[Comparison of the cost-effectiveness of the most common diagnostic methods for coronary artery disease].
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.


CONCLUSIONS
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.
Dewey
M
M
Institut für Radiologie der Charité-Universitätsmedizin Berlin, Freie Universität und Humboldt-Universität zu Berlin. marc.dewey@charite.de
Hamm
B
B
D015331:Cohort Studies; D017023:Coronary Angiography / Q000191:economics*; D003324:Coronary Artery Disease / Q000175:diagnosis* / Q000191:economics; D003362:Cost-Benefit Analysis; D003657:Decision Making; D003663:Decision Trees; D025401:Echocardiography, Stress / Q000191:economics*; D004562:Electrocardiography / Q000191:economics*; D005080:Exercise Test; D005858:Germany; D017048:Health Care Costs; D006321:Heart / Q000000981:diagnostic imaging / Q000503:physiopathology; D006801:Humans; D016013:Likelihood Functions; D012680:Sensitivity and Specificity; D015899:Tomography, Emission-Computed, Single-Photon / Q000191:economics*