Sixty-four–slice Computed Tomography of the Coronary Arteries: Cost–Effectiveness Analysis of Patients Presenting to the Emergency Department with Low-risk Chest Pain

Authors

  • Rahul K. Khare MD,

    1. From the Department of Emergency Medicine (RKK, DMC, ESP, AKV), Institute for Healthcare Studies and Division of General Internal Medicine (RKK, TAL), Northwestern University, Feinberg School of Medicine, Chicago, IL; and the Center for Management of Complex Chronic Care, Hines Veterans’ Administration Hospital (TAL), Hines, IL.
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  • D. Mark Courtney MD,

    1. From the Department of Emergency Medicine (RKK, DMC, ESP, AKV), Institute for Healthcare Studies and Division of General Internal Medicine (RKK, TAL), Northwestern University, Feinberg School of Medicine, Chicago, IL; and the Center for Management of Complex Chronic Care, Hines Veterans’ Administration Hospital (TAL), Hines, IL.
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  • Emilie S. Powell MD, MBA,

    1. From the Department of Emergency Medicine (RKK, DMC, ESP, AKV), Institute for Healthcare Studies and Division of General Internal Medicine (RKK, TAL), Northwestern University, Feinberg School of Medicine, Chicago, IL; and the Center for Management of Complex Chronic Care, Hines Veterans’ Administration Hospital (TAL), Hines, IL.
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  • Arjun K. Venkatesh MBA,

    1. From the Department of Emergency Medicine (RKK, DMC, ESP, AKV), Institute for Healthcare Studies and Division of General Internal Medicine (RKK, TAL), Northwestern University, Feinberg School of Medicine, Chicago, IL; and the Center for Management of Complex Chronic Care, Hines Veterans’ Administration Hospital (TAL), Hines, IL.
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  • Todd A. Lee PharmD, PhD

    1. From the Department of Emergency Medicine (RKK, DMC, ESP, AKV), Institute for Healthcare Studies and Division of General Internal Medicine (RKK, TAL), Northwestern University, Feinberg School of Medicine, Chicago, IL; and the Center for Management of Complex Chronic Care, Hines Veterans’ Administration Hospital (TAL), Hines, IL.
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  • Presented as an oral presentation at Society of Academic Emergency Medicine national conference, San Francisco, May 2006.

  • Research for this article was performed while Dr. Khare was a National Research Service Award T32HS000078 postdoctoral fellow at the Institute for Healthcare Studies at Northwestern University under an institutional award from the Agency for Healthcare Research and Quality. Dr. Courtney has received support from Grant 5K23HL077404-04 from the National Heart, Lung, and Blood Institute.

Address for correspondence and reprints: Rahul K. Khare, MD; e-mail: rkhare@northwestern.edu.

Abstract

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, <$2,097; cost of OU care, >$1,092; prevalence of CAD, <70%; MDCT specificity, >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.

ACADEMIC EMERGENCY MEDICINE 2008; 15:1–10 © 2008 by the Society for Academic Emergency Medicine

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