Cost-effectiveness of different diagnostic strategies in suspected stable coronary artery disease in Portugal.
BACKGROUND
Cost-effectiveness is an increasingly important factor in the choice of a test or therapy.


OBJECTIVE
To assess the cost-effectiveness of various methods routinely used for the diagnosis of stable coronary disease in Portugal.


METHODS
Seven diagnostic strategies were assessed. The cost-effectiveness of each strategy was defined as the cost per correct diagnosis (inclusion or exclusion of obstructive coronary artery disease) in a symptomatic patient. The cost and effectiveness of each method were assessed using Bayesian inference and decision-making tree analyses, with the pretest likelihood of disease ranging from 10% to 90%.


RESULTS
The cost-effectiveness of diagnostic strategies was strongly dependent on the pretest likelihood of disease. In patients with a pretest likelihood of disease of ≤50%, the diagnostic algorithms, which include cardiac computed tomography angiography, were the most cost-effective. In these patients, depending on the pretest likelihood of disease and the willingness to pay for an additional correct diagnosis, computed tomography angiography may be used as a frontline test or reserved for patients with positive/inconclusive ergometric test results or a calcium score of >0. In patients with a pretest likelihood of disease of ≥ 60%, up-front invasive coronary angiography appears to be the most cost-effective strategy.


CONCLUSIONS
Diagnostic algorithms that include cardiac computed tomography angiography are the most cost-effective in symptomatic patients with suspected stable coronary artery disease and a pretest likelihood of disease of ≤50%. In high-risk patients (pretest likelihood of disease ≥ 60%), up-front invasive coronary angiography appears to be the most cost-effective strategy. In all pretest likelihoods of disease, strategies based on ischemia appear to be more expensive and less effective compared with those based on anatomical tests.
Hospital da Luz, Lisboa, Portugal.
António Miguel
AM
Ferreira
Hospital da Luz, Lisboa, Portugal.
Hugo
H
Marques
Hospital da Luz, Lisboa, Portugal.
Pedro Araújo
PA
Gonçalves
Hospital da Luz, Lisboa, Portugal.
Nuno
N
Cardim
D001499:Bayes Theorem; D057791:Cardiac Imaging Techniques / Q000191:economics / Q000706:statistics & numerical data; D003324:Coronary Artery Disease / Q000175:diagnosis* / Q000191:economics*; D003362:Cost-Benefit Analysis; D003663:Decision Trees; D005080:Exercise Test / Q000191:economics / Q000706:statistics & numerical data; D005188:False Negative Reactions; D005189:False Positive Reactions; D006801:Humans; D011174:Portugal; D012016:Reference Values; D012680:Sensitivity and Specificity