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QUARTERLY FOCUS ISSUE: PREVENTION/OUTCOMES: COST-EFFECTIVENESS

Induced Cardiovascular Procedural Costs and Resource Consumption Patterns After Coronary Artery Calcium Screening

Results From the EISNER (Early Identification of Subclinical Atherosclerosis by Noninvasive Imaging Research) Study

Leslee J. Shaw, PhD^_*, James K. Min, MD, Matthew Budoff, MD, Heidi Gransar, MS, Alan Rozanski, MD^||, Sean W. Hayes, MD, John D. Friedman, MD, Romalisa Miranda, MPH, Nathan D. Wong, PhD^¶ and Daniel S. Berman, MD^,_*

^_* Emory University School of Medicine, Atlanta, Georgia
Weill Medical College of Cornell University, The New York Presbyterian Hospital, New York, New York
Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, California
Cedars-Sinai Medical Center, Los Angeles, California
^|| St. Luke's Roosevelt Hospital, New York, New York
^¶ University of California at Irvine, Irvine, California

Manuscript received March 27, 2009; revised manuscript received June 8, 2009, accepted July 6, 2009.

^_* Reprint requests and correspondence: Dr. Daniel S. Berman, Department of Imaging, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Room 1258, Los Angeles, California 90048 (Email: bermand{at}cshs.org).

Objectives: We prospectively evaluated procedural costs and resource consumption patterns in the EISNER (Early Identification of Subclinical Atherosclerosis by Noninvasive Imaging Research) study after coronary calcium (CAC) measurements.

Background: Controversy surrounds expansion of cardiovascular disease (CVD) screening to include atherosclerosis imaging as the result of concern whether induced costs will outweigh any benefit.

Methods: Detailed risk factor and CAC measurements with 4-year follow-up for CVD death or myocardial infarction and procedures were performed. Costs were estimated with the use of Medicare reimbursement rates (discounted and inflation corrected). Cox survival analysis was used to estimate procedures and events.

Results: CAC scores varied widely but were skewed toward low scores with 56.7% of screened subjects having CAC scores 10 and only 8.2% having CAC scores 400. Noninvasive testing was infrequent and medical costs were low among subjects with low CAC scores, both rising progressively with increasing CAC scores (p < 0.001), particularly in the 31 (2.2% of subjects) that had CAC scores 1,000. Similarly, invasive coronary angiography rose progressively with increasing scores (p < 0.001) but occurred exclusively among subjects first undergoing noninvasive testing and overall, was performed in only 19.4% of subjects with CAC scores 1,000.

Conclusions: CAC scanning is associated with a marked differential in downstream frequency of medical tests and costs, ranging from a very low frequency of testing and invasive procedures among a predominantly large percentage of subjects with low CAC scores, to selectively concentrated testing and procedures among a small number of subjects with CAC scores >400. Thus, CAC scanning appears to foster efficient selective testing patterns among asymptomatic individuals at risk for CVD.

Key Words: screening • cost • utilization • prognosis

Abbreviations and Acronyms   CAC = coronary artery calcium/calcification   CCTA = coronary computed tomographic angiography   CVD = cardiovascular disease   ECG = electrocardiographic/electrocardiogram   FRS = Framingham Risk Score   HU = Hounsfield units   ICA = invasive coronary angiography   MI = myocardial infarction

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