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Cost-Effectiveness of Diagnostic Strategies for Patients with Chest Pain

Karen M. Kuntz, ScD; Kirsten E. Fleischmann, MD, MPH; Maria G.M. Hunink, MD, PhD; and Pamela S. Douglas, MD
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From Brigham and Women's Hospital; Beth Israel Deaconess Medical Center, Harvard Medical School; and Harvard School of Public Health, Boston, Massachusetts; and the University of Groningen, Groningen, the Netherlands.

Ann Intern Med. 1999;130(9):709-718. doi:10.7326/0003-4819-130-9-199905040-00002
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Background: Many noninvasive tests exist to determine whether patients should undergo coronary angiography. The routine use of coronary angiography without previous noninvasive testing is typically not advocated.

Objective: To determine the cost-effectiveness of diagnostic strategies for patients with chest pain.

Design: Cost-effectiveness analysis.

Data Sources: Published data.

Target Population: Patients who present with chest pain, have no history of myocardial infarction, and are able to perform an exercise stress test.

Time Horizon: Lifetime.

Perspective: Societal.

Interventions: No testing, exercise electrocardiography, exercise echocardiography, exercise single-photon emission computed tomography (SPECT), and coronary angiography alone.

Outcome Measures: Quality-adjusted life expectancy, lifetime cost, and incremental cost-effectiveness.

Results of Base-Case Analysis: The incremental cost-effectiveness ratio of routine coronary angiography compared with exercise echocardiography was $36 400 per quality-adjusted life-year (QALY) saved for 55-year-old men with typical angina. For 55-year-old men with atypical angina, exercise echocardiography compared with exercise electrocardiography cost $41 900 per QALY saved. If adequate exercise echocardiography was not available, exercise SPECT cost $54 800 per QALY saved compared with exercise electrocardiography for these patients. For 55-year-old men with nonspecific chest pain, the incremental cost-effectiveness ratio of exercise electrocardiography compared with no testing was $57 700 per QALY saved.

Results of Sensitivity Analysis: On the basis of a probabilistic sensitivity analysis, there is a 75% chance that exercise echocardiography costs less than $50 900 per QALY saved for 55-year-old men with atypical angina.

Conclusions: Exercise electrocardiography or exercise echocardiography resulted in reasonable cost-effectiveness ratios for patients at mild to moderate risk for coronary artery disease in terms of age, sex, and type of chest pain. Coronary angiography without previous noninvasive testing resulted in reasonable cost-effectiveness ratios for patients with a high pretest probability of coronary artery disease.


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Figure 1.
Decision tree.M

Patients who do not undergo diagnostic testing are stratified by extent of underlying coronary artery disease and receive medical treatment. Patients who undergo noninvasive exercise testing undergo coronary angiography if the test result is positive. The postcatheterization management strategy depends on the result of angiography; the standard approach is shown. At the end of each branch, if patients are still alive, they enter a Markov cycle tree ( ) that models their lifetime prognosis. CABG = coronary artery bypass grafting; CAD = coronary artery disease; LMD = left main disease; MEDS = medical therapy; PTCA = percutaneous transluminal coronary angioplasty.

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Figure 2.
Prevalence of coronary artery disease.

The prevalence of any coronary artery disease is shown, based on age range, sex, and type of chest pain. Bars represent 95% CIs. Diamonds represent patients with typical angina; circles represent those with atypical angina; and Xs represent those with nonspecific chest pain.

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Figure 4.
Sensitivity analysis of the diagnostic performance of exercise single-photon emission computed tomography (SPECT).X

Results of three-way sensitivity analysis of the sensitivity and specificity of exercise SPECT and the acceptable cost-effectiveness threshold for 55-year-old men with atypical angina and mild symptoms are shown. Lines indicate four possible thresholds for allocating health-care resources. For a particular cost-effectiveness threshold, points to the top right of the line indicate that exercise SPECT compared with exercise echocardiography has a lower cost-effectiveness ratio than that depicted by the line. The indicates an example in which the sensitivity and specificity of exercise SPECT are both 0.88. QALY = quality-adjusted life-year.

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Figure 3.
Cost-effectiveness ratios for alternative patient cohorts. Top.Middle.Bottom.QALY

Women 40 to 59 years of age. Women 60 to 69 years of age and men 40 to 49 years of age. Men 50 to 69 years of age. Diamonds represent exercise electrocardiography compared with no testing; circles represent exercise echocardiography compared with exercise electrocardiography; and plus signs represent coronary angiography compared with exercise echocardiography. Comparisons not shown represent cases in which the incremental cost-effectiveness ratio is greater than $200 000 per quality-adjusted life-year ( ) gained or dominated strategies.

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