![[ Visit Client Website ]](images/banner.gif)
To determine whether CT-screening for coronary calcification is cost-effective in asymptomatic elderly individuals who have an intermediate Framingham Risk Score (10-20% 10-year risk) of coronary heart disease (CHD) events, in order to refine their risk assessment and initiate appropriate preventive measures.
Methods
We developed a Markov decision model to compare the following treatment strategies: (1) lifestyle changes only (smoking cessation, healthy-eating pattern, regular physical activity, weight management), (2) lifestyle changes with aspirin therapy, (3) lifestyle changes with medical treatment as needed (aspirin, statins, Ca-antagonist, diuretic, beta-blocker, ACE inhibitor), and (4) CT-screening for coronary calcifications followed by strategies 1, 2, or 3 in low, intermediate, and high risk individuals respectively. The model incorporated 4 states (alive, post-CHD-event, CHD death, and non-CHD death). Best-available evidence was retrieved from the literature and combined with primary data from the Rotterdam Coronary Calcification Study. Quality-adjusted-life years (QALYs), life-time costs, and incremental cost-effectiveness ratios (ICER) were calculated from the societal perspective using a threshold willingness-to-pay of €40000/QALY. Extensive (probabilistic) sensitivity analysis was performed and expected value of perfect information (EVPI) was calculated.
Results
In the base-case analysis, CT-screening was slightly more effective than lifestyle changes with aspirin therapy (QALY gain 0.006; 95%CI:-0.03, 0.05), cost more (additional costs € 400; 95%CI: 185, 669), and had an ICER of €66667/QALY. Full medical treatment was more effective compared to CT-screening (QALY gain 0.05; 95%CI: -0.004, 0.1) and was more expensive (additional costs € 1603; 95% CI: 1040, 2335) with an ICER of €32060/QALY, making CT-screening extended dominated. Compared to lifestyle changes with aspirin therapy, full medical treatment was more effective (QALY gain 0.06; 95% CI:-0.005, 0.13), cost more (€2004 (95% CI: 871, 2885)), and had an ICER of €33400/QALY. Sensitivity analysis suggested that CT-screening would be cost-effective in the case of high major bleeding risks with aspirin therapy (relative risk >5). Probabilistic sensitivity analysis showed that CT-screening was the optimal strategy in less than 6% of the simulations. The EVPI was €490 per person.
Conclusion CT-screening for coronary calcifications in asymptomatic elderly individuals at intermediate risk of developing CHD events is not cost-effective. Lifestyle changes combined with medical treatment is preferable unless a patient is at high risk for a major bleed from aspirin use.