title: Coronary computed tomography versus exercise testing in patients with stable chest pain: comparative effectiveness and costs.
abstract: BACKGROUND
  To determine the comparative effectiveness and costs of a CT-strategy and a stress-electrocardiography-based strategy (standard-of-care; SOC-strategy) for diagnosing coronary artery disease (CAD).
  
  
  METHODS
  A decision analysis was performed based on a well-documented prospective cohort of 471 outpatients with stable chest pain with follow-up combined with best-available evidence from the literature. Outcomes were correct classification of patients as CAD- (no obstructive CAD), CAD+ (obstructive CAD without revascularization) and indication for Revascularization (using a combination reference standard), diagnostic costs, lifetime health care costs, and quality-adjusted life years (QALY). Parameter uncertainty was analyzed using probabilistic sensitivity analysis.
  
  
  RESULTS
  For men (and women), diagnostic cost savings were €245 (€252) for the CT-strategy as compared to the SOC-strategy. The CT-strategy classified 82% (88%) of simulated men (women) in the appropriate disease category, whereas 83% (85%) were correctly classified by the SOC-strategy. The long-term cost-effectiveness analysis showed that the SOC-strategy was dominated by the CT-strategy, which was less expensive (-€229 in men, -€444 in women) and more effective (+0.002 QALY in men, +0.005 in women). The CT-strategy was cost-saving (-€231) but also less effective compared to SOC (-0.003 QALY) in men with a pre-test probability of ≥ 70%. The CT-strategy was cost-effective in 100% of simulations, except for men with a pre-test probability ≥ 70% in which case it was 59%.
  
  
  CONCLUSIONS
  The results suggest that a CT-based strategy is less expensive and equally effective compared to SOC in all women and in men with a pre-test probability <70%.
authors.affiliation: Department of Epidemiology, Erasmus University Medical Center, Rotterdam, The Netherlands.
authors.forename: Tessa S S
authors.initials: TS
authors.lastname: Genders
authors.forename: Bart S
authors.initials: BS
authors.lastname: Ferket
authors.forename: Admir
authors.initials: A
authors.lastname: Dedic
authors.forename: Tjebbe W
authors.initials: TW
authors.lastname: Galema
authors.forename: Nico R A
authors.initials: NR
authors.lastname: Mollet
authors.forename: Pim J
authors.initials: PJ
authors.lastname: de Feyter
authors.forename: Kirsten E
authors.initials: KE
authors.lastname: Fleischmann
authors.forename: Koen
authors.initials: K
authors.lastname: Nieman
authors.forename: M G Myriam
authors.initials: MG
authors.lastname: Hunink
mesh_terms: D000368:Aged; D002637:Chest Pain / Q000000981:diagnostic imaging* / Q000191:economics* / Q000503:physiopathology; D015331:Cohort Studies; D003362:Cost-Benefit Analysis / Q000191:economics; D005080:Exercise Test / Q000191:economics* / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D059039:Standard of Care / Q000191:economics; D014057:Tomography, X-Ray Computed / Q000191:economics* / Q000379:methods