title: Long-term Cost-Effectiveness of Diagnostic Tests for Assessing Stable Chest Pain: Modeled Analysis of Anatomical and Functional Strategies.
abstract: Several tests exist for diagnosing coronary artery disease, with varying accuracy and cost. We sought to provide cost-effectiveness information to aid physicians and decision-makers in selecting the most appropriate testing strategy. We used the state-transitions (Markov) model from the Brazilian public health system perspective with a lifetime horizon. Diagnostic strategies were based on exercise electrocardiography (Ex-ECG), stress echocardiography (ECHO), single-photon emission computed tomography (SPECT), computed tomography coronary angiography (CTA), or stress cardiac magnetic resonance imaging (C-MRI) as the initial test. Systematic review provided input data for test accuracy and long-term prognosis. Cost data were derived from the Brazilian public health system. Diagnostic test strategy had a small but measurable impact in quality-adjusted life-years gained. Switching from Ex-ECG to CTA-based strategies improved outcomes at an incremental cost-effectiveness ratio of 3100 international dollars per quality-adjusted life-year. ECHO-based strategies resulted in cost and effectiveness almost identical to CTA, and SPECT-based strategies were dominated because of their much higher cost. Strategies based on stress C-MRI were most effective, but the incremental cost-effectiveness ratio vs CTA was higher than the proposed willingness-to-pay threshold. Invasive strategies were dominant in the high pretest probability setting. Sensitivity analysis showed that results were sensitive to costs of CTA, ECHO, and C-MRI. Coronary CT is cost-effective for the diagnosis of coronary artery disease and should be included in the Brazilian public health system. Stress ECHO has a similar performance and is an acceptable alternative for most patients, but invasive strategies should be reserved for patients at high risk.
authors.affiliation: Internal Medicine Division, Federal University of Pelotas, Pelotas, Brazil.|Institute of Health Technology Assessment, Porto Alegre, Brazil.|Graduate Program in Cardiology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil.
authors.forename: Eduardo G
authors.identifier: http://orcid.org/0000-0001-7290-0348
authors.initials: EG
authors.lastname: Bertoldi
authors.affiliation: Institute of Health Technology Assessment, Porto Alegre, Brazil.|Graduate Program in Cardiology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil.
authors.forename: Steffan F
authors.initials: SF
authors.lastname: Stella
authors.affiliation: Graduate Program in Cardiology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil.
authors.forename: Luis E
authors.initials: LE
authors.lastname: Rohde
authors.affiliation: Institute of Health Technology Assessment, Porto Alegre, Brazil.|Graduate Program in Cardiology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil.
authors.forename: Carisi A
authors.initials: CA
authors.lastname: Polanczyk
mesh_terms: D000787:Angina Pectoris / Q000175:diagnosis* / Q000191:economics* / Q000209:etiology; D001938:Brazil; D000072226:Computed Tomography Angiography / Q000191:economics; D017023:Coronary Angiography / Q000191:economics; D003324:Coronary Artery Disease / Q000150:complications / Q000175:diagnosis* / Q000191:economics*; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D003935:Diagnostic Techniques, Cardiovascular / Q000191:economics*; D025401:Echocardiography, Stress / Q000191:economics; D005080:Exercise Test / Q000191:economics; D005260:Female; D017048:Health Care Costs; D006801:Humans; D008279:Magnetic Resonance Imaging / Q000191:economics; D008297:Male; D008390:Markov Chains; D008875:Middle Aged; D018803:Models, Economic; D055414:Myocardial Perfusion Imaging / Q000191:economics; D011237:Predictive Value of Tests; D011379:Prognosis; D011634:Public Health / Q000191:economics; D019057:Quality-Adjusted Life Years; D015203:Reproducibility of Results; D013997:Time Factors; D015899:Tomography, Emission-Computed, Single-Photon / Q000191:economics