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

描述（由申请人提供）： 我的目标是成为一名杰出的卫生服务调查员，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有效性和安全性。我提出了一个指导计划和学习计划，使我能够评估非侵入性成像在阻塞性冠状动脉疾病（心脏动脉阻塞引起的疾病）管理中的影响和价值。 冠状动脉疾病（CAD）仍然是美国退伍军人和非退伍军人发病和死亡的最常见原因之一。2010年，CAD在美国的估计成本，包括住院和生产力损失在内，约为5032亿美元。诊断成像占与患者护理相关的大部分费用。在过去的三十年里，非侵入性检测，特别是核检查的使用急剧增加，但目前还不清楚患者是否受益于更多的检测或仅仅接受更多的辐射暴露。 目前，对疑似CAD患者的常规评估需要进行初始非侵入性功能测试。如果怀疑缺血，则进行心导管插入术以确定潜在的动脉阻塞。该范例用于限制不必要地暴露于侵入性程序的风险（例如，心脏导管插入术），包括动脉并发症、心律失常（危险的心律）、中风，甚至死亡。此外，它确保获得有限的资源，并尽量减少不必要的费用。 最近在普通人群中的研究表明，目前的模式可能是无效的，并可能增加癌症风险。在一项针对超过35万名非退伍军人的研究中，他们被转介到基于当前范式的心脏导管插入术，只有三分之一的人患有严重疾病并从手术中受益。不仅三分之二的患者没有从手术中受益，而且他们还可能暴露于非侵入性成像测试的低剂量辐射（例如，核试验）。在过去的三十年里，核试验的辐射暴露急剧增加，潜在地增加了癌症风险。这些发现表明，目前的策略的影响和价值需要进一步评估，也许需要一个新的模式来管理阻塞性CAD。 为了解决这一争议，我首先需要确定非侵入性检测的利用模式和影响利用的因素（目标1）。这项检查将使我能够确定是否在利用变化也存在于退伍军人事务部的医疗保健系统。然后，我将使用建模和文献中的最新数据进行成本效益分析，并将辐射暴露量作为潜在的癌症风险（目标2）。最后，我将开发一个临床决策工具，以指导退伍军人护理提供者选择最具成本效益的战略，风险分层和诊断的退伍军人阻塞性CAD。我还将分析实施临床决策工具前后的结果（目标3）。

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).