Cost-effectiveness of different diagnostic strategies in suspected stable coronary artery disease in Portugal.

BACKGROUND: Cost-effectiveness is an increasingly important factor in the choice of a test or therapy. OBJECTIVE: To assess the cost-effectiveness of various methods routinely used for the diagnosis of stable coronary disease in Portugal. METHODS: Seven diagnostic strategies were assessed. The cost-effectiveness of each strategy was defined as the cost per correct diagnosis (inclusion or exclusion of obstructive coronary artery disease) in a symptomatic patient. The cost and effectiveness of each method were assessed using Bayesian inference and decision-making tree analyses, with the pretest likelihood of disease ranging from 10% to 90%. RESULTS: The cost-effectiveness of diagnostic strategies was strongly dependent on the pretest likelihood of disease. In patients with a pretest likelihood of disease of ≤50%, the diagnostic algorithms, which include cardiac computed tomography angiography, were the most cost-effective. In these patients, depending on the pretest likelihood of disease and the willingness to pay for an additional correct diagnosis, computed tomography angiography may be used as a frontline test or reserved for patients with positive/inconclusive ergometric test results or a calcium score of >0. In patients with a pretest likelihood of disease of ≥ 60%, up-front invasive coronary angiography appears to be the most cost-effective strategy. CONCLUSIONS: Diagnostic algorithms that include cardiac computed tomography angiography are the most cost-effective in symptomatic patients with suspected stable coronary artery disease and a pretest likelihood of disease of ≤50%. In high-risk patients (pretest likelihood of disease ≥ 60%), up-front invasive coronary angiography appears to be the most cost-effective strategy. In all pretest likelihoods of disease, strategies based on ischemia appear to be more expensive and less effective compared with those based on anatomical tests.

Custo-Efetividade de Diferentes Estratégias Diagnósticas de Doença Coronária Estável em Portugal / Cost-Effectiveness of Different Diagnostic Strategies in Suspected Stable Coronary Artery Disease in Portugal

Fundamento: O custo-efetividade é um fator de crescente importância na escolha de um exame ou terapêutica. Objetivo: Avaliar o custo-efetividade de vários métodos habitualmente empregados no diagnóstico de doença coronária estável em Portugal. Métodos: Foram avaliadas sete estratégias diagnósticas. O custo-efetividade de cada estratégia foi definido como o custo por cada diagnóstico correto (inclusão ou exclusão de doença arterial coronária obstrutiva) num doente sintomático. Os custos e a eficácia de cada método foram avaliados por meio de inferência bayesiana e análise de árvores de decisão, fazendo variar a probabilidade pré-teste entre 10 e 90%. Resultados: O custo-efetividade das várias estratégias diagnósticas é fortemente dependente da probabilidade pré-teste. Em doentes com probabilidade pré-teste ≤ 50%, os algoritmos diagnósticos, que incluem a angiotomografia computadorizada cardíaca são os mais custo-efetivos. Nesses doentes, dependendo da probabilidade pré-teste e da disponibilidade para pagar por diagnóstico correto adicional, a angiotomografia computadorizada pode ser usada como teste de primeira linha ou ser reservada a doentes com teste ergométrico positivo/inconclusivo ou escore de cálcio > 0. Em doentes com probabilidade pré-teste ≥ 60%, o envio direto para angiografia coronária invasiva parece ser a estratégia mais custo-efetiva. Conclusão: Os algoritmos diagnósticos, que incluem a angiotomografia computadorizada cardíaca, são os mais custo-efetivos em doentes sintomáticos com suspeita de doença arterial coronária estável e probabilidade pré-teste ≤ 50%. Em doentes de risco mais elevado (probabilidade pré-teste ≥ 60%), o envio ...

Background: Cost-effectiveness is an increasingly important factor in the choice of a test or therapy. Objective: To assess the cost-effectiveness of various methods routinely used for the diagnosis of stable coronary disease in Portugal. Methods: Seven diagnostic strategies were assessed. The cost-effectiveness of each strategy was defined as the cost per correct diagnosis (inclusion or exclusion of obstructive coronary artery disease) in a symptomatic patient. The cost and effectiveness of each method were assessed using Bayesian inference and decision-making tree analyses, with the pretest likelihood of disease ranging from 10% to 90%. Results: The cost-effectiveness of diagnostic strategies was strongly dependent on the pretest likelihood of disease. In patients with a pretest likelihood of disease of ≤50%, the diagnostic algorithms, which include cardiac computed tomography angiography, were the most cost-effective. In these patients, depending on the pretest likelihood of disease and the willingness to pay for an additional correct diagnosis, computed tomography angiography may be used as a frontline test or reserved for patients with positive/inconclusive ergometric test results or a calcium score of >0. In patients with a pretest likelihood of disease of ≥ 60%, up-front invasive coronary angiography appears to be the most cost-effective strategy. Conclusions: Diagnostic algorithms that include cardiac computed tomography angiography are the most cost-effective in symptomatic patients with suspected stable coronary artery disease and a pretest likelihood of disease of ≤50%. In high-risk patients (pretest likelihood of disease ≥ 60%), up-front invasive coronary angiography appears to be the most cost-effective strategy. In all pretest likelihoods of disease, strategies based on ischemia appear to be more expensive and less effective compared with those based on anatomical tests. .