Hulten Edward, Goehler Alexander, Bittencourt Marcio Sommer, Bamberg Fabian, Schlett Christopher L, Truong Quynh A, Nichols John, Nasir Khurram, Rogers Ian S, Gazelle Scott G, Nagurney John T, Hoffmann Udo, Blankstein Ron
Noninvasive Cardiovascular Imaging Program, Departments of Medicine.
Circ Cardiovasc Qual Outcomes. 2013 Sep 1;6(5):514-24. doi: 10.1161/CIRCOUTCOMES.113.000244. Epub 2013 Sep 10.
Coronary computed tomographic angiography (cCTA) allows rapid, noninvasive exclusion of obstructive coronary artery disease (CAD). However, concern exists whether implementation of cCTA in the assessment of patients presenting to the emergency department with acute chest pain will lead to increased downstream testing and costs compared with alternative strategies. Our aim was to compare observed actual costs of usual care (UC) with projected costs of a strategy including early cCTA in the evaluation of patients with acute chest pain in the Rule Out Myocardial Infarction Using Computer Assisted Tomography I (ROMICAT I) study.
We compared cost and hospital length of stay of UC observed among 368 patients enrolled in the ROMICAT I study with projected costs of management based on cCTA. Costs of UC were determined by an electronic cost accounting system. Notably, UC was not influenced by cCTA results because patients and caregivers were blinded to the cCTA results. Costs after early implementation of cCTA were estimated assuming changes in management based on cCTA findings of the presence and severity of CAD. Sensitivity analysis was used to test the influence of key variables on both outcomes and costs. We determined that in comparison with UC, cCTA-guided triage, whereby patients with no CAD are discharged, could reduce total hospital costs by 23% (P<0.001). However, when the prevalence of obstructive CAD increases, index hospitalization cost increases such that when the prevalence of ≥ 50% stenosis is >28% to 33%, the use of cCTA becomes more costly than UC.
cCTA may be a cost-saving tool in acute chest pain populations that have a prevalence of potentially obstructive CAD <30%. However, increased cost would be anticipated in populations with higher prevalence of disease.
冠状动脉计算机断层扫描血管造影（cCTA）能够快速、无创地排除阻塞性冠状动脉疾病（CAD）。然而，对于在急诊科因急性胸痛就诊的患者进行评估时采用cCTA，与其他替代策略相比是否会导致下游检查增加及成本上升，仍存在担忧。我们的目的是在使用计算机辅助断层扫描排除心肌梗死研究I（ROMICAT I）中，比较常规治疗（UC）的实际观察成本与包括早期cCTA在内的策略在评估急性胸痛患者时的预计成本。
我们将ROMICAT I研究中纳入的368例患者的UC成本和住院时间与基于cCTA的管理预计成本进行了比较。UC成本由电子成本核算系统确定。值得注意的是，UC不受cCTA结果影响，因为患者和护理人员对cCTA结果不知情。根据CAD的存在和严重程度的cCTA结果假设管理变化，估算早期实施cCTA后的成本。敏感性分析用于测试关键变量对结果和成本的影响。我们确定，与UC相比，cCTA引导的分诊（即无CAD的患者出院）可使总住院成本降低23%（P<0.001）。然而，当阻塞性CAD的患病率增加时，首次住院成本会增加，以至于当≥50%狭窄的患病率>28%至33%时，使用cCTA比UC成本更高。
对于潜在阻塞性CAD患病率<30%的急性胸痛人群，cCTA可能是一种节省成本的工具。然而，在疾病患病率较高的人群中预计成本会增加。
