Cost-effectiveness comparison of the most common diagnostic modalities in coronary artery disease

摘要

BACKGROUND AND OBJECTIVE: The cost-effectiveness of medical procedures is becoming a crucial factor besides their efficacy in clinical decision-making. We performed a cost-effectiveness analysis of the most common diagnostic modalities used in assessing coronary artery disease (CAD). METHODS: A decision tree model for determining the cost-effectiveness in CAD diagnosis was applied to the situation in Germany to calculate the cost-effectiveness of exercise ECG (ExECG), stress echocardiography (ECHO), myocardial scintigraphy (SPECT), and coronary angiography (ANGIO). The cost-effectiveness was defined as direct and induced costs per correctly identified patient. A sensitivity analysis was performed varying the predictive accuracies, the complication-related costs, and costs and complication rates of ANGIO. RESULTS: The costs per correctly identified patient decreased in a hyperbolic fashion as the pretest likelihood of CAD increased due to the higher incidence of positive findings. For a pretest likelihood between 10 and 40%, ExECG and ECHO were most cost effective with costs per CAD patient of 5,880 - 2,500 EUR and 6,410 - 2,280 EUR, respectively. The combination of ExECG und ECHO (application of the second modality in case the first one was nondiagnostic) further improved the cost-effectiveness up to a pretest likelihood of 35%. For a pretest likelihood of 50% or greater, ANGIO costing 1,880 - 940 EUR per correct diagnosis was most cost-effective. Sensitivity analysis revealed no significant changes demonstrating the robustness of the model. CONCLUSION: ANGIO is the most cost-effective procedure for a pretest likelihood of 50% or greater. At lower pretest likelihoods, ExECG, ECHO and the combined ExECG/ECHO strategy based on economic considerations are the preferred modalities for diagnosis of CAD.