This Article Abstract Free Full Text (Free PDF) Free Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to Saved Citations Download to citation manager Request Permissions Request Reprints Add to My Marked Citations Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Citing Articles via Scopus Google Scholar Articles by Hernández, R. Articles by Vale, L. Search for Related Content PubMed PubMed Citation Articles by Hernández, R. Articles by Vale, L. Social Bookmarking                         What's this?

The Value of Myocardial Perfusion Scintigraphy in the Diagnosis and Management of Angina and Myocardial Infarction: A Probabilistic Economic Analysis

Health Economics Research Unit, University of Aberdeen, Aberdeen, Scotland, UK, r.a.hernandez @abdn.ac.uk

Luke Vale, PhD

Health Economics Research Unit, University of Aberdeen, Aberdeen, Scotland, UK, Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland, UK

Background and Aim. Coronary heart disease (CHD) is the most common cause of death in the United Kingdom, accounting for more than 120,000 deaths in 2001, among the highest rates in the world. This study reports an economic evaluation of single photon emission computed tomography myocardial perfusion scintigraphy (SPECT) for the diagnosis and management of coronary artery disease (CAD). Methods. Strategies involving SPECT with and without stress electrocardiography (ECG) and coronary angiography (CA) were compared to diagnostic strategies not involving SPECT. The diagnosis decision was modeled with a decision tree model and long-term costs and consequences using a Markov model. Data to populate the models were obtained from a series of systematic reviews. Unlike earlier evaluations, a probabilistic analysis was included to assess the statistical imprecision of the results. The results are presented in terms of incremental cost per quality-adjusted life year (QALY). Results. At prevalence levels of CAD of 10.5%, SPECT-based strategies are cost-effective; ECG-CA is highly unlikely to be optimal. At a ceiling ratio of £20,000 per QALY, SPECT-CA has a 90% likelihood of being optimal. Beyond this threshold, this strategy becomes less likely to be cost-effective. At more than £75,000 per QALY, coronary angiography is most likely to be optimal. For higher levels of prevalence (around 50%) and more than a £10,000 per QALY threshold, coronary angiography is the optimal decision. Conclusions. SPECT-based strategies are likely to be cost-effective when risk of CAD is modest (10.5%). Sensitivity analyses show these strategies dominated non-SPECT-based strategies for risk of CAD up to 4%. At higher levels of prevalence, invasive strategies may become worthwhile. Finally, sensitivity analyses show stress echocardiography as a potentially cost-effective option, and further research to assess the relative cost-effectiveness of echocardiography should also be performed.

Key Words: coronary heart disease • coronary artery disease • cost-utility analyses • probabilistic sensitivity analysis.

