Cost Of Coronary Angiography Research Articles

Systematic review of the clinical effectiveness and cost-effectiveness of 64-slice or higher computed tomography angiography as an alternative to invasive coronary angiography in the investigation of coronary artery disease

To assess the clinical effectiveness and cost-effectiveness, in different patient groups, of the use of 64-slice or higher computed tomography (CT) angiography, instead of invasive coronary angiography (CA), for diagnosing people with suspected coronary artery disease (CAD) and assessing people with known CAD. Electronic databases were searched from 2002 to December 2006. Included studies were tabulated and sensitivity, specificity, positive and negative predictive values calculated. Meta-analysis models were fitted using hierarchical summary receiver operating characteristic curves. Summary sensitivity, specificity, positive and negative likelihood ratios and diagnostic odds ratios for each model were reported as a median and 95% credible interval (CrI). Searches were also carried out for studies on the cost-effectiveness of 64-slice CT in the assessment of CAD. The diagnostic accuracy and prognostic studies enrolled over 2500 and 1700 people, respectively. The overall quality of the studies was reasonably good. In the pooled estimates, 64-slice CT angiography was highly sensitive (99%, 95% CrI 97 to 99%) for patient-based detection of significant CAD (defined as 50% or more stenosis), while across studies the negative predictive value (NPV) was very high (median 100%, range 86 to 100%). In segment-level analysis compared with patient-based detection, sensitivity was lower (90%, 95% CrI 85 to 94%, versus 99%, 95% CrI 97 to 99%) and specificity higher (97%, 95% CrI 95 to 98%, versus 89%, 95% CrI 83 to 94%), while across studies the median NPV was similar (99%, range 95 to 100%, versus 100%, range 86 to 100%). At individual coronary artery level the pooled estimates for sensitivity ranged from 85% for the left circumflex (LCX) artery to 95% for the left main artery, specificity ranged from 96% for both the left anterior descending (LAD) artery and LCX to 100% for the left main artery, while across studies the positive predictive value (PPV) ranged from 81% for the LCX to 100% for the left main artery and NPV was very high, ranging from 98% for the LAD (range 95 to 100%), LCX (range 93 to 100%) and right coronary artery (RCA) (range 94 to 100%) to 100% for the left main artery. The pooled estimates for bypass graft analysis were 99% (95% CrI 95 to 100%) sensitivity, 96% (95% CrI 86 to 99%) specificity, with median PPV and NPV values across studies of 93% (range 90 to 95%) and 99% (range 98 to 100%), respectively. This compares with, for stent analysis, a pooled sensitivity of 89% (95% CrI 68 to 97%), specificity 94% (95% CrI 83 to 98%), and median PPV and NPV values across studies of 77% (range 33 to 100%) and 96% (range 71 to 100%), respectively. Sixty-four-slice CT is almost as good as invasive CA in terms of detecting true positives. However, it is somewhat poorer in its rate of false positives. It seems likely that diagnostic strategies involving 64-slice CT will still require invasive CA for CT test positives, partly to identify CT false positives, but also because CA provides other information that CT currently does not, notably details of insertion site and distal run-off for possible coronary artery bypass graft (CABG). The high sensitivity of 64-slice CT avoids the costs of unnecessary CA in those referred for investigation but who do not have CAD. Given the possible, although small, associated death rate, avoiding these unnecessary CAs through the use of 64-slice CT may also confer a small immediate survival advantage. This in itself may be sufficient to outweigh the very marginally inferior rates of detection of true positives by strategies involving 64-slice CT. The avoidance of unnecessary CA through the use of 64-slice CT also appears likely to result in overall cost savings in the diagnostic pathway. Only if both the cost of CA is relatively low and the prevalence of CAD in the presenting population is relatively high (so that most patients will go on to CA) will the use of 64-slice CT be likely to result in a higher overall diagnostic cost per patient. The main value of 64-slice CT may at present be to rule out significant CAD. It is unlikely to replace CA in assessment for revascularisation of patients, particularly as angiography and angioplasty are often done on the same occasion. Further research is needed into the marginal advantages and costs of 256-slice machines compared with 64-slice CT, the usefulness of 64-slice CT in people with suspected acute coronary syndrome, the potential of multislice computed tomography to examine plaque morphology, the role of CT in identifying patients suitable for CABG, and the concerns raised about repetitive use, or use of 64-slice or higher CT angiography in younger individuals or women of childbearing age.

