64-slice MDCT of the coronary arteries was less costly ($2,684 vs $3,265) and more effective (24.69 vs 24.63 QALYs) than observation unit-based stress echocardiography for low-risk chest pain.
Does 64-slice MDCT without observation unit care improve cost-effectiveness compared to observation unit care plus stress testing in patients presenting to the ED with low-risk chest pain?
A decision analytic model suggests that 64-slice MDCT is a cost-saving and more effective strategy than observation unit care with stress testing for evaluating low-risk chest pain in the ED.
Effect estimate: ICER dominant (95% CI dominant to 29,738)
Absolute Event Rate: 24.69% vs 24.63%
OBJECTIVES: The aim was to use a computer model to estimate the cost-effectiveness of 64-slice multidetector computed tomography (MDCT) of the coronary arteries in the emergency department (ED) compared to an observation unit (OU) stay plus stress electrocardiogram (ECG) or stress echocardiography for the evaluation of low-risk chest pain patients presenting to the ED. METHODS: A decision analytic model was developed to compare health outcomes and costs that result from three different risk stratification strategies for low-risk chest pain patients in the ED: stress ECG testing after OU care, stress echocardiography after OU care, and MDCT with no OU care. Three patient populations were modeled with the prevalence of symptomatic coronary artery disease (CAD) being very low risk, 2%; low risk, 6% (base case) ; and moderate risk, 10%. Outcomes were measured as quality-adjusted life years (QALYs). Incremental cost-effectiveness ratios (ICERs), the ratio of change in costs of one test over another to the change in QALY, were calculated for comparisons between each strategy. Sensitivity analyses were conducted to test the robustness of the results to assumptions regarding the characteristics of the risk stratification strategies, costs, utility weights, and likelihood of events. RESULTS: In the base case, the mean (+/- standard deviation SD) costs and QALYs for each risk stratification strategy were MDCT arm 2, 684 (+/- 1, 773 to 4, 418) and 24. 69 (+/- 24. 54 to 24. 76) QALYs, stress echocardiography arm 3, 265 (+/- 2, 383 to 4, 836) and 24. 63 (+/- 24. 28 to 24. 74) QALYs, and stress ECG arm 3, 461 (+/- 2, 533 to 4, 996) and 24. 59 (+/- 24. 21 to 24. 75) QALYs. The MDCT dominated (less costly and more effective) both OU plus stress echocardiography and OU plus stress ECG. This resulted in an ICER where the MDCT arm dominated the stress echocardiography arm (95% confidence interval CI = dominant to 29, 738) and where MDCT dominated the ECG arm (95% CI = dominant to 7, 332). The MDCT risk stratification arm also dominated stress echocardiography and stress ECG in the 2 and 10% prevalence scenarios, which demonstrated the same ICER trends as the 6% prevalence CAD base case. The thresholds where the MDCT arm remained a cost-saving strategy compared to the other risk stratification strategies were cost of MDCT, 1, 092; prevalence of CAD, 65%; and a MDCT indeterminate rate, < 30%. CONCLUSIONS: In this computer-based model analysis, the MDCT risk stratification strategy is less costly and more effective than both OU-based stress echocardiography and stress ECG risk stratification strategies in chest pain patients presenting to the ED with low to moderate prevalence of CAD.
Khare et al. (Tue,) conducted a other in Low-risk chest pain. 64-slice multidetector computed tomography (MDCT) vs. Observation unit stay plus stress electrocardiogram or stress echocardiography was evaluated on Quality-adjusted life years (QALYs) (ICER dominant, 95% CI dominant to 29,738). 64-slice MDCT of the coronary arteries was less costly ($2,684 vs $3,265) and more effective (24.69 vs 24.63 QALYs) than observation unit-based stress echocardiography for low-risk chest pain.