Cost-minimization analysis of three decision strategies for cardiac revascularization: results of the “suspected CAD” cohort of the european cardiovascular magnetic resonance registry

Abstract

BackgroundCoronary artery disease (CAD) continues to be one of the top public health burden. Perfusion cardiovascular magnetic resonance (CMR) is generally accepted to detect CAD, while data on its cost effectiveness are scarce. Therefore, the goal of the study was to compare the costs of a CMR-guided strategy vs two invasive strategies in a large CMR registry.MethodsIn 3’647 patients with suspected CAD of the EuroCMR-registry (59 centers/18 countries) costs were calculated for diagnostic examinations (CMR, X-ray coronary angiography (CXA) with/without FFR), revascularizations, and complications during a 1-year follow-up. Patients with ischemia-positive CMR underwent an invasive CXA and revascularization at the discretion of the treating physician (=CMR + CXA-strategy). In the hypothetical invasive arm, costs were calculated for an initial CXA and a FFR in vessels with ≥50 % stenoses (=CXA + FFR-strategy) and the same proportion of revascularizations and complications were applied as in the CMR + CXA-strategy. In the CXA-only strategy, costs included those for CXA and for revascularizations of all ≥50 % stenoses. To calculate the proportion of patients with ≥50 % stenoses, the stenosis-FFR relationship from the literature was used. Costs of the three strategies were determined based on a third payer perspective in 4 healthcare systems.ResultsRevascularizations were performed in 6.2 %, 4.5 %, and 12.9 % of all patients, patients with atypical chest pain (n = 1’786), and typical angina (n = 582), respectively; whereas complications (=all-cause death and non-fatal infarction) occurred in 1.3 %, 1.1 %, and 1.5 %, respectively. The CMR + CXA-strategy reduced costs by 14 %, 34 %, 27 %, and 24 % in the German, UK, Swiss, and US context, respectively, when compared to the CXA + FFR-strategy; and by 59 %, 52 %, 61 % and 71 %, respectively, versus the CXA-only strategy. In patients with typical angina, cost savings by CMR + CXA vs CXA + FFR were minimal in the German (2.3 %), intermediate in the US and Swiss (11.6 % and 12.8 %, respectively), and remained substantial in the UK (18.9 %) systems. Sensitivity analyses proved the robustness of results.ConclusionsA CMR + CXA-strategy for patients with suspected CAD provides substantial cost reduction compared to a hypothetical CXA + FFR-strategy in patients with low to intermediate disease prevalence. However, in the subgroup of patients with typical angina, cost savings were only minimal to moderate.Electronic supplementary materialThe online version of this article (doi:10.1186/s12968-015-0222-1) contains supplementary material, which is available to authorized users.

Strain‐encoded magnetic resonance: a method for the assessment of myocardial deformation

“…Thus, referral for a CMR examination of 50% of patients within the European cardiovascular magnetic resonance registry (Euro-CMR) is related to the diagnostic workup for ischaemic heart disease. 25 However, the detection of inducible ischaemia by adenosine or dobutamine CMR is currently based on the visual assessment of perfusion defects or wall motion abnormalities during stress, which is both subjective and depends on the experience of the readers. 25 However, the detection of inducible ischaemia by adenosine or dobutamine CMR is currently based on the visual assessment of perfusion defects or wall motion abnormalities during stress, which is both subjective and depends on the experience of the readers.…”

Low productivity of stress cardiac magnetic resonance imaging for screening of coronary artery disease

“…The cost, using average European prices (around 643 euro), would be 1.03 billion euro per intervention, and that is assuming that the costs of machines, education, technical and software maintenance are not included and that labour, electricity and hospital space are secondarily compensated 5. Indirect medical costs, from losing productivity to attend diagnostic procedures, would also be very high.…”

“…A multicentric study on the cost efficiency of adenosine CMR versus percutaneous coronary angiography (PCA) reported a remarkable three out of four negative tests (73%; n=1983/2717 total), with a further 6% of non-diagnostic cases (n=163/2717), totalling nearly 80% of examinations that basically did not find the disease, and shadowing the light of efficiency 5. Although this is conceptually in line with a high negative predictive value of stress CMR for excluding CAD, at the same time it provides little information on how exactly to prevent a major adverse cardiac outcome.…”

“…Although this is conceptually in line with a high negative predictive value of stress CMR for excluding CAD, at the same time it provides little information on how exactly to prevent a major adverse cardiac outcome. From the clinical perspective, it is also of concern not to see the results of previous treadmill testing in most of the registry-based studies concerning CMR and prognosis or economic efficiency 5 6. Even more interesting is the fact that numerous studies focusing on the cost-efficiency of CMR used partially flawed settings: comparing the functional test of CMR (optimal for excluding disease) with PCA (optimal for diagnosing and/or treatment), where the latter is only functional in exceptional cases such as fractional flow reserve studies.…”

“…Even more interesting is the fact that numerous studies focusing on the cost-efficiency of CMR used partially flawed settings: comparing the functional test of CMR (optimal for excluding disease) with PCA (optimal for diagnosing and/or treatment), where the latter is only functional in exceptional cases such as fractional flow reserve studies. These studies therefore usually ended with the convenient conclusion that one prevented PCA represents a saving of money, while resources spent on the large number of reports within the referral range, as well as on those with positive or unclear findings, requiring subsequent diagnostics (some of which also included PCA), were not addressed at all 5 6. In these propensity-unmatched situations, the chances are inevitably in favour of a single stress CMR examination over a single PCA, which could be of concern otherwise to the national health authorities of the member states, and assets being paid from government funds.…”