Based on an analysis of ROMICAT I data, coronary CT angiography could lower costs for hospitals treating emergency department (ED) patients with acute chest pain by 23 percent if the patients are at low to intermediate risk of coronary artery disease (CAD). But the cost pendulum could swing the other way if the prevalence of indeterminate or significant CAD is high.
The results were published online Sept. 10 in Circulation: Cardiovascular Quality and Outcomes.
ROMICAT I (Rule Out Myocardial Infarction Using Computer Assisted Tomography I) was a double-blind observational study that enrolled 368 consecutive patients with acute chest pain who awaited hospital admission between 2005 and 2007. The study contained costs for usual care, length of stay, resource use and CT angiography results for each patient.
“The ROMICAT I study design is uniquely suited for observing actual cost of care because physicians were blinded to cCTA [coronary CT angiography] findings and subsequent patient management was based exclusively on the ED and subsequent care team discretion,” wrote lead author Edward Hulten, MD, MPH, of the Noninvasive Cardiovascular Imaging Program at Brigham and Women’s Hospital in Boston, and colleagues.
They calculated total costs for each patient in 2007 dollars and divided patients into one of four groups based on cCTA findings: negative cCTA (50 percent of the total number of patients); no significant stenosis (less than 50 percent stenosis, 32 percent of patients); indeterminate stenosis (9 percent); and significant stenosis (50 percent or greater stenosis, 9 percent of patients). They then compared actual costs with hypothetical costs using a baseline and three alternate care scenarios.
Hulten et al reported substantial savings—63 percent to 56 percent of the costs of usual care—in scenarios of no to mild CAD due to shorter length of stay and the avoidance of downstream testing. But costs for patients with indeterminate or significant CAD were 10 percent to 14 percent higher than usual care because of additional testing and no reduction in length of stay.
Overall, they found that total hospital stay costs would be reduced by 15 percent to 23 percent using cCTA in the triage of ACS patients in the ED. “Given that $10 billion are spent each year in the United States on the evaluation of acute chest pain, on aggregate, these findings could translate into significant cost savings,” they proposed.
In an accompanying editorial, Peter W. Groeneveld, MD, of the University of Pennsylvania School of Medicine in Philadelphia, underscored the challenges of applying cCTA as a cost-saving approach in the ED. He wrote that savings hinge on the “frequency that the right ED chest pain patients, and only the right patients, undergo coronary CTA.” Identifying such patients is “not straightforward.”
Fear of litigation might motivate some physicians to order tests for patients who did not meet the eligibility criteria of ROMICAT I, he added.
“If coronary CTA becomes widely available in U.S. emergency departments, cost savings will only be realized if the thousands of patients with chest pain that is either too unlikely, or too likely, to be caused by myocardial ischemia do not undergo coronary CTA. This is a narrow path not often followed by clinicians using new medical technology, and even potentially cost-saving technologies can quickly become contributors to the national problem of rising healthcare costs,” Groeneveld concluded.