The Impact and Value of Non-invasive Testing in the Management of Obstructive CAD

无创检测在阻塞性 CAD 管理中的影响和价值

• 批准号: 8844236
• 负责人: Patricia Kim Phuong Nguyen
• 金额: --
• 依托单位: VETERANS ADMIN PALO ALTO HEALTH CARE SYS
• 依托单位国家: 美国
• 财政年份: 2011
• 资助国家: 美国
• 起止时间: 2011-10-01 至 2016-09-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8844236
• 关键词: Accounting; Address; Affect; Angiography; Area; Arrhythmia; Behavior; Cardiac Catheterization Procedures; Cardiovascular Diseases; Caring; Cessation of life; Clinical; Clinical Decision Support Systems; Coronary; Coronary Arteriosclerosis; Coronary artery; Cost Effectiveness Analysis; Data; Data Sources; Databases; Diagnosis; Diagnostic; Diagnostic Imaging; Diagnostic Procedure; Disease; Effectiveness; Ensure; Evaluation; Exposure to; Foundations; General Population; Goals; Guidelines; Health Services; Health Services Research; Healthcare; Healthcare Systems; Heart; Heart failure; Hospitalization; Image; Ischemia; Literature; Low Dose Radiation; Mentors; Mentorship; Meta-Analysis; Modality; Modeling; Morbidity - disease rate; Myocardial Infarction; Myocardial Ischemia; Nuclear; Obstruction; Outcome; Outcome Measure; Patient Care; Patients; Pattern; Positron-Emission Tomography; Procedures; Productivity; Provider; Publishing; Quality of life; Radiation; Research; Research Personnel; Resources; Risk; Safety; Series; Services; Stratification; Stroke; Techniques; Testing; Time; Tissues; Training and Infrastructure; United States; Variant; Vascular blood supply; Veterans; artery occlusion; base; cancer risk; career; career development; cost; cost effective; cost effectiveness; data modeling; design; heart rhythm; improved; markov model; mortality; non-invasive imaging; programs; research and development; research study; single photon emission computed tomography; skills training; tool

DESCRIPTION (provided by applicant): My goal is to become an exceptional health services investigator whose main research focus is to evaluate the efficacy and safety of non-invasive imaging strategies in the management of cardiovascular disease. I propose a mentoring plan and study program that will enable me to evaluate the impact and value of non-invasive imaging in the management of obstructive coronary artery disease (a disease caused by arterial blockages in the heart). Coronary artery disease (CAD) remains one of the most common causes of morbidity and mortality in Veterans and non-Veterans in the United States (U.S). In 2010, the estimated cost of CAD in the U.S., including hospitalizations and lost productivity, is approximately $503.2 billion. Diagnostic imaging accounts for much of the costs associated with patient care. The use of non-invasive testing, especially nuclear exams, has risen dramatically in the last three decades, but it is unclear whether patients are benefiting from more testing or merely receiving more radiation exposure. Routine evaluation of patients with suspected CAD currently requires an initial non-invasive functional test. If ischemia is suspected, cardiac catheterization is performed to identify potential arterial blockages. This paradigm is used to limit unnecessary exposure to the risks of an invasive procedure (e.g., cardiac catheterization) including arterial complications, arrhythmia (dangerous heart rhythms), stroke, and even death. Furthermore, it ensures access to limited resources and minimizes unnecessary costs. Recent studies in the general population suggest that the current paradigm may be potentially ineffective and may increase cancer risk. In a study of over 350,000 non-Veterans who were referred to a cardiac catheterization based on the current paradigm, only one-third had significant disease and benefitted from the procedure. Not only did two thirds of patients not benefit from the procedure, but they may also have been exposed to low dose radiation from non-invasive imaging tests (e.g., nuclear testing). Radiation exposure from nuclear testing has increased dramatically over the past three decades, potentially increasing cancer risk. These findings suggest that the impact and value of current strategies needs to be further evaluated and perhaps a new paradigm for the management of obstructive CAD is needed. To address this controversy, I will first need to determine the utilization pattern of non-invasive testing and the factors affecting utilization (Aim 1). This examination will enable me to determine whether variations in utilization also exist in the Veterans Affairs Health Care System. Then I will perform a cost-effective analysis using modeling and recent data from the literature, taking into account the amount of radiation exposure as a potential cancer risk (Aim 2). Finally, I will develop a clinical decision tool to guide VA care providers to select the most cost-effective strategy for the risk stratification and diagnosis of Veterans with obstructive CAD. I will also analyze outcomes before and after implementation of the clinical decision tool(Aim 3).

描述（由申请人提供）： 我的目标是成为一名杰出的卫生服务研究者，其主要研究重点是评估非侵入性成像策略在心血管疾病管理中的功效和安全性。我提出了一项指导计划和研究计划，该计划将使我能够评估非侵入性成像对阻塞性冠状动脉疾病管理的影响和价值（心脏中动脉堵塞引起的疾病）。 冠状动脉疾病（CAD）仍然是美国退伍军人和非退伍军人（美国）最常见的发病和死亡率原因之一。 2010年，美国CAD的估计成本，包括住院和生产率损失，约为5032亿美元。诊断成像是与患者护理相关的大部分费用。在过去的三十年中，使用非侵入性测试，尤其是核检查，但尚不清楚患者是否从更多的测试中受益还是仅受益于更多的辐射暴露。 当前可疑CAD患者的常规评估需要初始的非侵入性功能测试。如果怀疑缺血，则进行心脏导管插入术以识别潜在的动脉阻塞。该范式用于限制不必要的暴露于侵入性手术的风险（例如心脏导管插入术），包括动脉并发症，心律不齐（危险心律），中风甚至死亡。此外，它可以确保获得有限的资源并最大程度地减少不必要的成本。 对普通人群的最新研究表明，当前的范式可能无效，并可能增加癌症风险。在一项针对350,000多名非退伍军人的研究中，这些非退伍军人根据当前的范例被称为心脏导管插入术，只有三分之一患有重大疾病，并受益于该程序。不仅三分之二的患者无法从该手术中受益，而且还可能因非侵入性成像测试（例如核试验）暴露于低剂量辐射。在过去的三十年中，核试验暴露的辐射暴露已大大增加，可能会增加癌症的风险。这些发现表明，需要进一步评估当前策略的影响和价值，也许需要一个新的阻塞性CAD管理范式。 为了解决这一争议，我首先需要确定非侵入性测试的利用模式以及影响利用率的因素（AIM 1）。这项检查将使我能够确定退伍军人事务医疗保健系统中是否还存在利用方面的差异。然后，我将使用文献中的建模和最新数据进行具有成本效益的分析，并考虑到辐射暴露的量作为潜在的癌症风险（AIM 2）。最后，我将开发一种临床决策工具，以指导VA护理提供者选择最具成本效益的策略来进行阻塞性CAD的退伍军人的风险分层和诊断。我还将在实施临床决策工具之前和之后分析结果（AIM 3）。