Invasive evaluation (coronary arteriography) of the coronary artery disease patient: clinical, economic and social issues.

Radionuclide techniques have greatly enhanced noninvasive evaluation in the patient with suspected coronary artery disease (CAD). Although these techniques have high sensitivity and specificity, the published data contain significant inconsistencies and inaccuracies. Coronary arteriography remains the definitive method of determining the presence, site, severity and operability of CAD. Although the procedure is invasive, recent studies have shown that complication rates have been reduced to an acceptably low level, particularly in laboratories with extensive experience. The economic aspects of coronary arteriography are complex. Survey data acquired in early 1981 from 54 active cardiac catheterization laboratories around the country showed that the mean technical charge billed by the hospital for coronary angiographic procedures was $760 (range $307-1470). Analysis of the actual costs of the procedure to the hospital indicates that in most cases, these costs far exceed $760. Hospital budgeting practices in many states fail to create any incentive to match charges with costs. The mean professional fee billed by physicians for coronary arteriography was $640 (range $200-1200). An estimated 275,000 coronary arteriograms are performed annually in the United States, yielding a total cost of $577,500,000. Opportunities for significant cost cutting are limited, and seem to lie primarily in improving the utilization of existing laboratories that are underutilized. Unresolved economic, ethical and social issues pertaining to coronary arteriography include: centralizing the procedure in a smaller number of centers around the country; self-referral of patients for coronary arteriography; establishing training standards for coronary angiographers and performance standards for angiographic equipment; acceptable levels of sensitivity in noninvasive screening for suspected CAD; and utilization of coronary arteriography throughout the country.