Economic Outcomes With Anatomical Versus Functional Diagnostic Testing for Coronary Artery Disease.

Abstract

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.

Department

Description

Provenance

Citation

Published Version (Please cite this version)

10.7326/m15-2639

Publication Info

Mark, Daniel B, Jerome J Federspiel, Patricia A Cowper, Kevin J Anstrom, Udo Hoffmann, Manesh R Patel, Linda Davidson-Ray, Melanie R Daniels, et al. (2016). Economic Outcomes With Anatomical Versus Functional Diagnostic Testing for Coronary Artery Disease. Annals of internal medicine, 165(2). pp. 94–102. 10.7326/m15-2639 Retrieved from https://hdl.handle.net/10161/26201.

This is constructed from limited available data and may be imprecise. To cite this article, please review & use the official citation provided by the journal.

Scholars@Duke

Mark

Daniel Benjamin Mark

Professor of Medicine

Dr. Mark is a clinical cardiologist with the rank of Professor of Medicine (with tenure) as well as Vice Chief for Academic Affairs in the Division of Cardiology, Department of Medicine at Duke University Medical Center. He is also the Director of Outcomes Research at the Duke Clinical Research Institute. He has been on the full-time faculty at Duke since 1985. Prior to that he completed his cardiology fellowship at Duke, his residency and internship at the University of Virginia Hospital, and received his medical degree from Tufts University and his Master’s degree from Harvard. In 1998, he was given the honor of being elected to the American Society for Clinical Investigators and in 2002 he was honored by election to the Association of American Physicians. These organizations are the two most prestigious honor societies in academic medicine. In 2009, Dr. Mark was awarded the American College of Cardiology Distinguished Scientist Award.

Dr. Mark's major research interests include medical economics and quality of life outcomes, outcomes research, and quality of medical care. Currently, Dr. Mark is directing a number of outcomes analyses for ongoing clinical trials including PROMISE (anatomic versus functional testing for coronary artery disease, NIH), CABANA (catheter ablation versus antiarrhythmic drug therapy for atrial fibrillation, NIH), ISCHEMIA (percutaneous coronary intervention versus optimal medical therapy for moderate-severe ischemia), and STICH (CABG +/- ventricular reconstruction versus medical therapy for ischemic heart disease, NIH). He was the principal author of the AHCPR Unstable Angina Guidelines and is a co-author of both the American College of Cardiology Guideline on Exercise Testing and their Coronary Stent Consensus Guideline. He is also the Editor of the American Heart Journal. Dr. Mark has published over 270 peer-reviewed articles, two books, and 80 book chapters. He lectures widely in the US, as well as in Canada, South America, and Europe.

Keywords: cost-effectiveness analysis, disease management, quality of life assessment, resource use.

Federspiel

Jerome Jeffrey Federspiel

Assistant Professor of Obstetrics and Gynecology

Dr. Federspiel is a maternal fetal medicine physician at Duke University. His clinical and research interests focus on the care of people with cardiovascular and hematologic complications of pregnancy.


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