title: A simulation model of clinical and economic outcomes of cardiac CT triage of patients with acute chest pain in the emergency department.
abstract: OBJECTIVE
  Uncertainty exists as to whether coronary CT angiography (CTA) compared with standard of care (SOC) is more effective and efficient in the triage of low-risk emergency department (ED) patients with acute chest pain. Our objective was to construct a simulation model to estimate clinical and economic outcomes.
  
  
  METHODS
  We constructed a microsimulation model comparing SOC to coronary CTA-based triage of 1000 55-year-old patients (50% men) with acute chest pain, nonsignificant ECG changes, and initial negative cardiac markers. In SOC, patients were reevaluated with serial cardiac markers after 6-8 hours, followed by either nuclear stress imaging (SPECT) or stress echocardiography. In coronary CTA-based triage, patients were imaged immediately and, depending on the results, discharged, held for SPECT or stress echocardiography, or referred directly to invasive coronary angiography.
  
  
  RESULTS
  Compared with SOC, coronary CTA-based triage reduced the number of patients referred for invasive coronary angiography from 406 (SPECT) or 370 (stress echocardiography) to 255 per 1000 and resulted in fewer "missed" cases of acute coronary syndrome overall (5 vs 18). Coronary CTA-based triage also resulted in fewer deaths (4 vs 6). Coronary CTA led to immediate discharge of 706 patients and produced average cost-savings in the ED of $851 (SPECT) or $462 (stress echocardiography) per patient. At 30 days after initial ED triage, coronary CTA-based management produced average savings of $283 (SPECT) and average costs of $292 (stress echocardiography) per patient triaged.
  
  
  CONCLUSIONS
  Our model suggests that coronary CTA-based triage of low-risk patients with acute chest pain in the ED might reduce invasive catheterizations, could improve survival, and may save money.
authors.affiliation: Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, 101 Merrimac St, 10th Fl, Boston, MA 02114, USA. alex@mgh-ita.org
authors.forename: Alexander
authors.initials: A
authors.lastname: Goehler
authors.forename: Daniel A
authors.initials: DA
authors.lastname: Ollendorf
authors.forename: Marie
authors.initials: M
authors.lastname: Jaeger
authors.forename: Joseph
authors.initials: J
authors.lastname: Ladapo
authors.forename: Till
authors.initials: T
authors.lastname: Neumann
authors.forename: G Scott
authors.initials: GS
authors.lastname: Gazelle
authors.forename: Steven D
authors.initials: SD
authors.lastname: Pearson
mesh_terms: D002637:Chest Pain / Q000000981:diagnostic imaging*; D017023:Coronary Angiography / Q000191:economics*; D017046:Cost Savings; D003365:Costs and Cost Analysis; D025401:Echocardiography, Stress / Q000191:economics; D004562:Electrocardiography; D004636:Emergency Service, Hospital / Q000191:economics*; D005260:Female; D006801:Humans; D033162:Incidental Findings; D008297:Male; D008875:Middle Aged; D018803:Models, Economic; D009010:Monte Carlo Method; D012680:Sensitivity and Specificity; D059039:Standard of Care; D015899:Tomography, Emission-Computed, Single-Photon / Q000191:economics; D014057:Tomography, X-Ray Computed / Q000191:economics*; D014218:Triage / Q000191:economics*