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Screening of coronary artery disease: is there a cost-effective way to do it? |
Stanford W |
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Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. Health technology Screening tests in the diagnosis of coronary artery disease (CAD). The following tests were compared: stress electrocardiogram (ECG), stress thallium, stress echocardiogram, positron emission tomography (PET), ultrafast computed tomography (UFCT), and cardiac catheterization with coronary arteriography.
Economic study type Cost-effectiveness analysis.
Study population Individuals with high risk of CAD.
Setting Hospital. The economic study was carried out in Iowa, USA.
Dates to which data relate The effectiveness data were obtained from a paper published in 1995. The source of the resource use data was not reported. The charge data corresponded to charges prevailing in 1996. The fiscal year was 1996.
Source of effectiveness data Effectiveness data were derived from a paper containing a review of previously published studies.
Outcomes assessed in the review Sensitivity, specificity, and non-diagnostic rate were assessed.
Study designs and other criteria for inclusion in the review Sources searched to identify primary studies Criteria used to ensure the validity of primary studies Methods used to judge relevance and validity, and for extracting data Number of primary studies included Methods of combining primary studies Investigation of differences between primary studies Results of the review The sensitivity, specificity and non-diagnostic rates of the tests were:
stress electrocardiogram (ECG), 68%, 77%, 15%;
stress thallium, 84%, 87%, 5%;
stress echocardiogram, 83%, 84%, 9%;
positron emission tomography (PET), 95%, 95%, 2%;
ultrafast computed tomography (UFCT), 84%, 84%, 5%;
and cardiac catheterization with coronary arteriography, 100%, 100%, 0%.
Methods used to derive estimates of effectiveness Assumptions were also made by the author.
Estimates of effectiveness and key assumptions The prevalence rate of CAD in the general population was assumed to be 0.2, 0.7, and 1.0 as different scenarios.
Measure of benefits used in the economic analysis The non-diagnostic rate was used as the benefit measure.
Direct costs Discounting of costs was not required. Quantities were not reported separately from the costs. The cost analysis covered the costs of the initial test plus cardiac catheterization, with coronary arteriography as a definite test for truly positive or falsely negative subjects, with different assumptions regarding the prevalence rate in the general population. The perspective adopted in the cost analysis was not explicitly specified. The source of charge data (as a proxy for cost data) was University of Iowa hospitals. 1996 price data were used. The costs of complications and treatment after positive diagnosis were not included in the cost analysis.
Sensitivity analysis Sensitivity analysis was not carried out except for varying the prevalence rate of CAD in the general population.
Estimated benefits used in the economic analysis The non-diagnostic rates were stress electrocardiogram (15%), stress thallium (5%), stress echocardiogram (9%), positron emission tomography (2%), ultrafast computed tomography (5%), and cardiac catheterization with coronary arteriography (0%).
Cost results The costs of the tests at 0.2, 0.7 and 1 prevalence rates of CAD were: stress electrocardiogram (ECG), $1,200, $1,800, $2,700; stress thallium, $1,800, $2,700, $3,700; stress echocardiogram, $1,500, $2,300; $3,400; positron emission tomography (PET), $2,900, $4,300, $5,000; ultrafast computed tomography (UFCT), $900, $2,000, $3,100; and cardiac catheterization with coronary arteriography, $2,700, $2,700, $2,700.
Synthesis of costs and benefits Costs and benefits were not combined.
Authors' conclusions Because of cost constraints continued efforts are needed to develop strategies to identify coronary artery disease so that appropriate interventions can be undertaken to eliminate or minimise the number of patients experiencing cardiac events. In the discussed scenario, for prevalence of 20% and 70%, UFCT plus cardiac catheterization, appears to be the most favourable. For a prevalence of 1.0, cardiac catheterization is the better test.
CRD COMMENTARY - Selection of comparators A justification was provided for the choice of the comparator. It was regarded as the gold standard in the context in question. You, as a database user, should consider whether this is a widely used screening test in your own setting. Validity of estimate of measure of benefit The internal validity of the estimates of effectiveness can not be objectively assessed due to lack of information regarding the literature used as the source for the effectiveness data. Validity of estimate of costs The source utilisation was not reported separately from the costs, but adequate details of methods of cost estimation were given. The study lacked a prospective analysis of the costs. Charges were used as a proxy for true costs and the costs of complications were not included in the cost analysis. Other issues The issue of generalisability to other settings or countries was not addressed. A cost-utility analysis would have been appropriate in the context in question. Bibliographic details Stanford W. Screening of coronary artery disease: is there a cost-effective way to do it? American Journal of Cardiac Imaging 1996; 10(3): 180-186 Indexing Status Subject indexing assigned by NLM MeSH Calcinosis /diagnosis; Coronary Angiography; Coronary Disease /diagnosis /economics /epidemiology; Coronary Vessels /pathology; Cost-Benefit Analysis; Echocardiography; Electrocardiography; Humans; Prevalence; Sensitivity and Specificity; Tomography, Emission-Computed; Tomography, X-Ray Computed; Ultrasonography, Interventional AccessionNumber 21997006456 Date bibliographic record published 31/08/1999 Date abstract record published 31/08/1999 |
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