Browsing by Subject "Echocardiography, Stress"

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    ItemOpen Access
    Economic Outcomes With Anatomical Versus Functional Diagnostic Testing for Coronary Artery Disease.
    (Annals of internal medicine, 2016-07) Mark, Daniel B; Federspiel, Jerome J; Cowper, Patricia A; Anstrom, Kevin J; Hoffmann, Udo; Patel, Manesh R; Davidson-Ray, Linda; Daniels, Melanie R; Cooper, Lawton S; Knight, J David; Lee, Kerry L; Douglas, Pamela S; PROMISE Investigators

    Background

    PROMISE (PROspective Multicenter Imaging Study for Evaluation of Chest Pain) found that initial use of at least 64-slice multidetector computed tomography angiography (CTA) versus functional diagnostic testing strategies did not improve clinical outcomes in stable symptomatic patients with suspected coronary artery disease (CAD) requiring noninvasive testing.

    Objective

    To conduct an economic analysis for PROMISE (a major secondary aim of the study).

    Design

    Prospective economic study from the U.S. perspective. Comparisons were made according to the intention-to-treat principle, and CIs were calculated using bootstrap methods. (ClinicalTrials.gov: NCT01174550).

    Setting

    190 U.S. centers.

    Patients

    9649 U.S. patients enrolled in PROMISE between July 2010 and September 2013. Median follow-up was 25 months.

    Measurements

    Technical costs of the initial (outpatient) testing strategy were estimated from Premier Research Database data. Hospital-based costs were estimated using hospital bills and Medicare cost-charge ratios. Physician fees were taken from the Medicare Physician Fee Schedule. Costs were expressed in 2014 U.S. dollars, discounted at 3% annually, and estimated out to 3 years using inverse probability weighting methods.

    Results

    The mean initial testing costs were $174 for exercise electrocardiography; $404 for CTA; $501 to $514 for pharmacologic and exercise stress echocardiography, respectively; and $946 to $1132 for exercise and pharmacologic stress nuclear testing, respectively. Mean costs at 90 days were $2494 for the CTA strategy versus $2240 for the functional strategy (mean difference, $254 [95% CI, -$634 to $906]). The difference was associated with more revascularizations and catheterizations (4.25 per 100 patients) with CTA use. After 90 days, the mean cost difference between the groups out to 3 years remained small.

    Limitation

    Cost weights for test strategies were obtained from sources outside PROMISE.

    Conclusion

    Computed tomography angiography and functional diagnostic testing strategies in patients with suspected CAD have similar costs through 3 years of follow-up.

    Primary funding source

    National Heart, Lung, and Blood Institute.
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    Utility of observation units for young emergency department chest pain patients.
    (Journal of Emergency Medicine, 2013-02) Ely, Sora; Chandra, Abhinav; Mani, Giselle; Drake, Weiying; Freeman, Debbie; Limkakeng, Alexander T
    BACKGROUND: Determining which patients presenting to the Emergency Department (ED) require further work-up for acute coronary syndrome (ACS) can be difficult. The utility of routine observation for cardiac testing in low-risk young adult patients has been questioned. STUDY OBJECTIVES: We investigated the rate of positive findings yielded by routine cardiac observation unit work-up in patients aged 40 years or younger. METHODS: This was a retrospective observational cohort study of patients aged 18-40 years who were evaluated for ACS in an ED-based observation unit. Data were collected by trained abstractors from electronic medical records. RESULTS: A total of 362 patients met inclusion criteria. Of those, 239 received stress testing, yielding five positive and nine indeterminate results. One other patient had acute troponin elevation while under observation. The positive stress test patients and troponin-elevated patient underwent cardiac angiography. Only one positive stress test patient showed significant coronary stenosis and received coronary interventions. In follow-up data, one patient had an adverse cardiac outcome within 1 year of index visit, but no coronary interventions. Thus, only 3 patients had adverse cardiac events, with only one patient warranting intervention discovered by observation unit stress testing and a second via serial cardiac markers. CONCLUSION: Routine observation of symptomatic young adults for ACS had low yield. Observation identified one patient with acute cardiac marker elevation and further stress testing identified only one patient with intervenable ACS, despite a high false-positive rate. This suggests that observation and stress testing should not be routinely performed in this demographic absent other high-risk features.