Hlatky Mark A, Wilding Sam, Stuart Beth, Nicholas Zoe, Shambrook James, Eminton Zina, Fox Kim, Connolly Derek, O'Kane Peter, Hobson Alex, Chauhan Anoop, Uren Neal, Mccann Gerry P, Berry Colin, Carter Justin, Roobottom Carl, Mamas Mamas, Rajani Ronak, Ford Ian, Douglas Pamela S, Curzen Nick
Stanford University School of Medicine, Stanford, CA, USA.
University of Southampton, Southampton, United Kingdom.
J Cardiovasc Comput Tomogr. 2023 Jan-Feb;17(1):52-59. doi: 10.1016/j.jcct.2022.09.005. Epub 2022 Sep 24.
FFR assesses the functional significance of lesions seen on CTCA, and may be a more efficient approach to chest pain evaluation. The FORECAST randomized trial found no significant difference in costs within the UK National Health Service, but implications for US costs are unknown. The purpose of this study was to compare costs in the FORECAST trial based on US healthcare cost weights, and to evaluate factors affecting costs.
Patients with stable chest pain were randomized either to the experimental strategy (CTCA with selective FFR), or to standard clinical pathways. Pre-randomization, the treating clinician declared the planned initial test. The primary outcome was nine-month cardiovascular care costs.
Planned initial tests were CTCA in 912 patients (65%), stress testing in 393 (28%), and invasive angiography in 94 (7%). Mean US costs did not differ overall between the experimental strategy and standard care (cost difference +7% (+$324), CI -12% to +26%, p = 0.49). Costs were 4% lower with the experimental strategy in the planned invasive angiography stratum (p for interaction = 0.66). Baseline factors independently associated with costs were older age (+43%), male sex (+55%), diabetes (+37%), hypertension (+61%), hyperlipidemia (+94%), prior angina (+24%), and planned invasive angiography (+160%). Post-randomization cost drivers were coronary revascularization (+348%), invasive angiography (267%), and number of tests (+35%).
Initial evaluation of chest pain using CTCA with FFR had similar US costs as standard care pathways. Costs were increased by baseline coronary risk factors and planned invasive angiography, and post-randomization invasive procedures and the number of tests. Registration at ClinicalTrials.gov (NCT03187639).
血流储备分数（FFR）评估CTCA所见病变的功能意义，可能是评估胸痛的更有效方法。FORECAST随机试验发现，在英国国家医疗服务体系内成本无显著差异，但对美国成本的影响尚不清楚。本研究的目的是根据美国医疗成本权重比较FORECAST试验中的成本，并评估影响成本的因素。
将稳定型胸痛患者随机分为试验策略组（CTCA联合选择性FFR）或标准临床路径组。随机分组前，主治医生声明计划的初始检查。主要结局为9个月的心血管护理成本。
计划的初始检查中，912例患者（65%）为CTCA，393例（28%）为负荷试验，94例（7%）为有创血管造影。试验策略组与标准治疗组的总体美国平均成本无差异（成本差异+7%（+$324），CI -12%至+26%，p = 0.49）。在计划进行有创血管造影的亚组中，试验策略组的成本低4%（交互作用p = 0.66）。与成本独立相关的基线因素包括年龄较大（+43%）、男性（+55%）、糖尿病（+37%）、高血压（+61%）、高脂血症（+94%）、既往心绞痛（+24%）和计划进行有创血管造影（+160%）。随机分组后的成本驱动因素为冠状动脉血运重建（+348%）、有创血管造影（267%）和检查次数（+35%）。
使用CTCA联合FFR对胸痛进行初始评估的美国成本与标准护理路径相似。基线冠状动脉危险因素、计划进行的有创血管造影、随机分组后的有创操作和检查次数会增加成本。在ClinicalTrials.gov注册（NCT03187639）。
