CORONARY COMPUTED TOMOGRAPHY VERSUS EXERCISE TESTING IN PATIENTS WITH STABLE CHEST PAIN: COMPARATIVE EFFECTIVENESS AND COSTS

Purpose: To determine the comparative effectiveness and costs of a CT-based strategy (CT-strategy) and a stress-electrocardiography-based strategy (standard-of-care; SOC-strategy), for diagnosing coronary artery disease (CAD).

Method: Decision analysis based on a real-world population of 471 outpatients with follow-up. All patients presented with stable chest pain and were scheduled for both stress electrocardiography (X-ECG) and coronary CT angiography (CCTA). Outcomes were correct classification of patients as CAD– (no obstructive CAD), CAD+ (obstructive CAD without revascularization) and Revascularization (using a combination reference standard based on catheter-based coronary angiography, CCTA and revascularization within 6 months), diagnostic costs, lifetime health care costs, and quality-adjusted life years (QALY).

Result: For men (and women), diagnostic cost savings were €245 (€252) for the CT-strategy as compared to the SOC-strategy. The CT-strategy classified 82% (88%) of simulated men (women) in the appropriate disease category, whereas 83% (85%) were correctly classified by the SOC-strategy. The long term cost-effectiveness analysis showed that the SOC-strategy was dominated by the CT-strategy, which was less expensive (-€229 in men, -€444 in women) and more effective (+0.002 QALY in men, +0.005 in women). The CT-strategy was less effective compared to SOC (-0.003 QALY) in men with a pre-test probability of ≥70%. When correcting for (potential) overestimation of disease by CCTA, cost-savings and gains in effectiveness were reduced.

Conclusion: Our decision analysis suggests that a CT-based strategy is superior to standard-of-care in particular for all women and for men with a pre-test probability <70%.