Cost-Effectiveness of Screening Strategies for Left Main Coronary Artery Disease in Patients with Stable Angina

Abstract

To define optimal strategies for screening for left main coronary artery disease (LMCAD), the authors evaluated the cost-effectiveness of exercise tolerance testing and cardiac catheterization in patients with mild stable chest pain, such as patients with definite or probable angina in the Coronary Artery Surgery Study registry (prevalence of LMCAD = 9%). Performance characteristics of the exercise test, operative mortality, long-term survival rates, and rates of crossing over to surgical therapy for patients initially managed with medical therapy were derived from pooled literature data; cost estimates were based on local charge data. Strategies using the exercise test to identify candidates for catheterization were associated with longer life expectancies than either the conservative strategy in which patients would be observed or the more aggressive strategy in which all patients would undergo coronary angiography. The most cost-effective option was to screen patients with an exercise test and to perform catheterization in patients with greater than or equal to 2 mm of ST-segment change. Compared with a strategy of catheterization for greater than or equal to 3 mm of ST-segment change only, this strategy increased life expectancy at marginal costs per year of life saved ranging from $11,263 to $18,100 for 40- to 70-year-old patients, respectively, while, compared with a strategy of observation unless symptoms worsened, its incremental cost-effectiveness was $6,510 to $12,428 per year of life saved. Thus, screening patients with stable chest pain syndromes with exercise tests and performing catheterization for patients with greater than or equal to 2 mm of ST-segment change has cost-effectiveness comparable to that of the treatment of moderate diastolic hypertension.

Principles of Cost-Effective Resource Allocation in Health Care organizations

“…The analysis by T. H. Lee et al also illustrates another pitfall in the use and interpretation of C/E ratios (6). The (incremental) C/E ratio for the screening strategy with a 3 mm ST-segment threshold for angiography, as noted, is $5,092 per year of life saved.…”

“…One of the most widely misunderstood concepts in CEA is the principle of incremental cost-effectiveness (2). This principle is illustrated by a recent analysis of screening strategies for left-main coronary artery disease (6). In that study, the authors calculated the cost and effectiveness of five alternative strategies: observe only; three strategies involving exercise electrocardiography but differing according to the criterion for proceeding to angiography (ST-segment depression greater than 3 mm, 2 mm, or 1 mm, respectively); and angiography for all patients.…”

A review of health care models for coronary heart disease interventions

“…The cost effectiveness of diagnostic strategies for people with chest pain has been assessed by several studies [49][50][51][52][53][54][55][56][57]. The studies used similar methods: a decision tree to model the initial diagnostic process and then either life expectancy data [53,54,56] or a Markov model [49][50][51]55] to derive the long term prognoses of those patients still alive at the terminal nodes of the decision tree.…”

“…The studies used similar methods: a decision tree to model the initial diagnostic process and then either life expectancy data [53,54,56] or a Markov model [49][50][51]55] to derive the long term prognoses of those patients still alive at the terminal nodes of the decision tree. Health benefits result from the successful treatment of angina pectoris, and the prevention of coronary events, such as MI or death.…”