title: Cost-minimization analysis of three decision strategies for cardiac revascularization: results of the "suspected CAD" cohort of the european cardiovascular magnetic resonance registry.
abstract: BACKGROUND
  Coronary artery disease (CAD) continues to be one of the top public health burden. Perfusion cardiovascular magnetic resonance (CMR) is generally accepted to detect CAD, while data on its cost effectiveness are scarce. Therefore, the goal of the study was to compare the costs of a CMR-guided strategy vs two invasive strategies in a large CMR registry.
  
  
  METHODS
  In 3'647 patients with suspected CAD of the EuroCMR-registry (59 centers/18 countries) costs were calculated for diagnostic examinations (CMR, X-ray coronary angiography (CXA) with/without FFR), revascularizations, and complications during a 1-year follow-up. Patients with ischemia-positive CMR underwent an invasive CXA and revascularization at the discretion of the treating physician (=CMR + CXA-strategy). In the hypothetical invasive arm, costs were calculated for an initial CXA and a FFR in vessels with ≥50% stenoses (=CXA + FFR-strategy) and the same proportion of revascularizations and complications were applied as in the CMR + CXA-strategy. In the CXA-only strategy, costs included those for CXA and for revascularizations of all ≥50% stenoses. To calculate the proportion of patients with ≥50% stenoses, the stenosis-FFR relationship from the literature was used. Costs of the three strategies were determined based on a third payer perspective in 4 healthcare systems.
  
  
  RESULTS
  Revascularizations were performed in 6.2%, 4.5%, and 12.9% of all patients, patients with atypical chest pain (n = 1'786), and typical angina (n = 582), respectively; whereas complications (=all-cause death and non-fatal infarction) occurred in 1.3%, 1.1%, and 1.5%, respectively. The CMR + CXA-strategy reduced costs by 14%, 34%, 27%, and 24% in the German, UK, Swiss, and US context, respectively, when compared to the CXA + FFR-strategy; and by 59%, 52%, 61% and 71%, respectively, versus the CXA-only strategy. In patients with typical angina, cost savings by CMR + CXA vs CXA + FFR were minimal in the German (2.3%), intermediate in the US and Swiss (11.6% and 12.8%, respectively), and remained substantial in the UK (18.9%) systems. Sensitivity analyses proved the robustness of results.
  
  
  CONCLUSIONS
  A CMR + CXA-strategy for patients with suspected CAD provides substantial cost reduction compared to a hypothetical CXA + FFR-strategy in patients with low to intermediate disease prevalence. However, in the subgroup of patients with typical angina, cost savings were only minimal to moderate.
authors.affiliation: Healthcare Evaluation Unit, Institute of Social and Preventive Medicine (IUMSP), Lausanne, Switzerland. karine.moschetti@chuv.ch.|Technology Assessment Unit, University Hospital of Lausanne, Lausanne, Switzerland. karine.moschetti@chuv.ch.
authors.forename: Karine
authors.initials: K
authors.lastname: Moschetti
authors.affiliation: William Harvey Research Institute, NIHR Cardiovascular Biomedical Research Unit at Barts, Queen Mary University of London, London, UK. s.e.petersen@qmul.ac.uk.
authors.forename: Steffen E
authors.initials: SE
authors.lastname: Petersen
authors.affiliation: Clinic Agatharied, Academic Teaching Hospital, University of Munich, Munich, Germany. pilz@khagatharied.de.
authors.forename: Guenter
authors.initials: G
authors.lastname: Pilz
authors.affiliation: Brigham and Women's Hospital, Harvard Medical School, Boston, USA. rykwong@partners.org.
authors.forename: Raymond Y
authors.initials: RY
authors.lastname: Kwong
authors.affiliation: Technology Assessment Unit, University Hospital of Lausanne, Lausanne, Switzerland. Jean-Blaise.Wasserfallen@chuv.ch.
authors.forename: Jean-Blaise
authors.initials: JB
authors.lastname: Wasserfallen
authors.affiliation: Policlinics of San Donato, Italian Research Hospital, Milano, Italy. Massimo.Lombardi@grupposandonato.it.
authors.forename: Massimo
authors.initials: M
authors.lastname: Lombardi
authors.affiliation: University Hospital of Heidelberg, Heidelberg, Germany. gkorosoglou@hotmail.com.
authors.forename: Grigorios
authors.initials: G
authors.lastname: Korosoglou
authors.affiliation: VU University Medical Center, Amsterdam, The Netherlands. ac.vrossum@vumc.nl.
authors.forename: Albert C
authors.initials: AC
authors.lastname: Van Rossum
authors.affiliation: Elisabeth Hospital, Department of Cardiology and Angiology, Elisabeth Hospital Essen, Essen, Germany. o.bruder@contilia.de.
authors.forename: Oliver
authors.initials: O
authors.lastname: Bruder
authors.affiliation: Department of Cardiology, Robert Bosch Hospital, Stuttgart, Germany. heiko.mahrholdt@rbk.de.
authors.forename: Heiko
authors.initials: H
authors.lastname: Mahrholdt
authors.affiliation: Division of Cardiology, Director Cardiac MR Center, University Hospital Lausanne - CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland. jurg.schwitter@chuv.ch.
authors.forename: Juerg
authors.initials: J
authors.lastname: Schwitter
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000787:Angina Pectoris / Q000175:diagnosis / Q000191:economics / Q000628:therapy; D006328:Cardiac Catheterization / Q000191:economics*; D017023:Coronary Angiography / Q000191:economics* / Q000379:methods; D003324:Coronary Artery Disease / Q000175:diagnosis* / Q000191:economics* / Q000453:epidemiology / Q000503:physiopathology / Q000628:therapy*; D017046:Cost Savings; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D005060:Europe / Q000453:epidemiology; D005260:Female; D053805:Fractional Flow Reserve, Myocardial; D017048:Health Care Costs; D006801:Humans; D008279:Magnetic Resonance Imaging / Q000191:economics*; D008297:Male; D008875:Middle Aged; D018803:Models, Economic; D055414:Myocardial Perfusion Imaging / Q000191:economics* / Q000379:methods; D009204:Myocardial Revascularization / Q000009:adverse effects / Q000191:economics*; D018579:Patient Selection; D011237:Predictive Value of Tests; D015995:Prevalence; D011446:Prospective Studies; D012042:Registries; D012720:Severity of Illness Index; D013997:Time Factors; D014057:Tomography, X-Ray Computed / Q000191:economics*; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology; D055815:Young Adult