title: Cost-effectiveness of coronary CT angiography in evaluation of patients without symptoms who have positive stress test results.
abstract: OBJECTIVE
  Patients without symptoms who have positive stress test results are often referred for diagnostic catheter angiography in an evaluation for coronary artery disease (CAD). The purpose of this study was to use decision tree analysis to determine the cost-effectiveness and radiation dose that would result from performing coronary CT angiography (CTA) before catheterization.
  
  
  METHODS
  A decision tree was constructed to compare the false-negative rates, false-positive rates, costs, and radiation exposure of direct referral of patients for cardiac catheterization with the values associated with performing coronary CTA before catheterization. We assumed that patients referred for coronary CTA proceed to catheterization only when significant disease is identified. Costs for coronary CTA and diagnostic catheterization were obtained from the 2009 physician Medicare fee schedule. Sensitivity, specificity, and radiation dose were obtained by literature review.
  
  
  RESULTS
  Cost reduction with coronary CTA depends on the prevalence of coronary artery disease, but overall costs are reduced as long as the prevalence is less than 85%. At a 50% prevalence of coronary artery disease, performing coronary CTA before cardiac catheterization results in an average cost saving of $789 per patient with a false-negative rate of 2.5% and average additional radiation exposure of 1-2 mSv.
  
  
  CONCLUSIONS
  Performing coronary CTA before cardiac catheterization is a cost-effective strategy in the care of patients without symptoms who have positive stress test results when the probability that the patient has significant coronary artery disease is less than 50%. The false-negative rate with this strategy compares favorably with the false-negative rate of stress testing. The use of coronary CTA in this role can avoid many unnecessary cardiac catheterization procedures.
authors.affiliation: Department of Radiology, Thomas Jefferson University, 132 S 10th St, Philadelphia, PA 19107-5244, USA. ethan.halpern@jefferson.edu
authors.forename: Ethan J
authors.initials: EJ
authors.lastname: Halpern
authors.forename: Michael P
authors.initials: MP
authors.lastname: Savage
authors.forename: David L
authors.initials: DL
authors.lastname: Fischman
authors.forename: David C
authors.initials: DC
authors.lastname: Levin
mesh_terms: D017023:Coronary Angiography / Q000191:economics*; D003324:Coronary Artery Disease / Q000175:diagnosis* / Q000453:epidemiology*; D003362:Cost-Benefit Analysis; D005080:Exercise Test / Q000191:economics*; D005260:Female; D017048:Health Care Costs / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D010414:Pennsylvania / Q000453:epidemiology; D015995:Prevalence; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D014057:Tomography, X-Ray Computed / Q000191:economics*