Cost-effectiveness Analysis of Anatomic vs Functional Index Testing in Patients With Low-Risk Stable Chest Pain.
Cost-effectiveness Analysis of Anatomic vs Functional Index Testing in Patients With Low-Risk Stable Chest Pain.
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低风险稳定性胸痛患者解剖与功能指数测试的成本效益分析
DOI：
10.1001/jamanetworkopen.2020.28312
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发表时间：
2020-12-01
影响因子：
13.8
通讯作者：
Hoffmann U
中科院分区：
文献类型：
--
作者：
Karády J;Mayrhofer T;Ivanov A;Foldyna B;Lu MT;Ferencik M;Pursnani A;Salerno M;Udelson JE;Mark DB;Douglas PS;Hoffmann U
Are first-line anatomic approaches to low-risk stable chest pain evaluation cost-effective compared with functional testing? In this cost-effectiveness analysis using an individual-based Markov microsimulation model based on 10 003 participants in a randomized clinical trial, anatomic approaches were cost-effective compared with functional testing across a wide range of variations in clinical care and patient characteristics. Adding fractional flow reserve to coronary computed tomography angiography resulted in modest improvements after the initially increased costs of care were offset by fewer and more targeted coronary revascularizations. These findings suggest that anatomic strategies may present a favorable initial diagnostic option in the evaluation of low-risk stable chest pain compared with functional testing. This economic evaluation determines whether anatomic approaches are cost-effective compared with functional tests for the assessment of low-risk stable chest pain. Both noninvasive anatomic and functional testing strategies are now routinely used as initial workup in patients with low-risk stable chest pain (SCP). To determine whether anatomic approaches (ie, coronary computed tomography angiography [CTA] and coronary CTA supplemented with noninvasive fractional flow reserve [FFRCT], performed in patients with 30% to 69% stenosis) are cost-effective compared with functional testing for the assessment of low-risk SCP. This cost-effectiveness analysis used an individual-based Markov microsimulation model for low-risk SCP. The model was developed using patient data from the Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE) trial. The model was validated by comparing model outcomes with outcomes observed in the PROMISE trial for anatomic (coronary CTA) and functional (stress testing) strategies, including diagnostic test results, referral to invasive coronary angiography (ICA), coronary revascularization, incident major adverse cardiovascular event (MACE), and costs during 60 days and 2 years. The validated model was used to determine whether anatomic approaches are cost-effective over a lifetime compared with functional testing. Choice of index test for evaluation of low-risk SCP. Downstream ICA and coronary revascularization, MACE (death, nonfatal myocardial infarction), cost, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER) of competing strategies. The model cohort included 10 003 individual patients (median [interquartile range] age, 60.0 [54.4-65.9] years; 5270 [52.7%] women; 7693 [77.4%] White individuals), who entered the model 100 times. The Markov model accurately estimated the test assignment, results of anatomic and functional index testing, referral to ICA, revascularization, MACE, and costs at 60 days and 2 years compared with observed data in PROMISE (eg, coronary CTA: ICA, 12.2% [95% CI, 10.9%-13.5%] vs 12.3% [95% CI, 12.2%-12.4%]; revascularization, 6.2% [95% CI, 5.5%-6.9%] vs 6.4% [95% CI, 6.3%-6.5%]; functional strategy: ICA, 8.1% [95% CI, 7.4%-8.9%] vs 8.2% [95% CI, 8.1%-8.3%]; revascularization, 3.2% [95% CI, 2.7%-3.7%] vs 3.3% [95% CI, 3.2%-3.4%]; 2-year MACE rates: coronary CTA, 2.1% [95% CI, 1.7%-2.5%] vs 2.3% [95% CI, 2.2%-2.4%]; functional strategy, 2.2% [95% CI, 1.8%-2.6%] vs 2.4% [95% CI, 2.3%-2.4%]). Anatomic approaches led to higher ICA and revascularization rates at 60 days, 2 years, and 5 years compared with functional testing but were more effective in patient selection for ICA (eg, 60-day revascularization-to-ICA ratio, CTA: 53.7% [95% CI, 53.3%-54.0%]; CTA with FFRCT: 59.5% [95% CI, 59.2%-59.8%]; functional testing: 40.7% [95% CI, 40.4%-50.0%]). Over a lifetime, anatomic approaches gained an additional 6 months in perfect health compared with functional testing (CTA, 25.16 [95% CI, 25.14-25.19] QALYs; CTA with FFRCT, 25.14 [95% CI, 25.12-25.17] QALYs; functional testing, 24.68 [95% CI, 24.66-24.70] QALYs). Anatomic strategies were less costly and more effective; thus, CTA with FFRCT dominated and CTA alone was cost-effective (ICERs ranged from $1912/QALY for women and $3,559/QALY for men) compared with functional testing. In probabilistic sensitivity analyses, anatomic approaches were cost-effective in more than 65% of scenarios, assuming a willingness-to-pay threshold of $100 000/QALY. The results of this study suggest that anatomic strategies may present a more favorable initial diagnostic option in the evaluation of low-risk SCP compared with functional testing.
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影响因子：
24
作者：
Anderson, Jeffrey L.;Heidenreich, Paul A.;Shaw, Leslee J.
通讯作者：
Shaw, Leslee J.
影响因子：
39.3
作者：
Cho, Iksung;Al'Aref, Subhi J.;Min, James K.
通讯作者：
Min, James K.
影响因子：
2.1
作者：
Gandhi, Sanjay K.;Jensen, Marie M.;Paulsson, Thomas
通讯作者：
Paulsson, Thomas
影响因子：
37.8
作者：
CHAITMAN, BR;BOURASSA, MG;KILLIP, T
通讯作者：
KILLIP, T
影响因子：
39.3
作者：
Douglas PS;Pontone G;Hlatky MA;Patel MR;Norgaard BL;Byrne RA;Curzen N;Purcell I;Gutberlet M;Rioufol G;Hink U;Schuchlenz HW;Feuchtner G;Gilard M;Andreini D;Jensen JM;Hadamitzky M;Chiswell K;Cyr D;Wilk A;Wang F;Rogers C;De Bruyne B;PLATFORM Investigators
通讯作者：
PLATFORM Investigators