Comparative cost-effectiveness analyses of cardiovascular magnetic resonance and coronary angiography combined with fractional flow reserve for the diagnosis of coronary artery disease

Karine Moschetti, David Favre, Christophe Pinget, Guenter Pilz, Steffen E Petersen, Anja Wagner, Jean-Blaise Wasserfallen, Juerg J Schwitter, Karine Moschetti, David Favre, Christophe Pinget, Guenter Pilz, Steffen E Petersen, Anja Wagner, Jean-Blaise Wasserfallen, Juerg J Schwitter

Abstract

Background: According to recent guidelines, patients with coronary artery disease (CAD) should undergo revascularization if significant myocardial ischemia is present. Both, cardiovascular magnetic resonance (CMR) and fractional flow reserve (FFR) allow for a reliable ischemia assessment and in combination with anatomical information provided by invasive coronary angiography (CXA), such a work-up sets the basis for a decision to revascularize or not. The cost-effectiveness ratio of these two strategies is compared.

Methods: Strategy 1) CMR to assess ischemia followed by CXA in ischemia-positive patients (CMR + CXA), Strategy 2) CXA followed by FFR in angiographically positive stenoses (CXA + FFR). The costs, evaluated from the third party payer perspective in Switzerland, Germany, the United Kingdom (UK), and the United States (US), included public prices of the different outpatient procedures and costs induced by procedural complications and by diagnostic errors. The effectiveness criterion was the correct identification of hemodynamically significant coronary lesion(s) (= significant CAD) complemented by full anatomical information. Test performances were derived from the published literature. Cost-effectiveness ratios for both strategies were compared for hypothetical cohorts with different pretest likelihood of significant CAD.

Results: CMR + CXA and CXA + FFR were equally cost-effective at a pretest likelihood of CAD of 62% in Switzerland, 65% in Germany, 83% in the UK, and 82% in the US with costs of CHF 5'794, € 1'517, £ 2'680, and $ 2'179 per patient correctly diagnosed. Below these thresholds, CMR + CXA showed lower costs per patient correctly diagnosed than CXA + FFR.

Conclusions: The CMR + CXA strategy is more cost-effective than CXA + FFR below a CAD prevalence of 62%, 65%, 83%, and 82% for the Swiss, the German, the UK, and the US health care systems, respectively. These findings may help to optimize resource utilization in the diagnosis of CAD.

Figures

Figure 1
Figure 1
Decision tree for CAD diagnosis including strategy 1 and strategy 2 used to design the model.
Figure 2
Figure 2
Example for the Swiss health care system: Proportion of patients with suspected CAD correctly diagnosed (CAD Dx) by the CMR + CXA and CXA + FFR strategies in relation to pre-test likelihood of significant CAD (Pisch.)
Figure 3
Figure 3
Costs per patient (Pt) tested in relation to the pre-test likelihood of significant CAD (=Pisch) for both strategies.
Figure 4
Figure 4
Results for outpatient procedures performed in the 4 countries. Costs per effect (= cost-effectiveness) for both strategies in relation to the prevalence of significant CAD (=Pisch).
Figure 5
Figure 5
Sensitivity analysis: Switzerland.
Figure 6
Figure 6
Sensitivity analysis: Germany.
Figure 7
Figure 7
Sensitivity analysis: The United Kingdom.
Figure 8
Figure 8
Sensitivity analysis: The United States.

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