspected coronary disease, the model shows little difference in health outcomes across all of the strategies, although CCTA--with and without subsequent stress testing and stress SPECT--appears to be marginally associated with the greatest quality-of-life-adjusted longevity. The model also shows that CCTA raises healthcare costs, primarily by increasing CAD detection and treatment but also with the costs of following up "incidental findings." The higher costs are partially offset by lowering costs related to nonfatal MIs and strokes.

Overall, the incremental cost-effectiveness ratio of CCTA plus stress ECG is under $50 000 per quality-adjusted life-years gained--"well within the range of what is generally considered to be cost-effective," the authors conclude.

"It is important to note that the finding of similarity in health outcomes across all of the diagnostic strategies offers support for the application of any of the modalities to the diagnosis of CAD, including CCTA, but also highlights the relevance and importance of large randomized controlled trials to further illuminate decision-making and policy," the authors conclude.

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