Stokes Elizabeth A, Doble Brett, Pufulete Maria, Reeves Barnaby C, Bucciarelli-Ducci Chiara, Dorman Stephen, Greenwood John P, Anderson Richard A, Wordsworth Sarah
Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
Clinical Trials and Evaluation Unit, Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK.
BMJ Open. 2019 Jul 11;9(7):e025700. doi: 10.1136/bmjopen-2018-025700.
To identify the key drivers of cost-effectiveness for cardiovascular magnetic resonance (CMR) when patients activate the primary percutaneous coronary intervention (PPCI) pathway.
Economic decision models for two patient subgroups populated from secondary sources, each with a 1 year time horizon from the perspective of the National Health Service (NHS) and personal social services in the UK.
Usual care (with or without CMR) in the NHS.
Patients who activated the PPCI pathway, and for Model 1: underwent an emergency coronary angiogram and PPCI, and were found to have multivessel coronary artery disease. For Model 2: underwent an emergency coronary angiogram and were found to have unobstructed coronary arteries.
Model 1 (multivessel disease) compared two different ischaemia testing methods, CMR or fractional flow reserve (FFR), versus stress echocardiography. Model 2 (unobstructed arteries) compared CMR with standard echocardiography versus standard echocardiography alone.
Key drivers of cost-effectiveness for CMR, incremental costs and quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios.
In both models, the incremental costs and QALYs between CMR (or FFR, Model 1) versus no CMR (stress echocardiography, Model 1 and standard echocardiography, Model 2) were small (CMR: -£64 (95% CI -£232 to £187)/FFR: £360 (95% CI -£116 to £844) and CMR/FFR: 0.0012 QALYs (95% CI -0.0076 to 0.0093)) and (£98 (95% CI -£199 to £488) and 0.0005 QALYs (95% CI -0.0050 to 0.0077)), respectively. The diagnostic accuracy of the tests was the key driver of cost-effectiveness for both patient groups.
If CMR were introduced for all subgroups of patients who activate the PPCI pathway, it is likely that diagnostic accuracy would be a key determinant of its cost-effectiveness. Further research is needed to definitively answer whether revascularisation guided by CMR or FFR leads to different clinical outcomes in acute coronary syndrome patients with multivessel disease.
确定在患者启动直接经皮冠状动脉介入治疗（PPCI）途径时，心血管磁共振成像（CMR）成本效益的关键驱动因素。
从二手资料中获取两个患者亚组的经济决策模型，从英国国家医疗服务体系（NHS）和个人社会服务的角度来看，每个模型的时间跨度均为1年。
NHS中的常规治疗（有或无CMR）。
启动PPCI途径的患者，模型1的参与者：接受了急诊冠状动脉造影和PPCI，且被发现患有多支冠状动脉疾病。模型2的参与者：接受了急诊冠状动脉造影，且被发现冠状动脉无阻塞。
模型1（多支血管疾病）比较了两种不同的缺血检测方法，即CMR或血流储备分数（FFR），与负荷超声心动图。模型2（动脉无阻塞）比较了CMR联合标准超声心动图与单纯标准超声心动图。
CMR成本效益的关键驱动因素、增量成本和质量调整生命年（QALY）以及增量成本效益比。
在两个模型中，CMR（或FFR，模型1）与无CMR（负荷超声心动图，模型1；标准超声心动图，模型2）之间的增量成本和QALY均较小（CMR：-64英镑（95%CI -232至187英镑）/FFR：360英镑（95%CI -116至844英镑），CMR/FFR：0.0012 QALY（95%CI -0.0076至0.0093））以及（98英镑（95%CI -199至488英镑）和0.0005 QALY（95%CI -0.0050至0.0077））。检测的诊断准确性是两个患者组成本效益的关键驱动因素。
如果对启动PPCI途径的所有患者亚组都引入CMR，那么诊断准确性很可能是其成本效益的关键决定因素。需要进一步研究以明确回答在患有多支血管疾病的急性冠状动脉综合征患者中，由CMR或FFR引导的血运重建是否会导致不同的临床结局。
