Cost-effectiveness in diagnosis of stable angina patients: a decision-analytical modelling approach

Economical aspects of coronary angiography for diagnostic purposes: a Belgian perspective

Coronary angiography (CA) is an increasing diagnostic procedure in Belgium. The aim of this analysis was to look at the financial aspects of CA in a large tertiary Belgium hospital to establish if current reimbursement is appropriate. For the analysis of costs we considered the use of the catheterisation laboratory, personnel costs and material costs during multiple weekly periods in the spring of 2023. We calculated that one cathlab needs to perform 8.21 CA's to equal incomes with costs. To allow for a small positive income (200€) for the hospital/cardiologist 9 procedures per cathlab day are required. Our hospital performs a 7 (mean) ± 0.75 (standard deviation) of CA's per cathlab day and therefore does not reach this financial break-even point. Our calculations are on the safe side, since coronary physiological interrogation with fractional flow reserve (FFR) was excluded from this analysis. Nevertheless, this is a cost-effective technique for which no extra reimbursement is foreseen in the current Belgium system.

Health economic consequences of optimal vs. observed guideline adherence of coronary angiography in patients with suspected obstructive stable coronary artery in Germany: a microsimulation model

AIMS

While the number of patients with stable coronary artery disease (SCAD) is similar across European countries, Germany has the highest per capita volume of coronary angiographies (CA). This study evaluated the health economic consequences of guideline-non-adherent use of CA in patients with SCAD.

METHODS AND RESULTS

As part of the ENLIGHT-KHK trial, a prospective observational study, this microsimulation model compared the number of major adverse cardiac events (MACE) and the costs of real-world use of CA with those of (assumed) complete guideline-adherent use (according to the German National Disease Management Guideline 2019). The model considered non-invasive testing, CA, revascularization, MACE (30 days after CA), and medical costs. Model inputs were obtained from the ENLIGHT-KHK trial (i.e. patients' records, a patient questionnaire, and claims data). Incremental cost-effectiveness ratios were calculated by comparing the differences in costs and MACE avoided from the perspective of the Statutory Health Insurance (SHI). Independent on pre-test probability (PTP) of SCAD, complete guideline adherence for usage of CA would result in a slightly lower rate of MACE (-0.0017) and less cost (€-807) per person compared with real-world guideline adherence. While cost savings were shown for moderate and low PTP (€901 and €502, respectively), for a high PTP, a guideline-adherent process results in slightly higher costs (€78) compared with real-world guideline adherence. Sensitivity analyses confirmed the results.

CONCLUSION

Our analysis indicates that improving guideline adherence in clinical practice by reducing the amount of CAs in patients with SCAD would lead to cost savings for the German SHI.

Coronary Computed Tomography Angiography Versus Invasive Coronary Angiography in Stable Chest Pain: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

The efficacy of coronary computed tomography angiography (CCTA) versus invasive coronary angiography (ICA) among patients with stable chest pain has been studied in several trials with conflicting results.

METHODS

We performed a systematic review and meta-analysis comparing CCTA first versus direct ICA among patients with stable chest pain, who were initially referred to ICA. PubMed, EMBASE, and Cochrane Central were searched for randomized controlled trials comparing the 2 strategies. Risk ratios (RRs) and mean differences with 95% CIs were computed for binary and continuous outcomes, respectively.

RESULTS

Five randomized controlled trials with a total of 5727 patients were included, of whom 51.1% were referred to CCTA and 22.5% of patients had evidence of ischemia on a prior functional test. In the follow-up ranging from 1 to 3.5 years, 660 of the 2928 patients randomized to CCTA first underwent ICA (23%). Patients who underwent CCTA had lower rates of coronary revascularization (RR, 0.74 [95% CI, 0.66-0.84]; P<0.001) and stroke (RR, 0.50 [95% CI, 0.26-0.98]; P=0.043). Cardiovascular mortality (RR, 0.55 [95% CI, 0.24-1.23]; P=0.146), major adverse cardiovascular events (RR, 0.84 [95% CI, 0.64-1.10]; P=0.198), nonfatal myocardial infarction (RR, 1.09 [95% CI, 0.63-1.88]; P=0.768), and cardiovascular hospitalizations (RR, 0.91 [95% CI, 0.59-1.39]; P=0.669) did not differ significantly between groups.

CONCLUSIONS

In patients with stable chest pain referred for ICA, CCTA avoided the need for ICA in 77% of patients otherwise referred for ICA. CCTA was associated with a reduction in the rates of coronary revascularization and stroke compared with direct ICA.

REGISTRATION

URL: https://www.crd.york.ac.uk/prospero/; Unique identifier: CRD42023383143.

Management of Residual Risk in Chronic Coronary Syndromes. Clinical Pathways for a Quality-Based Secondary Prevention

Chronic coronary syndrome (CCS), which encompasses a broad spectrum of clinical presentations of coronary artery disease (CAD), is the leading cause of morbidity and mortality worldwide. Recent guidelines for the management of CCS emphasize the dynamic nature of the CAD process, replacing the term "stable" with "chronic", as this disease is never truly "stable". Despite significant advances in the treatment of CAD, patients with CCS remain at an elevated risk of major cardiovascular events (MACE) due to the so-called residual cardiovascular risk. Several pathogenetic pathways (thrombotic, inflammatory, metabolic, and procedural) may distinctly contribute to the residual risk in individual patients and represent a potential target for newer preventive treatments. Identifying the level and type of residual cardiovascular risk is essential for selecting the most appropriate diagnostic tests and follow-up procedures. In addition, new management strategies and healthcare models could further support available treatments and lead to important prognostic benefits. This review aims to provide an overview of the diagnostic and therapeutic challenges in the management of patients with CCS and to promote more effective multidisciplinary care.

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.

Assessment of the Efficiency of Non-Invasive Diagnostic Imaging Modalities for Detecting Myocardial Ischemia in Patients Suspected of Having Stable Angina

This study aimed to assess and compare the efficiency of non-invasive imaging modalities in detecting myocardial ischemia in patients with suspected stable angina as easy-to-understand indices. Our study included 1000 patients with chest pain and possible stable myocardial ischemia. The modalities to be assessed were cardiac magnetic resonance imaging (CMRI), single-photon emission computed tomography, positron emission computed tomography (PET), stress echocardiography, and fractional flow reserve derived from coronary computed tomography angiography (FFRCT). As a simulation study, we assumed that all five imaging modalities were performed on these patients, and a decision tree analysis was conducted. From the results, the following efficiencies were assessed and compared: (1) number of true positive (TP), false positive (FP), false negative (FN), and true negative (TN) test results; (2) positive predictive value (PPV); (3) negative predictive value (NPV); (4) post-test probability; (5) diagnostic accuracy (DA); and (6) number needed to diagnose (NND). In the basic settings (pre-test probability: 30%), PET generated the highest TP (267) and NPV (95%, 95% confidence interval (CI): 93-96%). In contrast, CMRI produced the highest TN (616), PPV (76%, 95% CI: 71-80%), and DA (88%, 95% CI: 86-90%) and the lowest NND (1.33, 95% CI: 1.24-1.47). Although FFRCT generated the highest TP (267) and lowest FN (33), it generated the highest FP (168). In terms of detecting myocardial ischemia, compared with the other modalities, PET and CMRI were more efficient. The results of our study might be helpful for both patients and medical professionals associated with their examination.