Cost-effectiveness and future implications for cardiovascular imaging

Coronary Computed Tomography Angiography for Assesment of Stable Coronary Artery Disease – a Cost-effectiveness Perspective

Patients with chest pain presenting to the emergency room are currently investigated using either invasive coronary angiography (ICA) or noninvasive coronary computed tomography angiography (CCTA). ICA remains an expensive diagnostic tool and exposes patients to a high risk of periprocedural complication. Besides the currently available expansive economic evidence, there is still an important lingering issue: to establish, from the healthcare provider’s point of view, which is the most cost-effective investigation tool for the detection of significant coronary artery disease. The aim of this article is to present the latest developments in the field of imaging tools for the detection of coronary atherosclerosis in patients with chest pain, from the perspective of a cost-effectiveness analysis.

A Novel Timesaving Method for Hepatobiliary Imaging for Suspected Acute Cholecystitis

OBJECTIVE

To optimize resource utilization of cholescintigraphy for suspected acute cholecystitis with a time-saving method without a loss in diagnostic accuracy.

MATERIALS AND METHODS

Institutional review board approval was obtained for this retrospective study. Hepatobiliary imaging data for 81 patients with suspected acute cholecystitis were recalled for modification into 2 summed static images, using only the first and last 5 minutes of the dynamic images, thereby eliminating the middle 50 minutes of imaging data. Two nuclear medicine physicians interpreted the summed images to assess visualization, and those interpretations were compared to the original reports based on using all 60 minutes of dynamic imaging. A third nuclear medicine physician mediated rare inter-reader interpretive disagreements. Comparison of interpretations of time-saving and conventional methods and also inter-observer variability was achieved using the Cohen κ coefficient analysis.

RESULTS

Interpretations rendered using the time-saving method showed near-perfect agreement with those based on the full dynamic imaging protocol (Cohen κ coefficient = 0.92 for both readers). Furthermore, nuclear medicine physician readers agreed with each other (Cohen κ coefficient = 0.95 between the 2 readers), indicating minimal inter-observer variability using this novel optimized technique.

CONCLUSION

In the setting of suspected acute cholecystitis, imaging resource utilization may be improved, via reduced gamma camera and technologist time, using a novel time-saving method without sacrificing diagnostic accuracy. Multicenter larger trials, however, will be necessary to establish reproducibility.

Appropriate Use Criteria in Echocardiography: An Observational Institutional Study with the Perspective of a Quality Improvement Project

BACKGROUND

Appropriate use criteria (AUC) in echocardiography are essential tools for aligning the indications of echocardiography with the best clinical standards, improving clinical outcome, restraining abuse, and preserving health-care resources.

OBJECTIVES

The aim of this study was to ascertain the AUC for transthoracic echocardiography in a university hospital and create a quality improvement project (QIP).

METHODS

The assessment of 501 inpatients who received transthoracic cardiac echo was conducted according to the 2011 AUC report. Indications were classified as appropriate, uncertain, or inappropriate, and patients not matching any of the abovementioned divisions were grouped in the nonfitting category.

RESULTS

Of the 501 eligible patients, 374 patients (74.66%) were in the appropriate group, 85 patients (16.96%) in the inappropriate group, 20 patients (3.99%) in the uncertain group, and 22 patients (4.39%) in the nonfitting category.

DISCUSSION

Interpretation and analysis of the obtained results are presented, along with the results of many comparable studies; moreover, a QIP was set up accordingly.

CONCLUSION

AUC are useful to assess local practice, preserve health-care resources, and improve clinical outcome.

Cost-effectiveness of computed tomography coronary angiography versus conventional invasive coronary angiography

OBJECTIVES

To determine the costs and cost-effectiveness of a diagnostic strategy including computed tomography coronary angiography (CTCA) in comparison with invasive conventional coronary angiography (CA) for the detection of significant coronary artery disease from the point of view of the healthcare provider.

METHODS

The average cost per CTCA was determined via a micro-costing method in four French hospitals, and the cost of CA was taken from the 2011 French National Cost Study that collects data at the patient level from a sample of 51 public or not-for-profit hospitals.

RESULTS

The average cost of CTCA was estimated to be 180<euro> (95 % CI 162-206<euro>) based on the use of a 64-slice CT scanner active for 10 h per day. The average cost of CA was estimated to be 1,378<euro> (95 % CI 1,126-1,670<euro>). The incremental cost-effectiveness ratio of CA for all patients over a strategy including CTCA triage in the intermediate risk group, no imaging test in the low risk group, and CA in the high risk group, was estimated to be 6,380<euro> (95 % CI 4,714-8,965<euro>) for each additional correctly classified patient. This strategy correctly classifies 95.3 % (95 % CI 94.4-96.2) of all patients in the population studied.

CONCLUSIONS

A strategy of CTCA triage in the intermediate-risk group, no imaging test in the low-risk group, and CA in the high-risk group, has good diagnostic accuracy and could significantly cut costs. Medium-term and long-term outcomes need to be evaluated in patients with coronary stenosis potentially misclassified by CTCA due to false negative examinations.

Cost-effectiveness analysis for imaging techniques with a focus on cardiovascular magnetic resonance

With the need for healthcare cost-containment, increased scrutiny will be placed on new medical therapeutic or diagnostic technologies. Several challenges exist for a new diagnostic test to demonstrate cost-effectiveness. New diagnostic tests differ from therapeutic procedures due to the fact that diagnostic tests do not generally directly affect long-term patient outcomes. Instead, the results of diagnostic tests can influence management decisions for patients and by this route, diagnostic tests indirectly affect long-term outcomes. The benefits from a specific diagnostic technology depend therefore not only on its performance characteristics, but also on other factors such as prevalence of disease, and effectiveness of existing treatments for the disease of interest. We review the concepts and theories of cost-effectiveness analyses (CEA) as they apply to diagnostic tests in general. The limitations of CEA across different study designs and geographic regions are discussed, and we also examine the strengths and weakness of the existing publications where CMR was the focus of CEA compared to other diagnostic options.