AJR: CCTA is cost-saving for low-risk womennot men

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Coronary CT angiography (CCTA)-based triage for patients with low-risk chest pain is modestly more effective than the standard-of-care, and it is also associated with cost-saving in women and low cost-effectiveness ratios in men, according to a study in the August issue of the American Journal Roentgenology.

Joseph A. Ladapo, MD, from the Harvard PhD Program in Health Policy in Cambridge, Mass., and colleagues undertook the study to determine if patients at low risk for acute coronary syndrome (ACS), who present to the emergency department (ED) complaining of acute chest pain, place a substantial economic burden on the U.S. healthcare system.

The researchers developed a microsimulation model to compare costs and health effects of performing CCTA angiography and either discharging, stress testing or referring ED patients for invasive coronary angiography, depending on their severity of atherosclerosis, which they compared with a standard-of-care algorithm that based management on biomarkers and stress tests alone.

Using CCTA to triage 55-year-old men with acute chest pain increased ED and hospital costs by $110 and raised total healthcare costs by $200, according to the investigators. In 55-year-old women, the technology was cost-saving; ED and hospital costs decreased by $410, and total healthcare costs decreased by $380.

Compared with the standard-of-care, Ladapo and colleagues found that CCTA-based triage extended life expectancy by 10 days in men and by six days in women, which translated into corresponding improvements of 0.03 quality-adjusted life years (QALYs) and 0.01 QALYs, respectively.

The authors wrote that the incremental cost-effectiveness ratio for CCTA was $6,400 per QALY in men; in women, CCTA was cost-saving. They also found that the cost-effectiveness ratios were sensitive to several parameters, but generally remained in the range of what is typically considered cost-effective.

The researchers also found that both CCTA and the standard-of-care are associated with a low rate of missed ACS, and that the portion of these cases that represent incidences of cardiac syndrome X is much higher with CCTA. However, the incidence is higher because, under the standard-of-care, nearly all syndrome X patients are admitted, whereas CCTA-based triage will generally lead to their discharge because most will have negative imaging tests.

The authors noted that CCTA raised overall costs in men primarily because it was more likely to identify patients with CAD, and the patients incurred costs related to a lifetime of cardiovascular treatment. “However, they also gained risk reductions because of this treatment,” the researchers added.

Ladapo and colleagues said they hoped researchers will analyze the cost-effectiveness of CCTA in the context of other management algorithms in future studies.