CLINICAL STUDIES
The economic consequences of available diagnostic and prognostic strategies for the evaluation of stable angina patients: an observational assessment of the value of precatheterization ischemia
Leslee J. Shaw, PhD*  ,
Rory Hachamovitch, MD ,
Daniel S. Berman, MD ,
Thomas H. Marwick, MD ,
Michael S. Lauer, MD ,
Gary V. Heller, MD|| ,
Ami E. Iskandrian, MD ,
Karen L. Kesler, MS¶ ,
Mark I. Travin, MD# ,
Howard C. Lewin, MD ,
Robert C. Hendel, MD** ,
Salvador Borges-Neto, MD¶ ,
D. Douglas Miller, MD for the Economics of Noninvasive Diagnosis (END) Multicenter Study Group
* Division of Cardiology, Emory University, Atlanta, Georgia, USA
New York Presbyterian Hospital, Weill Medical College of Cornell University, New York, New York, USA
Cedars-Sinai Medical Center, Los Angeles, California; USA
Cleveland Clinic Foundation, Cleveland, Ohio, USA
|| Hartford Hospital, Hartford, Connecticut, USA
¶ Duke University Medical Center, Durham, North Carolina, USA
# Roger Williams Hospital, Providence, Rhode Island, USA
** Northwestern University, Chicago, Illinois, USA
Saint Louis University, Saint Louis, Missouri, USA
Allegheny University of the Health Sciences, Philadelphia, Pennsylvania, USA
Manuscript received October 14, 1997;
revised manuscript received September 28, 1998,
accepted November 5, 1998.
Reprint requests and correspondence: Dr. Leslee J. Shaw, Division of Cardiology, Room 638, 1518 Clifton Road, Rollins School of Public Health, Emory University, Atlanta, Georgia 30303
OBJECTIVES
The study aim was to determine observational differences in costs of care by the coronary disease diagnostic test modality.
BACKGROUND
A number of diagnostic strategies are available with few data to compare the cost implications of the initial test choice.
METHODS
We prospectively enrolled 11,372 consecutive stable angina patients who were referred for stress myocardial perfusion tomography or cardiac catheterization. Stress imaging patients were matched by their pretest clinical risk of coronary disease to a series of patients referred to cardiac catheterization. Composite 3-year costs of care were compared for two patients management strategies: 1) direct cardiac catheterization (aggressive) and 2) initial stress myocardial perfusion tomography and selective catheterization of high risk patients (conservative). Analysis of variance techniques were used to compare costs, adjusting for treatment propensity and pretest risk.
RESULTS
Observational comparisons of aggressive as compared with conservative testing strategies reveal that costs of care were higher for direct cardiac catheterization in all clinical risk subsets (range: $2,878 to $4,579), as compared with stress myocardial perfusion imaging plus selective catheterization (range: $2,387 to $3,010, p < 0.0001). Coronary revascularization rates were higher for low, intermediate and high risk direct catheterization patients as compared with the initial stress perfusion imaging cohort (13% to 50%, p < 0.0001); cardiac death or myocardial infarction rates were similar (p > 0.20).
CONCLUSIONS
Observational assessments reveal that stable chest pain patients who undergo a more aggressive diagnostic strategy have higher diagnostic costs and greater rates of intervention and follow-up costs. Cost differences may reflect a diminished necessity for resource consumption for patients with normal test results.
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