0

The full content of Annals is available to subscribers

Subscribe/Learn More  >
Academia and the Profession |

Noninvasive Imaging for the Diagnosis of Coronary Artery Disease: Focusing the Development of New Diagnostic Technology

Maria G.M. Hunink, MD, PhD; Karen M. Kuntz, ScD; Kirsten E. Fleischmann, MD, MPH; and Thomas J. Brady, MD
[+] Article and Author Information

From Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands; Harvard School of Public Health, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts; and University of California, San Francisco, School of Medicine, San Francisco, California.


Acknowledgments: Dr. Hunink was supported in part by a Persoongerichte Impuls voor Onderzoeksgroepen met Nieuwe Ideëen voor Excellente Research (PIONIER 900-92-146) award from the Netherlands Organization for Scientific Research. Drs. Fleischmann and Kuntz were supported by a project grant from the American Society of Echocardiography. Dr. Fleischmann is the recipient of a Clinical Investigator Development Award (1K08HL02964-01) from the National Heart, Lung, and Blood Institute.

Requests for Reprints: Maria G.M. Hunink, MD, PhD, Department of Epidemiology and Biostatistics and Department of Radiology, Erasmus Medical Center Rotterdam, Room EE21-40a, Box 1738, 3000 DR Rotterdam, the Netherlands; e-mail, hunink@epib.fgg.eur.nl. For reprint orders in quantities exceeding 100, please contact the Reprints Coordinator; phone, 215-351-2657; e-mail, reprints@mail.acponline.org.

Current Author Addresses: Dr. Hunink: Department of Epidemiology and Biostatistics and Department of Radiology, Erasmus Medical Center Rotterdam, Room EE21-40a, Box 1738, 3000 DR Rotterdam, the Netherlands.

Dr. Kuntz: Center for Risk Analysis, Harvard School of Public Health, 718 Huntington Avenue, Boston, MA 02115-5924.

Dr. Fleischmann: School of Medicine Division of Cardiology, University of California, San Francisco, 505 Parnassus Avenue, M 326, San Francisco, CA 94143-0214.

Dr. Brady: Center for Innovative Minimally Invasive Therapy, Partners Healthcare System, Massachusetts General Hospital, 55 Fruit Street, BAR 703, Boston, MA 02114-2696.


Ann Intern Med. 1999;131(9):673-680. doi:10.7326/0003-4819-131-9-199911020-00008
Text Size: A A A

Background: New tests, such as magnetic resonance imaging (MRI) and electron-beam computed tomography (CT), are being developed for the diagnosis of coronary artery disease.

Objective: To determine the conditions that a new test must meet to be a cost-effective alternative to established imaging tests.

Design: Decision model and cost-effectiveness analysis.

Data Sources: Literature review and meta-analysis.

Target Population: 55-year-old men and 65-year-old women presenting with chest pain.

Time Horizon: Lifetime of the patient.

Perspective: Health care policy.

Interventions: MRI, electron-beam CT, exercise echocardiography, exercise single-photon emission CT, and coronary angiography.

Outcome Measures: Target sensitivity and specificity values for a new noninvasive test.

Results of Base-Case Analysis: Assuming that society is willing to pay $75 000 per quality-adjusted life-year (QALY) gained, a new test that costs $1000 would need a sensitivity of 94% and a specificity of 90% to be cost-effective.

Results of Sensitivity Analysis: Assuming that society is willing to pay $50 000 per QALY gained, a new test that costs $1000 or more would never be cost-effective. For a test that costs $500, the sensitivity and specificity must each be 95%.

Conclusions: New imaging techniques, such as MRI and electron-beam CT, must be relatively inexpensive and have excellent sensitivity and specificity to be cost-effective compared with other techniques for the diagnosis of coronary artery disease. Similar analyses in other areas of health care may help to focus the development of new diagnostic technology.

Figures

Grahic Jump Location
Figure 1.
Challenge receiver-operating characteristic (ROC) curves for a new noninvasive imaging test compared with exercise echocardiography in 55-year-old men with atypical mild chest pain.Top.dashed linesolid lineBottom.dashed linesolid linebeaded line

All pairs of true-positive and false-positive rates on or to the upper left of the curve represent performance variables for which a new noninvasive test would be cost-effective compared with exercise echocardiography. For a new test that costs $1000, willingness-to-pay thresholds of $100 000 per quality-adjusted life-year (QALY) gained ( ) and $75 000 per QALY gained ( ) are assumed. For a new test that costs $500, willingness-to-pay thresholds of $100 000 per QALY gained ( ), $75 000 per QALY gained ( ), and $50 000 per QALY gained ( ) are assumed.

Grahic Jump Location
Grahic Jump Location
Figure 2.
Challenge receiver-operating characteristic curves for a new noninvasive imaging test (cost, $1000) compared with exercise echocardiography (solid line), exercise single-photon emission computed tomography (dashed line), direct contrast angiography (circles), and use of the new test as a comprehensive examination (diamond) in 55-year-old men with atypical mild chest pain.

A willingness-to-pay threshold of $75 000 per quality-adjusted life-year gained is assumed. All pairs of true-positive and false-positive rates on or to the upper left of the curve represent performance variables for which a new noninvasive test would be cost-effective compared with the established test.

Grahic Jump Location
Grahic Jump Location
Figure 3.
Challenge receiver-operating characteristic regions for a new noninvasive imaging test compared with exercise echocardiography in 55-year-old men and 65-year-old women.Top.Bottom.

All pairs of true-positive and false-positive rates on or to the upper left of the line represent performance variables for which a new noninvasive test would be cost-effective compared with exercise echocardiography. The cost of the new test is $1000. A willingness-to-pay threshold of $75 000 per quality-adjusted life-year gained is assumed. The solid line indicates men with atypical mild chest pain, and the dashed line indicates men with nonspecific severe chest pain. The striped area represents the intersection of the two regions (that is, the area in which the new test is cost-effective for both cohorts). The solid line indicates women with atypical mild chest pain, the dashed line indicates women with atypical severe chest pain, and the dotted line indicates women with typical mild chest pain. The striped area represents the intersection of the three regions (that is, the area in which the new test is cost-effective for all three cohorts).

Grahic Jump Location

Tables

References

Letters

NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Comments

Submit a Comment
Submit a Comment

Summary for Patients

Clinical Slide Sets

Terms of Use

The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.

Toolkit

Buy Now

to gain full access to the content and tools.

Want to Subscribe?

Learn more about subscription options

Advertisement
Related Articles
Related Point of Care
Topic Collections
PubMed Articles

Buy Now

to gain full access to the content and tools.

Want to Subscribe?

Learn more about subscription options

Forgot your password?
Enter your username and email address. We'll send you a reminder to the email address on record.
(Required)
(Required)