Cost-effectiveness of alternative test strategies for the diagnosis of coronary artery disease

被引:167
作者
Garber, AM
Solomon, NA
机构
[1] Stanford Univ, Sch Med, Ctr Primary Care & Outcomes Res, Stanford, CA 94305 USA
[2] Vet Affairs Palo Alto Hlth Care Syst, Stanford, CA 94305 USA
[3] Kaiser Permanente, CAre Management Inst, Oakland, CA 94612 USA
关键词
cost-benefit analysis; coronary disease; outcome and process assessment (health care); coronary angiography; echocardiography;
D O I
10.7326/0003-4819-130-9-199905040-00003
中图分类号
R5 [内科学];
学科分类号
1002 ; 100201 ;
摘要
Background: The appropriate roles for several diagnostic tests for coronary disease are uncertain. Objective: To evaluate the cost-effectiveness of alternative approaches to diagnosis of coronary disease. Design: Meta-analysis of the accuracy of alternative diagnostic tests plus decision analysis to assess the health outcomes and costs of alternative diagnostic strategies for patients at intermediate pretest risk for coronary disease. Data Sources: Studies of test accuracy that met inclusion criteria; published information on treatment effectiveness and disease prevalence. Target Population: Men and women 45, 55, and 65 years of age with a 25% to 75% pretest risk for coronary disease. Time Horizon: 30 years. Perspective: Societal. Interventions: Diagnostic strategies were initial angiography and initial testing with one of five noninvasive tests-exercise treadmill testing, planar thallium imaging, single-photon emission computed tomography (SPECT), stress echocardiography, and positron emission tomography (PET)-followed by coronary angiography if noninvasive test results were positive. Testing was followed by observation, medical treatment, or revascularization. Outcome Measures: Life-years, quality-adjusted life-years (QALYs), costs, and costs per QALY. Results of Base-Case Analysis: Life expectancy varied little with the initial diagnostic test; for a 55-year-old man, the best-performing test increased life expectancy by 7 more days than the worst-performing test. More sensitive tests increased QALYs more. Echocardiography improved health outcomes and reduced costs relative to stress testing and planar thallium imaging. The incremental cost-effectiveness ratio was $75 000/QALY for SPECT relative to echocardiography and was greater than $640 000 for PET relative to SPECT. Compared with SPECT, immediate angiography had an incremental cost-effectiveness ratio of $94 000/QALY. Results of Sensitivity Analysis: Qualitative findings varied little with age, sex, pretest probability of disease, or the test indeterminacy rate. Results varied most with sensitivity to severe coronary disease. Conclusions: Echocardiography, SPECT, and immediate angiography are cost-effective alternatives to PET and other diagnostic approaches. Test selection should reflect local variation in test accuracy.
引用
收藏
页码:719 / +
页数:11
相关论文
共 50 条
[31]   THALLIUM SCINTIGRAPHY DURING DOBUTAMINE INFUSION - NONEXERCISE-DEPENDENT SCREENING-TEST FOR CORONARY-DISEASE [J].
MASON, JR ;
PALAC, RT ;
FREEMAN, ML ;
VIRUPANNAVAR, S ;
LOEB, HS ;
KAPLAN, E ;
GUNNAR, RM .
AMERICAN HEART JOURNAL, 1984, 107 (03) :481-485
[32]  
MAZEIKA P, 1992, BRIT HEART J, V67, P144
[33]   DOBUTAMINE STRESS ECHOCARDIOGRAPHY FOR DETECTION AND ASSESSMENT OF CORONARY-ARTERY DISEASE [J].
MAZEIKA, PK ;
NADAZDIN, A ;
OAKLEY, CM .
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, 1992, 19 (06) :1203-1211
[34]   VARIATION IN PATIENT UTILITIES FOR OUTCOMES OF THE MANAGEMENT OF CHRONIC STABLE ANGINA - IMPLICATIONS FOR CLINICAL-PRACTICE GUIDELINES [J].
NEASE, RF ;
KNEELAND, T ;
OCONNOR, GT ;
SUMNER, W ;
LUMPKINS, C ;
SHAW, L ;
PRYOR, D ;
SOX, HC .
JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, 1995, 273 (15) :1185-1190
[35]   QUANTITATIVE TL-201 SINGLE-PHOTON EMISSION COMPUTED-TOMOGRAPHY DURING MAXIMAL PHARMACOLOGICAL CORONARY VASODILATION WITH ADENOSINE FOR ASSESSING CORONARY-ARTERY DISEASE [J].
NISHIMURA, S ;
MAHMARIAN, JJ ;
BOYCE, TM ;
VERANI, MS .
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, 1991, 18 (03) :736-745
[36]   COMPARISON OF COST-EFFECTIVENESS AND UTILITY OF EXERCISE ECG, SINGLE-PHOTON EMISSION COMPUTED-TOMOGRAPHY, POSITRON EMISSION TOMOGRAPHY, AND CORONARY ANGIOGRAPHY FOR DIAGNOSIS OF CORONARY-ARTERY DISEASE [J].
PATTERSON, RE ;
EISNER, RL ;
HOROWITZ, SF .
CIRCULATION, 1995, 91 (01) :54-65
[37]   COMPARISON OF DOBUTAMINE STRESS ECHOCARDIOGRAPHY, DIPYRIDAMOLE STRESS ECHOCARDIOGRAPHY AND EXERCISE STRESS-TESTING FOR DIAGNOSIS OF CORONARY-ARTERY DISEASE [J].
PREVITALI, M ;
LANZARINI, L ;
FETIVEAU, R ;
POLI, A ;
FERRARIO, M ;
FALCONE, C ;
MUSSINI, A .
AMERICAN JOURNAL OF CARDIOLOGY, 1993, 72 (12) :865-870
[38]   10-YEAR FOLLOW-UP OF QUALITY-OF-LIFE IN PATIENTS RANDOMIZED TO RECEIVE MEDICAL THERAPY OR CORONARY-ARTERY BYPASS GRAFT-SURGERY - THE CORONARY-ARTERY SURGERY STUDY (CASS) [J].
ROGERS, WJ ;
COGGIN, CJ ;
GERSH, BJ ;
FISHER, LD ;
MYERS, WO ;
OBERMAN, A ;
SHEFFIELD, LT .
CIRCULATION, 1990, 82 (05) :1647-1658
[39]   DOBUTAMINE STRESS ECHOCARDIOGRAPHY - ITS ROLE IN THE DIAGNOSIS OF CORONARY-ARTERY DISEASE [J].
SALUSTRI, A ;
FIORETTI, PM ;
POZZOLI, MMA ;
MCNEILL, AJ ;
ROELANDT, JRTC .
EUROPEAN HEART JOURNAL, 1992, 13 (01) :70-77
[40]  
SCHWAIGER M, 1994, J NUCL MED, V35, P693