Cardiovascular magnetic resonance in emergency patients with multivessel disease or unobstructed coronary arteries: a cost-effectiveness analysis in the UK

Cost-effectiveness of cardiovascular magnetic resonance imaging compared to common strategies in the diagnosis of coronary artery disease: a systematic review

Cardiovascular magnetic resonance imaging (CMR) has established exceptional diagnostic utility and prognostic value in coronary artery disease (CAD). An assessment of the current evidence on the cost-effectiveness of CMR in patients referred for the investigation of CAD is essential for developing an economic model to evaluate the cost-effectiveness of CMR in CAD. We conducted a comprehensive search of multiple electronic databases, including PubMed, Scopus, Web of Science core collection, Embase, National Health Service Economic Evaluation Database (NHS EED), and health technology assessment, to identify relevant literature. After removing duplicates and screening the title/abstract, a total of 13 articles were deemed eligible for full-text assessment. We included studies that reported one or more of the following outcomes: incremental cost-effectiveness ratio (ICER), cost per quality-adjusted life year (QALYs), cost per life year gained, sensitivity and specificity rate as the primary outcome, and health utility measures or health-related quality of life as the secondary outcome. The quality of the included studies was assessed using the CHEERS 2022 guidelines. The findings of this study demonstrate that in patients undergoing urgent percutaneous coronary intervention, CMR over a one-year and lifetime horizon leads to higher quality-adjusted life years (QALYs) compared to current strategies in cases of multivessel disease. The systematic review indicates that the CMR-based strategy is more cost-effective when compared to standard methods such as single-photon emission computed tomography (SPECT), coronary computed tomography angiography (CCTA), and coronary angiography (CA) (CMR = $19,273, SPECT = $19,578, CCTA = $19,886, and immediate CA = $20,929). The results also suggest that the CMR strategy can serve as a cost-effective gatekeeping tool for patients at risk of obstructive CAD. A CMR-based strategy for managing patients with suspected CAD is more cost-effective compared to both invasive and non-invasive strategies, particularly in real-world patient populations with a low to intermediate prevalence of the disease.

Health Economic Analysis of CMR: A Systematic Review

INTRODUCTION

Uptake of cardiac magnetic resonance (CMR) in Australia has been limited by issues of cost and access. There is a need to inform future application of CMR by evaluating pertinent health economic literature. We sought to perform a systematic review on the health economic data as it pertains to CMR.

METHODS

Eight databases (biomedical/health economic) were searched for relevant articles highlighting economic evaluations of CMR. Following screening, studies that reported health economic outcomes (e.g., dollars saved, quality adjusted life years [QALY] and cost effectiveness ratios) were included. Data on cost effectiveness, clinical/disease characteristics, type of modelling were extracted and summarised.

RESULTS

Thirty-eight (38) articles informed the systematic review. Health economic models used to determine cost effectiveness included both trial-based studies (n=14) and Markov modelling (n=24). Comparative strategies ranged from nuclear imaging, stress echocardiography and invasive angiography. The disease states examined included coronary artery disease (23/38), acute coronary syndrome (3/38), heart failure (5/38) and miscellaneous (7/38). The majority of studies (n=29/38) demonstrated CMR as a strategy which is either economically dominant, cost-effective or cost-saving.

CONCLUSION

This systematic review demonstrates that CMR is cost-effective depending on diagnostic strategy, population and disease state. The lack of standardised protocols for application of CMR, economic models used and outcomes reported limits the ability to meta-analyse the available health economic data.

The Merits, Limitations, and Future Directions of Cost-Effectiveness Analysis in Cardiac MRI with a Focus on Coronary Artery Disease: A Literature Review

Cardiac magnetic resonance (CMR) imaging has a wide range of clinical applications with a high degree of accuracy for many myocardial pathologies. Recent literature has shown great utility of CMR in diagnosing many diseases, often changing the course of treatment. Despite this, it is often underutilized possibly due to perceived costs, limiting patient factors and comfort, and longer examination periods compared to other imaging modalities. In this regard, we conducted a literature review using keywords “Cost-Effectiveness” and “Cardiac MRI” and selected articles from the PubMed MEDLINE database that met our inclusion and exclusion criteria to examine the cost-effectiveness of CMR. Our search result yielded 17 articles included in our review. We found that CMR can be cost-effective in quality-adjusted life years (QALYs) in select patient populations with various cardiac pathologies. Specifically, the use of CMR in coronary artery disease (CAD) patients with a pretest probability below a certain threshold may be more cost-effective compared to patients with a higher pretest probability, although its use can be limited based on geographic location, professional society guidelines, and differing reimbursement patterns. In addition, a stepwise combination of different imaging modalities, with conjunction of AHA/ACC guidelines can further enhance the cost-effectiveness of CMR.

