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QUARTERLY FOCUS ISSUE: PREVENTION/OUTCOMES: EFFECTIVENESS OF CARDIAC IMAGING

Clinical Outcomes and Cost-Effectiveness of Coronary Computed Tomography Angiography in the Evaluation of Patients With Chest Pain

Joseph A. Ladapo, MD, PhD^_*,,_*, Farouc A. Jaffer, MD, PhD^,, Udo Hoffmann, MD, MPH^,, Carey C. Thomson, MD, MPH^,¶, Fabian Bamberg, MD, MPH^,#, William Dec, MD, David M. Cutler, PhD^_**, Milton C. Weinstein, PhD and G. Scott Gazelle, MD, MPH, PhD^,||,

^_* Beth Israel Deaconess Medical Center, Boston, Massachusetts
Harvard Medical School, Boston, Massachusetts
Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
^|| Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
^¶ Department of Medicine, Mount Auburn Hospital, Cambridge, Massachusetts
^# Department of Clinical Radiology, Ludwig-Maximilians University, University Hospital Grosshadern, Munich, Germany
^_** Department of Economics, Harvard University and National Bureau of Economic Research, Cambridge, Massachusetts
Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts

Manuscript received August 4, 2009; revised manuscript received September 16, 2009, accepted October 14, 2009.

^_* Reprint requests and correspondence: Dr. Joseph A. Ladapo, Department of Ambulatory Care and Prevention, Harvard Medical School, 133 Brookline Avenue, 6th floor, Boston, Massachusetts 02215 (Email: jladapo{at}bidmc.harvard.edu).

Objectives: The aim of this study was to project clinical outcomes, health care costs, and cost-effectiveness of coronary computed tomography angiography (CCTA), as compared with conventional diagnostic technologies, in the evaluation of patients with stable chest pain and suspected coronary artery disease (CAD).

Background: CCTA has recently been found to be effective in the evaluation of patients with suspected CAD, but investigators have raised concerns related to radiation exposure, incidental findings, and nondiagnostic exams.

Methods: With published data, we developed a computer simulation model to project clinical outcomes, health care costs, and cost-effectiveness of CCTA, compared with conventional testing modalities, in the diagnosis of CAD. Our target population included 55-year-old patients who present to their primary care physicians with stable chest pain.

Results: All diagnostic strategies yielded similar health outcomes, but performing CCTA—with or without stress testing or performing stress single-photon emission computed tomography—marginally minimized adverse events and maximized longevity and quality-adjusted life-years (QALYs). Health outcomes associated with these strategies were comparable, with CCTA in men and women yielding the greatest QALYs but only by modest margins. Overall differences were small, and performing the most effective test—compared with the least effective—decreased adverse event rates by 3% in men and women. Comparable increases in longevity and QALYs were 2 months and 0.1 QALYs in men and 1 month and 0.03 QALYs in women. CCTA raised overall costs, partly through the follow-up of incidental findings, and when performed with stress testing, its incremental cost-effectiveness ratio ranged from $26,200/QALY in men to $35,000/QALY in women. Health outcomes were marginally less favorable in women when radiation risks were considered.

Conclusions: CCTA is comparable to other diagnostic studies and might hold good clinical value, but large randomized controlled trials are needed to guide policy.

Key Words: coronary artery disease • coronary computed tomography angiography • cost-effectiveness • economics • outcomes research

Abbreviations and Acronyms   CABG = coronary artery bypass graft   CAD = coronary artery disease   CCTA = coronary computed tomography angiography   CT = computed tomography   CTA = computed tomography angiography   ECG = electrocardiography   MI = myocardial infarction   PCI = percutaneous coronary intervention   QALE = quality-adjusted life expectancy   QALY = quality-adjusted life-year   QoL = quality of life   SPECT = single-photon emission computed tomography

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