冠状动脉 CT 血管造影与心肌灌注 SPECT 评估胸痛且无已知冠状动脉疾病患者的成本效益比较。

Cost-effectiveness of coronary CT angiography versus myocardial perfusion SPECT for evaluation of patients with chest pain and no known coronary artery disease.

机构信息

Departments of Medicine and Radiology, Weill Medical College of Cornell University and the New York Presbyterian Hospital, 520 E 70th St, Room K415, New York, NY 10021, USA.

出版信息

Radiology. 2010 Mar;254(3):801-8. doi: 10.1148/radiol.09090349.

DOI:10.1148/radiol.09090349

PMID:20177094

Abstract

PURPOSE

To evaluate the cost-effectiveness of diagnostic strategies for individuals with chest pain without known coronary artery disease (CAD) in the Assessment by Coronary Computed Tomographic Angiography of Individuals Undergoing Invasive Coronary Angiography-eligible population.

MATERIALS AND METHODS

A decision analysis was performed in which the following were compared: coronary computed tomographic (CT) angiography followed by invasive coronary angiography for positive or equivocal findings (coronary CT angiography only), coronary CT angiography followed by invasive coronary angiography for positive findings and myocardial perfusion single photon emission computed tomography (SPECT) for equivocal findings (coronary CT angiography first), myocardial perfusion SPECT followed by invasive coronary angiography for positive/equivocal findings (myocardial perfusion SPECT only), myocardial perfusion SPECT followed by invasive coronary angiography for positive findings and coronary CT angiography for equivocal findings (myocardial perfusion SPECT first), and invasive coronary angiography. Analyses were conducted from the payer perspective for a near-term diagnostic period and a long-term lifetime period. The base case was a 55-year-old man with 30% risk of obstructive CAD.

RESULTS

By using the base case for near-term cost per correct diagnosis, a coronary CT angiography-first strategy was the least expensive, followed by coronary CT angiography only (incremental cost-effectiveness ratio [ICER] = $17516). For long-term cost-effectiveness, a coronary CT angiography-only strategy demonstrated a favorable ICER of $20429 per quality-adjusted life-year (QALY) relative to the least expensive coronary CT angiography-first strategy. Both myocardial perfusion SPECT-only and myocardial perfusion SPECT-first strategies were more costly and less effective than either coronary CT angiographic strategy. Long-term results were sensitive to coronary CT angiographic sensitivity, myocardial perfusion SPECT sensitivity, and CAD prevalence. Coronary CT angiography-first and coronary CT angiography-only strategies remained dominant up to a baseline coronary CT angiography test cost of $1100 and 80% CAD prevalence.

CONCLUSION

With a $20000 threshold level for cost per correct diagnosis and $50000 per QALY, a coronary CT angiography-only approach is the most cost-effective diagnostic strategy for evaluation of patients who have stable chest pain without known CAD with intermediate CAD prevalence.

SUPPLEMENTAL MATERIAL

http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.09090349/-/DC1.

摘要

目的

在经血管造影确诊适合行侵入性冠状动脉检查的个体中，评估对无已知冠状动脉疾病（CAD）的胸痛个体的诊断策略的成本效益。

材料与方法

进行了决策分析，对以下情况进行了比较：对阳性或不确定结果行冠状动脉 CT 血管造影术（CCTA），然后行侵入性冠状动脉血管造影术（仅 CCTA）；对阳性结果行 CCTA，对不确定结果行心肌灌注单光子发射计算机断层扫描（SPECT），然后行侵入性冠状动脉血管造影术（CCTA 优先）；对阳性/不确定结果行心肌灌注 SPECT，然后行侵入性冠状动脉血管造影术（仅 SPECT）；对阳性结果行心肌灌注 SPECT，对不确定结果行 CCTA，然后行侵入性冠状动脉血管造影术（SPECT 优先）；以及行侵入性冠状动脉血管造影术。分析从支付者角度考虑了近期诊断期和长期终生期。基础病例为一位 55 岁男性，其患阻塞性 CAD 的风险为 30%。

结果

采用近期正确诊断的单位成本，CCTA 优先策略的成本最低，其次是仅行 CCTA（增量成本效益比[ICER]为$17516）。在长期成本效益方面，与成本最低的 CCTA 优先策略相比，仅行 CCTA 策略的每质量调整生命年（QALY）成本效益比为$20429。仅行 SPECT 和 SPECT 优先策略的成本均高于两种 CCTA 策略，且效果较差。长期结果对 CCTA 敏感性、心肌灌注 SPECT 敏感性和 CAD 流行率敏感。在基线 CCTA 检查费用为$1100 和 CAD 流行率为 80%时，CCTA 优先和仅 CCTA 策略仍然占据主导地位。