title: Cost-effectiveness analysis of diagnostic strategies for suspected pulmonary embolism including helical computed tomography.
abstract: We performed a formal decision analysis to evaluate the cost-effectiveness of various strategies for pulmonary embolism, including helical computed tomography (CT), and determined the most cost-effective schemes for each clinical probability of pulmonary embolism. Other tests included D-dimer (DD), lower limb venous ultrasound (US), ventilation-perfusion (V/Q) scan, and angiography. Outcome measures were 3-month survival and costs per patient managed. Baseline sensitivity of CT was 70%, corresponding to the performance of single-detector CT, and that figure was raised in sensitivity analysis to account for the expected higher sensitivity of newer multidetector CT scanners. All strategies were compared with a reference strategy, namely the V/Q scan in all patients followed when nondiagnostic by an angiogram. For low clinical probability patients, the most cost-effective strategy was DD, US, and V/Q scan, patients with a nondiagnostic V/Q scan being left untreated. Replacing V/Q scan by CT was also cost-effective. For intermediate and high clinical probability patients, a fourth test must be added, either CT or angiography in patients with nondiagnostic V/Q scan, or angiography in patients with a negative helical CT. When using sensitivity figures above 85% (in the multidetector range), DD, US, and CT became the most cost-effective strategy for all clinical probability categories. Helical CT as a single test was not cost-effective. In summary, including helical CT in diagnostic strategies for pulmonary embolism is cost-effective provided that it is combined with DD and US. In contrast, helical CT as a single test is not cost-effective.
authors.affiliation: Medical Clinic 1, Geneva University Hospital, Geneva, Switzerland. arnaud.perrier@medecine.unige.ch
authors.forename: Arnaud
authors.initials: A
authors.lastname: Perrier
authors.forename: Mathieu R
authors.initials: MR
authors.lastname: Nendaz
authors.forename: François P
authors.initials: FP
authors.lastname: Sarasin
authors.forename: Nigel
authors.initials: N
authors.lastname: Howarth
authors.forename: Henri
authors.initials: H
authors.lastname: Bounameaux
mesh_terms: D000792:Angiography; D003362:Cost-Benefit Analysis; D003663:Decision Trees; D005338:Fibrin Fibrinogen Degradation Products / Q000032:analysis; D006801:Humans; D007866:Leg / Q000098:blood supply; D011655:Pulmonary Embolism / Q000175:diagnosis*; D012680:Sensitivity and Specificity; D036542:Tomography, Spiral Computed / Q000191:economics*; D014463:Ultrasonography; D014692:Ventilation-Perfusion Ratio
chemical_list: D005338:Fibrin Fibrinogen Degradation Products; C036309:fibrin fragment D