A cost effectiveness study into the detection of functionally significant coronary artery disease in patients with chronic coronary syndrome: a decision-analytic modelling approach

Abstract

Abstract Background ESC guidelines recommend functional or anatomical imaging for stable coronary artery disease (CAD) diagnosis. We investigated cost-effective diagnostic strategies for CAD detection with invasive coronary angiography (ICA) and fractional flow reserve (FFR) as reference standard [1,2], using NHS reference costs. Methods Deterministic and probabilistic decision-analytic models for diagnostic strategies in low (25%), intermediate (50%) and high (75%) risk CAD were devised. Strategies: standalone or combined testing with computed tomographic coronary angiography (CTCA), stress echocardiography (SE), CT-FFR, single-photon emission computed tomography (SPECT), cardiac magnetic resonance (CMR), positron emission tomography (PET), ICA, and ICA-FFR. Proportion of correct diagnosis served as measure of clinical effectiveness. Incremental cost-effectiveness ratios were calculated for dominant strategies. Cost-effectiveness acceptability curves (CEAC) tested variation of cost-effectiveness threshold (CET). Results Base case (Table 1) consistent with probabilistic analysis (Figure 1 left). CEACs (Figure 1 right). Conclusions Direct ICA is not cost-effective. Functional testing has significant role in low/intermediate risk. CMR is cost-effective in all risk and most likely cost-effective in CETs <£10,000. ICA-FFR yields highest correct diagnoses in all at highest cost. Future long-term follow-up studies with quality of life measures are needed.