Health economic consequences of optimal vs. observed guideline adherence of coronary angiography in patients with suspected obstructive stable coronary artery in Germany: a microsimulation model

Abstract

Aims While the number of patients with stable coronary artery disease (SCAD) is similar across European countries, Germany has the highest per capita volume of coronary angiographies (CA). This study evaluated the health economic consequences of guideline-non-adherent use of CA in patients with SCAD. Methods and results As part of the ENLIGHT-KHK trial, a prospective observational study, this microsimulation model compared the number of major adverse cardiac events (MACE) and the costs of real-world use of CA with those of (assumed) complete guideline-adherent use (according to the German National Disease Management Guideline 2019). The model considered non-invasive testing, CA, revascularization, MACE (30 days after CA), and medical costs. Model inputs were obtained from the ENLIGHT-KHK trial (i.e. patients’ records, a patient questionnaire, and claims data). Incremental cost-effectiveness ratios were calculated by comparing the differences in costs and MACE avoided from the perspective of the Statutory Health Insurance (SHI). Independent on pre-test probability (PTP) of SCAD, complete guideline adherence for usage of CA would result in a slightly lower rate of MACE (-0.0017) and less costs (€-807) per person compared with real-world guideline adherence. While cost savings were shown for moderate and low PTP (€901 and €502, respectively), for a high PTP a guideline-adherent process results in slightly higher costs (€78) compared with real-world guideline adherence. Sensitivity analyses confirmed the results. Conclusion Our analysis indicates that improving guideline adherence in clinical practice by reducing the amount of CAs in patients with SCAD would lead to cost savings for the German SHI.

Guideline adherence in the use of coronary angiography in patients presenting at the emergency department without myocardial infarction – Results from the German ENLIGHT-KHK project

“…Especially difficulties in access is considered a major barrier in the use of the NIGT modalities [14] . In addition to preventing unnecessary invasive CAs and reducing health care expenditures [12] , extending the use of NIGT could also lead to further benefits for patients: As outlined by Weir-McCall et al, an increased use of coronary CT-angiography did not increase the overall volume of CA, but appeared to result in a population-wide reduction of cardiovascular mortality (at least in a National Health Service setting in the United Kingdom) [22] .…”

“…To fill this gap in evidence, to evaluate the health-economic consequences of GL non-adherent use of CA, and to detect facilitators and barriers of GL-adherent care the multi-facetted ENLIGHT-KHK project was conducted [11] . Results on GL-adherence in the use of CA in chronic coronary syndrome (CCS), on health economic consequences and on factors influencing GL-adherence were already published [12] , [13] , [14] .…”