Noninvasive Cardiovascular Imaging Section, Cardiovascular Division of Department of Medicine and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts.
Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.
JACC Cardiovasc Imaging. 2020 Jul;13(7):1505-1517. doi: 10.1016/j.jcmg.2020.02.029. Epub 2020 May 13.
The aim of this study was to compare, using results from the multicenter SPINS (Stress CMR Perfusion Imaging in the United States) study, the incremental cost-effectiveness of a stress cardiovascular magnetic resonance (CMR)-first strategy against 4 other clinical strategies for patients with stable symptoms suspicious for myocardial ischemia: 1) immediate x-ray coronary angiography (XCA) with selective fractional flow reserve for all patients; 2) single-photon emission computed tomography; 3) coronary computed tomographic angiography with selective computed tomographic fractional flow reserve; and 4) no imaging.
Stress CMR perfusion imaging has established excellent diagnostic utility and prognostic value in coronary artery disease (CAD), but its cost-effectiveness in current clinical practice has not been well studied in the United States.
A decision analytic model was developed to project health care costs and lifetime quality-adjusted life years (QALYs) for symptomatic patients at presentation with a 32.4% prevalence of obstructive CAD. Rates of clinical events, costs, and quality-of-life values were estimated from SPINS and other published research. The analysis was conducted from a U.S. health care system perspective, with health and cost outcomes discounted annually at 3%.
Using hard cardiovascular events (cardiovascular death or acute myocardial infarction) as the endpoint, total costs per person were lowest for the no-imaging strategy ($16,936) and highest for the immediate XCA strategy ($20,929). Lifetime QALYs were lowest for the no-imaging strategy (12.72050) and highest for the immediate XCA strategy (12.76535). The incremental cost-effectiveness ratio for the CMR-based strategy compared with the no-imaging strategy was $52,000/QALY, whereas the incremental cost-effectiveness ratio for the immediate XCA strategy was $12 million/QALY compared with CMR. Results were sensitive to variations in model inputs for prevalence of disease, hazard rate ratio for treatment of CAD, and annual discount rate.
Prior to invasive XCA, stress CMR can be a cost-effective gatekeeping tool in patients at risk for obstructive CAD in the United States. (Stress CMR Perfusion Imaging in the United States [SPINS] Study; NCT03192891.
本研究旨在通过多中心 SPINS（美国应激心血管磁共振灌注成像）研究的结果，比较应激心血管磁共振（CMR）优先策略与其他 4 种用于稳定型疑似心肌缺血症状患者的临床策略的增量成本效益，这 4 种策略分别为：1）所有患者立即进行 X 射线冠状动脉造影（XCA）并选择性进行血流储备分数检测；2）单光子发射计算机断层扫描；3）选择性计算机断层扫描血流储备分数的冠状动脉计算机断层血管造影；4）不进行影像学检查。
应激 CMR 灌注成像在冠状动脉疾病（CAD）中已确立了卓越的诊断效用和预后价值，但在美国，其在当前临床实践中的成本效益尚未得到充分研究。
我们开发了一个决策分析模型，用于预测就诊时 CAD 患病率为 32.4%的有症状患者的医疗保健成本和终生质量调整生命年（QALY）。临床事件、成本和生活质量值的发生率根据 SPINS 和其他已发表的研究进行估计。该分析从美国医疗保健系统的角度进行，健康和成本结果每年以 3%贴现。
以硬心血管事件（心血管死亡或急性心肌梗死）为终点，每个人的总费用最低的是不进行影像学检查策略（$16936），最高的是立即进行 XCA 策略（$20929）。终生 QALY 最低的是不进行影像学检查策略（12.72050），最高的是立即进行 XCA 策略（12.76535）。CMR 为基础的策略与不进行影像学检查策略相比的增量成本效益比为$52000/QALY，而立即进行 XCA 策略与 CMR 相比的增量成本效益比为$1200 万/QALY。结果对模型输入中的疾病患病率、CAD 治疗的危险比和年度贴现率的变化敏感。
在进行有创性 XCA 之前，应激 CMR 在美国阻塞性 CAD 高危患者中可以作为一种具有成本效益的把关工具。（美国应激心血管磁共振灌注成像[SPINS]研究；NCT03192891）
