Chew Derek S, Mark Daniel B, Li Yanhong, Nanna Michael G, Kelsey Michelle D, Daniels Melanie R, Davidson-Ray Linda, Baloch Khaula N, Rogers Campbell, Patel Manesh R, Anstrom Kevin J, Curzen Nick, Vemulapalli Sreekanth, Douglas Pamela S
Libin Cardiovascular Institute and O'Brien Institute for Public Health, University of Calgary, Calgary, Canada (D.S.C.).
Duke Clinical Research Institute, Duke University, Durham, NC (D.B.M., Y.L., M.D.K., M.R.D., L.D.-R., K.N.B., M.R.P., S.V., P.S.D.).
Circ Cardiovasc Qual Outcomes. 2025 Feb;18(2):e011008. doi: 10.1161/CIRCOUTCOMES.123.011008. Epub 2025 Feb 3.
The PRECISE (Prospective Randomized Trial of the Optimal Evaluation of Cardiac Symptoms and Revascularization) demonstrated that a precision diagnostic strategy reduced the primary composite of death, nonfatal myocardial infarction, or catheterization without obstructive coronary artery disease by 65% in patients with nonacute chest pain compared with usual testing. Medical cost was a prespecified secondary end point.
PRECISE randomized 2103 patients between December 2018 and May 2021 to usual testing or a precision strategy that used deferred testing for the lowest risk patients (20%) and coronary computed tomographic angiography with selective computed tomography-derived fractional flow reserve for the remainder. Resource use consumption data were collected from all study participants and hospital cost data from US participants (n=1125) to estimate total medical costs. The primary and secondary economic outcomes were total costs at 12 months and at 45 days, respectively, from the US health care system perspective. The mean cost differences between the 2 strategies were reported by intention-to-treat.
At 45 days, total costs were similar between the precision strategy and usual testing (mean difference, $182 [95% CI, -$555 to $661]). By 12 months, percutaneous coronary intervention and coronary artery bypass surgery had been performed in 7.2% and 2.0% of precision strategy patients and 3.5% and 1.7% of usual testing patients, respectively. At 1 year, precision strategy costs were $5299 versus $4821 for usual testing (mean difference, $478 [95% CI, -$889 to $1437]; =0.43). Precision care decreased mean per-patient diagnostic cost by 27% and increased mean per-patient revascularization costs by 67%.
In the PRECISE trial, the precision strategy, a risk-based approach endorsed by current clinical practice guidelines, improved the clinical efficiency of testing and had similar costs to usual testing at 45 days and a nonsignificant $478 cost difference at 1 year.
URL: https://www.clinicaltrials.gov; Unique identifier: NCT03702244.
“PRECISE（心脏症状最佳评估与血运重建前瞻性随机试验）”表明，与常规检测相比，精准诊断策略可使非急性胸痛患者死亡、非致命性心肌梗死或无阻塞性冠状动脉疾病的导管插入术这一主要复合终点降低65%。医疗成本是预先设定的次要终点。
2018年12月至2021年5月期间，PRECISE将2103例患者随机分为常规检测组或精准策略组，精准策略组对风险最低的患者（20%）采用延迟检测，对其余患者采用冠状动脉计算机断层血管造影术并结合选择性计算机断层扫描衍生的血流储备分数。收集所有研究参与者的资源使用消耗数据以及美国参与者（n = 1125）的医院成本数据，以估算总医疗成本。主要和次要经济结局分别是从美国医疗保健系统角度出发，12个月和45天时的总成本。两种策略之间的平均成本差异按意向性分析报告。
在45天时，精准策略组和常规检测组的总成本相似（平均差异为182美元[95%CI，-555美元至661美元]）。到12个月时，精准策略组患者中分别有7.2%和2.0%接受了经皮冠状动脉介入治疗和冠状动脉旁路移植术，常规检测组患者中这一比例分别为3.5%和1.7%。1年时，精准策略组的成本为5299美元，常规检测组为4821美元（平均差异为478美元[95%CI，-889美元至1437美元]；P = 0.43）。精准医疗使每位患者的平均诊断成本降低了27%，使每位患者的平均血运重建成本增加了67%。
在PRECISE试验中，精准策略作为当前临床实践指南认可的基于风险的方法，提高了检测的临床效率，在45天时成本与常规检测相似，1年时成本差异为478美元，无统计学意义。
