Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
J Am Coll Cardiol. 2009 Dec 15;54(25):2409-22. doi: 10.1016/j.jacc.2009.10.012.
The aim of this study was to project clinical outcomes, health care costs, and cost-effectiveness of coronary computed tomography angiography (CCTA), as compared with conventional diagnostic technologies, in the evaluation of patients with stable chest pain and suspected coronary artery disease (CAD).
CCTA has recently been found to be effective in the evaluation of patients with suspected CAD, but investigators have raised concerns related to radiation exposure, incidental findings, and nondiagnostic exams.
With published data, we developed a computer simulation model to project clinical outcomes, health care costs, and cost-effectiveness of CCTA, compared with conventional testing modalities, in the diagnosis of CAD. Our target population included 55-year-old patients who present to their primary care physicians with stable chest pain.
All diagnostic strategies yielded similar health outcomes, but performing CCTA-with or without stress testing or performing stress single-photon emission computed tomography-marginally minimized adverse events and maximized longevity and quality-adjusted life-years (QALYs). Health outcomes associated with these strategies were comparable, with CCTA in men and women yielding the greatest QALYs but only by modest margins. Overall differences were small, and performing the most effective test-compared with the least effective-decreased adverse event rates by 3% in men and women. Comparable increases in longevity and QALYs were 2 months and 0.1 QALYs in men and 1 month and 0.03 QALYs in women. CCTA raised overall costs, partly through the follow-up of incidental findings, and when performed with stress testing, its incremental cost-effectiveness ratio ranged from $26,200/QALY in men to $35,000/QALY in women. Health outcomes were marginally less favorable in women when radiation risks were considered.
CCTA is comparable to other diagnostic studies and might hold good clinical value, but large randomized controlled trials are needed to guide policy.
本研究旨在预测冠状动脉计算机断层扫描血管造影（CCTA）与传统诊断技术相比，在评估稳定型胸痛和疑似冠心病（CAD）患者中的临床结局、医疗成本和成本效益。
CCTA 最近被证明在评估疑似 CAD 患者方面有效，但研究人员对辐射暴露、偶然发现和非诊断性检查提出了担忧。
我们利用已发表的数据，开发了一个计算机模拟模型，以预测在 CAD 诊断中，与常规检查方法相比，CCTA 的临床结局、医疗成本和成本效益。我们的目标人群包括 55 岁的患者，他们因稳定型胸痛就诊于初级保健医生。
所有诊断策略均产生相似的健康结果，但进行 CCTA（无论是否进行压力测试）或进行压力单光子发射计算机断层扫描，可适度减少不良事件并最大限度地延长寿命和质量调整生命年（QALY）。这些策略相关的健康结果相当，男性和女性进行 CCTA 可获得最大的 QALY，但仅略有优势。总体差异较小，与进行最有效的检查相比，与进行最不有效的检查相比，男性和女性的不良事件发生率分别降低了 3%。男性和女性的寿命和 QALY 分别增加了 2 个月和 0.1 QALY，增加了 1 个月和 0.03 QALY。CCTA 增加了总体成本，部分原因是偶然发现的随访，当与压力测试一起进行时，其增量成本效益比在男性中为 26200 美元/QALY，在女性中为 35000 美元/QALY。当考虑到辐射风险时，女性的健康结果略有不利。
CCTA 与其他诊断研究相当，可能具有良好的临床价值，但需要大型随机对照试验来指导政策。