Computed Tomographic Coronary Angiography: Experience at Baylor University Medical Center/Baylor Jack and Jane Hamilton Heart and Vascular Hospital

Noninvasive cardiac computed tomographic imaging using multislice or electron beam technology has been shown to be highly specific and sensitive in diagnosing coronary heart disease. It is about a fifth of the cost of coronary angiography and is particularly well suited for evaluating patients with a low or low to moderate probability of having obstructive coronary atherosclerosis. In addition, it offers more information than calcium scoring: because of the intravenous contrast used, it temporarily increases the density of the lumen and allows differentiation of soft plaque from calcified plaque. The Baylor Hamilton Heart and Vascular Hospital now uses this modality to define coronary atherosclerosis in patients who would otherwise have needed invasive coronary angiography; several research protocols with the technique are also under way. Baylor has recently upgraded to the 64-slice scanner. It is expected that computed tomographic coronary angiography will replace a significant percentage of invasive cardiac catheterizations.

Coronary angiography and angioplasty after acute myocardial infarction.

To assess the data that support the use of coronary angiography and angioplasty after acute myocardial infarction, that identify the risks of these procedures, and that analyze their use and costs. English-language articles published between 1970 and June 1995 identified through a search of the MEDLINE database. Studies that contained information about benefits, risks, use, and costs of coronary angiography and angioplasty after acute myocardial infarction. Descriptive and analytic data from each study were collected. The outcome for patients who have complications of myocardial infarction (such as shock) is poor. Such patients usually undergo angiography, although the evidence that supports this practice is weak. Preliminary data suggest that patients who immediately have angiography and angioplasty after acute myocardial infarction have better outcomes than do patients who receive thrombolytic therapy with angioplasty only for specific indications in experienced centers. After the acute phase of myocardial infarction, patients who have noninvasive evidence of persistent or recurrent ischemia are believed to benefit from angiography. In the remaining patients, however, angiography after myocardial infarction has not been shown to be beneficial. Coronary angiography is done in 30% to 81% of patients after acute myocardial infarction in different settings and regions; for many of these patients, the benefit is questionable. Better outcomes are not always associated with more frequent use of the procedure. In the United States, catheterizations after myocardial infarction cost approximately $1 billion per year. Although many patients benefit from angiography and angioplasty after myocardial infarction, others probably do not. Substantial resources are at stake.

Cost of Coronary Angiography

<h3>To the Editor.—</h3> In his articles of cost and risk of coronary arteriography, Charles E. Hansing, MD (242:731; 242:735, 1979), demonstrated in a study of cardiac catheterization laboratories in the state of Washington that no correlation existed between the total number of cardiac catheterization procedures performed in a laboratory and the cost per procedure. Furthermore, no relationship existed between the risk per procedure and the number performed. Risk was more related to the type of patient undergoing angiography, with higher risk occurring in those with main left coronary stenosis, triple-vessel coronary disease, severe aortic stenosis, and congestive heart failure. These cost data corroborate findings of an impartial study of three hospitals in the San Francisco Bay area by the subcommittee on Cardiac Catheterization and Surgical Services of the Regional Medical Planning Committee (1976). Depreciation, wages and benefits, materials, services, and indirect expenses were taken into account. The three hospitals all

Cost of coronary angiography

Cost of coronary angiography

The risk and cost of coronary angiography. I. Cost of coronary angiography in Washington State

The risk and cost of coronary angiography. I. Cost of coronary angiography in Washington State

The Risk and Cost of Coronary Angiography

The risk of coronary angiography has been decreasing since development of the procedure 19 years ago. Deaths resulting from angiography now occur only in high-risk clinical circumstances. Whether a certain case load per angiographer or laboratory is necessary for adequate safety is still a question. Even though little available data exist on the relationship of case loads to risk, the National Guidelines for Health Planning now require 300 cardiac catheterizations per laboratory per year and forbid development of new laboratories in hospitals without heart surgery programs. Data collected from all 16 laboratories in Washington showed 26 deaths (0.19%) during 14,050 coronary angiograms. Eighteen of those who died had a severe left main coronary obstruction, and three had severe triple-vessel disease. There were 18 myocardial infarctions (0.13%) and nine strokes (0.06%). The risks in hospitals without cardiac surgery programs and in hospitals performing fewer than 200 cases per year were no higher than in the other hospitals studied. The National Guidelines should be reevaluated before they are used to change the existing pattern of health care.

The risk and cost of coronary angiography. II. The risk of coronary angiography in Washington State

The risk and cost of coronary angiography. II. The risk of coronary angiography in Washington State

The Risk and Cost of Coronary Angiography

The Risk and Cost of Coronary Angiography