Powell Emilie S, Patterson Brian W, Venkatesh Arjun K, Khare Rahul K
Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA.
Crit Pathw Cardiol. 2012 Mar;11(1):20-5. doi: 10.1097/HPC.0b013e318246854c.
A common strategy for excluding coronary artery disease among patients presenting with low-risk chest pain is observation unit (OU) admission with serial cardiac biomarkers and stress testing for cardiac risk stratification. Patients with positive- or indeterminate-stress tests are often admitted for cardiac catheterization despite a low likelihood of disease. The aim of this study is to estimate the cost-effectiveness of computed tomography of the coronary arteries (CTCA) in the OU for the evaluation of low-risk chest pain patients with indeterminate- or positive-stress test results.
We conducted a decision analytic study to compare health outcomes and costs between 3 cardiac risk-stratification strategies in a population of patients at low cardiac risk admitted to the OU, who later had indeterminate- or abnormal-stress tests. Our population and test characteristics were based on data obtained both from the published literature and from a retrospective cohort review previously performed at our institution. The 3 strategies compared were (1) A CTCA strategy in which patients with positive- or indeterminate-stress tests subsequently underwent CTCA, and only received catheterization if results were positive, (2) A standard-of-care arm in which all patients with positive- or indeterminate-stress tests were admitted for catheterization, and (3) A do-nothing strategy in which all patients were discharged home after stress testing regardless of outcome. Outcomes measured were cost of care and life expectancy. Sensitivity analysis was performed with a multivariate Monte Carlo methodology.
Both the CTCA and standard-of-care strategies dominated the do-nothing strategy in the base case. When comparing the standard-of-care with the CTCA strategy, the incremental cost-effectiveness ratio was $3,423,309 per additional year of life gained. Sensitivity analysis showed that below a willingness to pay of $600,000 per additional year of life, CTCA was the most likely strategy to be cost-effective.
In this computer-modeled analysis, the addition of CTCA following positive- or indeterminate-stress tests to an OU cardiac risk-stratification pathway for low-risk chest pain patients achieved significant cost savings with a small decrease in life expectancy per patient. Adding CTCA after indeterminate- or positive-stress test results is a cost-effective intervention for further risk-stratifying low-risk chest pain patients in the OU setting before proceeding to traditional coronary angiography.
在出现低风险胸痛的患者中，排除冠状动脉疾病的常用策略是将患者收入观察单元（OU），进行系列心脏生物标志物检测和心脏应激试验以进行心脏风险分层。尽管患病可能性较低，但应激试验结果为阳性或不确定的患者通常会因心脏导管插入术而入院。本研究的目的是评估在观察单元中进行冠状动脉计算机断层扫描（CTCA）对于评估应激试验结果不确定或为阳性的低风险胸痛患者的成本效益。
我们进行了一项决策分析研究，比较了收入观察单元且后来应激试验结果不确定或异常的低心脏风险患者群体中三种心脏风险分层策略的健康结果和成本。我们的人群和试验特征基于从已发表文献以及我们机构之前进行的一项回顾性队列研究中获得的数据。比较的三种策略为：（1）CTCA策略，即应激试验结果为阳性或不确定的患者随后接受CTCA检查，只有结果为阳性时才进行导管插入术；（2）标准治疗组，即所有应激试验结果为阳性或不确定的患者均因导管插入术而入院；（3）不采取任何措施策略，即所有患者在应激试验后无论结果如何均出院回家。测量的结果为护理成本和预期寿命。采用多变量蒙特卡洛方法进行敏感性分析。
在基础病例中，CTCA策略和标准治疗策略均优于不采取任何措施策略。将标准治疗策略与CTCA策略进行比较时，每增加一年的生命所增加的成本效益比为3,423,309美元。敏感性分析表明，在每增加一年生命的支付意愿低于600,000美元时，CTCA是最有可能具有成本效益的策略。
在这项计算机模拟分析中，对于低风险胸痛患者，在观察单元的心脏风险分层路径中，对应激试验结果为阳性或不确定的患者增加CTCA检查，可显著节省成本，且每位患者的预期寿命略有下降。在应激试验结果不确定或为阳性后增加CTCA检查，是在进行传统冠状动脉造影之前，在观察单元环境中对低风险胸痛患者进行进一步风险分层的一种具有成本效益的干预措施。
