Cost-effectiveness of diagnostic strategies for patients with chest pain.
BACKGROUND
Many noninvasive tests exist to determine whether patients should undergo coronary angiography. The routine use of coronary angiography without previous noninvasive testing is typically not advocated.


OBJECTIVE
To determine the cost-effectiveness of diagnostic strategies for patients with chest pain.


METHODS
Cost-effectiveness analysis.


METHODS
Published data.


METHODS
Patients who present with chest pain, have no history of myocardial infarction, and are able to perform an exercise stress test.


METHODS
Lifetime.


CONCLUSIONS
Societal.


METHODS
No testing, exercise electrocardiography, exercise echocardiography, exercise single-photon emission computed tomography (SPECT), and coronary angiography alone.


METHODS
Quality-adjusted life expectancy, lifetime cost, and incremental cost-effectiveness.


RESULTS
The incremental cost-effectiveness ratio of routine coronary angiography compared with exercise echocardiography was $36,400 per quality-adjusted life-year (QALY) saved for 55-year-old men with typical angina. For 55-year-old men with atypical angina, exercise echocardiography compared with exercise electrocardiography cost $41,900 per QALY saved. If adequate exercise echocardiography was not available, exercise SPECT cost $54,800 per QALY saved compared with exercise electrocardiography for these patients. For 55-year-old men with nonspecific chest pain, the incremental cost-effectiveness ratio of exercise electrocardiography compared with no testing was $57,700 per QALY saved.


RESULTS
On the basis of a probabilistic sensitivity analysis, there is a 75% chance that exercise echocardiography costs less than $50,900 per QALY saved for 55-year-old men with atypical angina.


CONCLUSIONS
Exercise electrocardiography or exercise echocardiography resulted in reasonable cost-effectiveness ratios for patients at mild to moderate risk for coronary artery disease in terms of age, sex, and type of chest pain. Coronary angiography without previous noninvasive testing resulted in reasonable cost-effectiveness ratios for patients with a high pretest probability of coronary artery disease.
Kuntz
K M
KM
Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts, USA. kmk@hsph.harvard.edu
Fleischmann
K E
KE
Hunink
M G
MG
Douglas
P S
PS
D000328:Adult; D000368:Aged; D002637:Chest Pain / Q000209:etiology*; D017023:Coronary Angiography / Q000009:adverse effects / Q000191:economics*; D003327:Coronary Disease / Q000175:diagnosis* / Q000191:economics / Q000453:epidemiology; D003362:Cost-Benefit Analysis; D003663:Decision Trees; D004452:Echocardiography / Q000191:economics* / Q000379:methods; D004562:Electrocardiography / Q000191:economics* / Q000379:methods; D005080:Exercise Test / Q000191:economics; D017048:Health Care Costs; D006801:Humans; D008297:Male; D008875:Middle Aged; D009010:Monte Carlo Method; D015995:Prevalence; D011379:Prognosis; D019057:Quality-Adjusted Life Years; D012307:Risk Factors; D012680:Sensitivity and Specificity; D015899:Tomography, Emission-Computed, Single-Photon / Q000191:economics*