A national registry to assess the value of cardiovascular magnetic resonance imaging after primary percutaneous coronary intervention pathway activation: a feasibility cohort study

Background

Cardiovascular magnetic resonance (CMR) is increasingly used in patients who activate the primary percutaneous coronary intervention (PPCI) pathway to assess heart function. It is uncertain whether having CMR influences patient management or the risk of major adverse cardiovascular events in these patients.

Objective

To determine whether or not it is feasible to set up a national registry, linking routinely collected data from hospital information systems (HISs), to investigate the role of CMR in patients who activate the PPCI pathway.

Design

A feasibility prospective cohort study.

Setting

Four 24/7 PPCI hospitals in England and Wales (two with and two without a dedicated CMR facility).

Participants

Patients who activated the PPCI pathway and underwent an emergency coronary angiogram.

Interventions

CMR either performed or not performed within 10 weeks of the index event.

Main outcome measures

A. Feasibility parameters – (1) patient consent implemented at all hospitals, (2) data extracted from more than one HIS and successfully linked for > 90% of consented patients at all four hospitals, (3) HIS data successfully linked with Hospital Episode Statistics (HES) and Patient Episode Database Wales (PEDW) for > 90% of consented patients at all four hospitals and (4) CMR requested and carried out for ≥ 10% of patients activating the PPCI pathway in CMR hospitals. B. Key drivers of cost-effectiveness for CMR (identified from simple cost-effectiveness models) in patients with (1) multivessel disease and (2) unobstructed coronary arteries. C. A change in clinical management arising from having CMR (defined using formal consensus and identified using HES follow-up data in the 12 months after the index event).

Results

A. (1) Consent was implemented (for all hospitals, consent rates were 59–74%) and 1670 participants were recruited. (2) Data submission was variable – clinical data available for ≥ 82% of patients across all hospitals, biochemistry and echocardiography (ECHO) data available for ≥ 98%, 34% and 87% of patients in three hospitals and medications data available for 97% of patients in one hospital. (3) HIS data were linked with hospital episode data for 99% of all consented patients. (4) At the two CMR hospitals, 14% and 20% of patients received CMR. B. In both (1) multivessel disease and (2) unobstructed coronary arteries, the difference in quality-adjusted life-years (QALYs) between CMR and no CMR [‘current’ comparator, stress ECHO and standard ECHO, respectively] was very small [0.0012, 95% confidence interval (CI) –0.0076 to 0.0093 and 0.0005, 95% CI –0.0050 to 0.0077, respectively]. The diagnostic accuracy of the ischaemia tests was the key driver of cost-effectiveness in sensitivity analyses for both patient subgroups. C. There was consensus that CMR leads to clinically important changes in management in five patient subgroups. Some changes in management were successfully identified in hospital episode data (e.g. new diagnoses/procedures, frequency of outpatient episodes related to cardiac events), others were not (e.g. changes in medications, new diagnostic tests).

Conclusions

A national registry is not currently feasible. Patients were consented successfully but conventional consent could not be implemented nationally. Linking HIS and hospital episode data was feasible but HIS data were not uniformly available. It is feasible to identify some, but not all, changes in management in the five patient subgroups using hospital episode data. The delay in obtaining hospital episode data influenced the relevance of some of our study objectives.

Future work

To test the feasibility of conducting the study using national data sets (e.g. HES, British Cardiovascular Intervention Society audit database, Diagnostic Imaging Dataset, Clinical Practice Research Datalink).

Funding

The National Institute for Health Research (NIHR) Health Services and Delivery Research programme. This study was designed and delivered in collaboration with the Clinical Trials and Evaluation Unit, a UK Clinical Research Collaboration-registered clinical trials unit that, as part of the Bristol Trials Centre, is in receipt of NIHR clinical trials unit support funding.