Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada.
ICES, Toronto, Ontario, Canada.
J Am Soc Echocardiogr. 2024 Mar;37(3):288-299. doi: 10.1016/j.echo.2023.11.004. Epub 2023 Nov 14.
Noninvasive cardiac diagnostic tests (NITs) for the diagnosis of coronary artery disease have been estimated to cost >$3 billion annually in the United States alone and have recently undergone scrutiny over concerns of overuse. Consequently, comparing costs of different NIT testing strategies is of urgent importance to health care planning.
We utilized population-based administrative and clinical data from Ontario, Canada, to compare downstream costs between 4 available NIT testing strategies (graded exercise stress testing [GXT], stress echocardiography, cardiac computed tomography angiography [CCTA], and myocardial perfusion imaging [MPI] as well as no testing), among patients evaluated for chest pain. To compare costs among the tested (overall and by testing strategy) and nontested groups, we used a log-gamma generalized linear model to account for the skewed distribution of health care cost data, adjusting for relevant clinical covariates.
A total of 2,340,699 patients were included in our cohort, of whom 481,170 (21%) patients received 1 of the 4 NITs. Among patients who received a NIT, 254,492 (53%) received a GXT as their initial test, 154,137 (32%) received MPI, 69,160 (14%) received a stress echo, and 3,381 (<1%) received a CCTA. After adjustment for differences in baseline patient characteristics, receipt of any NIT was associated with an approximate 12% reduction in downstream 1-year mean costs (cost ratio = 0.88; 95% CI, 0.87, 0.89) compared with those without any testing. Comparing the different testing strategies with no testing, both GXT (cost ratio = 0.80; 95% CI, 0.79-0.81) and stress echocardiography (cost ratio = 0.82; 95% CI, 0.81-0.83) were associated with the lower downstream costs, while both MPI (cost ratio = 1.26; 95% CI, 1.25, 1.27) and CCTA (cost ratio = 1.29; 95% CI, 1.23, 1.35) were associated with higher downstream costs.
In a large population-based cohort consisting of >2 million people evaluated for chest pain, we report that receipt of noninvasive testing was associated with a 12% reduction in downstream costs when compared with no testing. Graded exercise stress testing and stress echocardiography were associated with the least downstream costs, whereas CCTA and MPI were associated with higher costs when compared with no testing. These findings may help inform testing decisions in chest pain patients.
在美国，仅用于诊断冠状动脉疾病的非侵入性心脏诊断测试（NIT）每年的估计费用超过 30 亿美元，并且最近因过度使用而受到审查。因此，比较不同 NIT 测试策略的成本对于医疗保健规划至关重要。
我们利用加拿大安大略省基于人群的行政和临床数据，比较了 4 种可用的 NIT 测试策略（分级运动压力测试[GXT]、心脏超声心动图、心脏计算机断层扫描血管造影[CCTA]和心肌灌注成像[MPI]以及无测试）之间在胸痛患者中的下游成本。为了比较测试组（总体和按测试策略）和未测试组之间的成本，我们使用对数伽马广义线性模型来考虑医疗保健成本数据的偏态分布，并调整了相关的临床协变量。
我们的队列共纳入 2340699 名患者，其中 481170 名（21%）患者接受了 4 种 NIT 中的 1 种。在接受 NIT 的患者中，254492 名（53%）患者作为初始测试接受了 GXT，154137 名（32%）接受了 MPI，69160 名（14%）接受了心脏超声心动图，3381 名（<1%）接受了 CCTA。在调整了基线患者特征差异后，与未接受任何测试的患者相比，接受任何 NIT 都与 1 年内下游平均成本降低约 12%相关（成本比=0.88；95%CI，0.87，0.89）。与无测试相比，比较不同的测试策略，GXT（成本比=0.80；95%CI，0.79-0.81）和心脏超声心动图（成本比=0.82；95%CI，0.81-0.83）都与较低的下游成本相关，而 MPI（成本比=1.26；95%CI，1.25，1.27）和 CCTA（成本比=1.29；95%CI，1.23，1.35）都与较高的下游成本相关。
在一项由超过 200 万人组成的大型基于人群的胸痛队列中，我们报告说，与不进行任何测试相比，接受非侵入性测试与下游成本降低 12%相关。GXT 和心脏超声心动图与最低的下游成本相关，而 CCTA 和 MPI 与无测试相比与更高的成本相关。这些发现可能有助于为胸痛患者的测试决策提供信息。