References

• British Heart Foundation Health Promotion Research Group. Coronary Heart Disease Statistics. Oxford , UK: University of Oxford, Department of Public Health; 2003.
• Liu JLY, Maniadakis N., Gray A., Rayner M. The economic burden of coronary heart disease in the UK . Heart. 2002;88: 597—603 .[Abstract/Free Full Text]
• American College of Cardiology & American Heart Association. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina [homepage on the Internet]. 2002. Available at: http://www.acc.org/clinical/guidelines/stable/stable.pdf.
• Mowatt G., Vale L., Brazzelli M., et al. Systematic review of the effectiveness and cost-effectiveness, and economic evaluation, of myocardial perfusion scintigraphy for the diagnosis and management of angina and myocardial infarction . Health Technol Assess. 2004;8: iii—iv , 1—207 .[Medline] [Order article via Infotrieve]
• Manning WG, Fryback DG, Weinstein MC Reflecting uncertainty in cost-effectiveness analysis. In: Gold MR, Siegel JE, Russell LB, Weinstein MC, eds. Cost-Effectiveness in Health and Medicine. New York: Oxford University Press; 1996. p 247—75.
• Microsoft Corporation. Microsoft Excel 2000 [homepage on the Internet]. Available at: http://www.microsoft.com/uk/office/excel/prodinfo/default.mspx.
• TreeAge Software, Inc. TreeAge data 4.0 [homepage on the Internet]. 2001. Available at: http://www.treeage.com/products.htm. 8. Weinstein M., Fineberg H. Clinical Decision Analysis. London: Saunders; 1980.
• Dittus RS, Roberts SD, Adolph RJ Cost-effectiveness analysis of patient management alternatives after uncomplicated myocardial infarction: a model . J Am Coll Cardiol. 1987;10: 869—78 .[Abstract]
• Garber AM, Solomon NA Cost-effectiveness of alternative test strategies for the diagnosis of coronary artery disease . Ann Intern Med. 1999;130: 719—28 .[Abstract/Free Full Text]
• Kim C., Kwok YS, Saha S., Redberg RF Diagnosis of suspected coronary artery disease in women: a cost-effectiveness analysis . Am Heart J. 1999;137: 1019—27 .[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• Kuntz KM, Fleischmann KE, Hunink MG, Douglas PS Cost-effectiveness of diagnostic strategies for patients with chest pain . Ann Intern Med. 1999;130: 709—18 .[Abstract/Free Full Text]
• Maddahi J., Gambhir SS Cost-effective selection of patients for coronary angiography . J Nucl Cardiol. 1997;4(pt 2): S141—51 .[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• Patterson RE, Eng C., Horowitz SF, Gorlin R., Goldstein SR Bayesian comparison of cost-effectiveness of different clinical approaches to diagnose coronary artery disease . J Am Coll Cardiol. 1984;4: 278—89 .[Abstract]
• Patterson RE, Eisner RL, Horowitz SF Comparison of cost-effectiveness and utility of exercise ECG, single photon emission computed tomography, positron emission tomography, and coronary angiography for diagnosis of coronary artery disease . Circulation. 1995;91: 54—65 .[Abstract/Free Full Text]
• Rumberger JA, Behrenbeck T., Breen JF, Sheedy PF Coronary calcification by electron beam computed tomography and obstructive coronary artery disease: a model for costs and effectiveness of diagnosis as compared with conventional cardiac testing methods . J Am Coll Cardiol. 1999;33: 453—62 .[Abstract/Free Full Text]
• Shaw LJ, Heller GV, Travin MI, et al. Cost analysis of diagnostic testing for coronary artery disease in women with stable chest pain: Economics of Noninvasive Diagnosis (END) study group . J Nucl Cardiol. 1999;6: 559—69 .[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• UK Department of Health. National service framework for coronary heart disease [homepage on the Internet]. 2000. Available at: http://www.doh.gov.uk/nsf/coronary.htm.
• Government Actuary's Department. Interim life tables 1999—2001 [homepage on the Internet]. 2003. Available at: http://www.gad.gov.uk/Life_Tables/Interim_life_tables.htm.
• Lampe FC, Whincup PH, Wannamethee SG, Shaper AG, Walker M., Ebrahim S. The natural history of prevalent ischaemic heart disease in middle-aged men . Eur Heart J. 2000;21: 1052—62 .[Abstract/Free Full Text]
• Shaw LJ, Hachamovitch R., Berman DS, et al. The economic consequences of available diagnostic and prognostic strategies for the evaluation of stable angina patients: an observational assessment of the value of precatheterization ischemia. Economics of Noninvasive Diagnosis (END) multicenter study group . J Am Coll Cardiol. 1999;33: 661—9 .[Abstract/Free Full Text]
• Volmink JA, Newton JN, Hicks NR, Sleight P., Fowler GH, Neil HA Coronary event and case fatality rates in an English population: results of the Oxford Myocardial Infarction Incidence Study . Heart. 1998;80: 40—4 .[Abstract/Free Full Text]
• Hartwell D., Colquitt J., Loveman E., et al. Clinical effectiveness and cost effectiveness of immediate angioplasty for acute myocardial infarction . Health Technol Assess. 2003;9(17).
• Underwood SR, Godman B., Salyani S., Ogle JR, Ell PJ Economics of myocardial perfusion imaging in Europe: the EMPIRE study . Eur Heart J. 1999;20: 157—66 .[Abstract/Free Full Text]
• Department of Health, UK. NHS reference costs [homepage on the Internet]. 2001. Available at: http://www.doh.gov.uk/nhsexec/refcosts2001.htm.
• Netten A, Curtis L, eds. Unit Costs of Health and Social Care. Canterbury , UK: University of Kent at Canterbury, Personal Social Services Research Unit; 2003.
• Sculpher MJ, Smith DH, Clayton T., et al. Coronary angioplasty versus medical therapy for angina: health service costs based on the second randomized intervention treatment of angina (RITA-2) trial . Eur Heart J. 2002;23: 1291—300 .[Abstract/Free Full Text]
• British Medical Association & Royal Pharmaceutical Society of Great Britain. British National Formulary [homepage on the Internet]. 2002. Available at: http://bnf.vhn.net/home/.
• Boland A., Bagust A., Hill R., et al. Early thombolysis for the treatment of acute myocardial infarction: technology assessment review submitted to NICE. 2002. Available at: http://www.nice.org.uk/Docrefasp?d=34366.
• Euroqol [homepage on the Internet]. 2004. Available at: http://www.euroqol.org/.
• Harvard Center for Risk Analysis, Harvard Center for Public Health. The CEA registry: standardizing the methods and practices for cost-effectiveness analysis [homepage on the Internet]. 2003. Available at: http://www.hsph.harvard.edu/cearegistry/.
• British Heart Foundation. Heart attack recovery [homepage on the Internet]. 2001. Available at: http://www.bhf.org.uk/questions/index.asp?secondlevel=370&thirdlevel=493.
• National Institute for Health and Clinical Excellence. Guidance for manufacturers and sponsors [homepage on the Internet]. 2001. Available at: http://www.nice.org.uk/pdf/technicalguidanceformanufacturersandsponsors.pdf.
• Fenwick E., Claxton K., Sculpher M., Briggs A. Improving the efficiency and relevance of health technology assessment: the role of iterative decision analytic modelling. In: Centre for Health Economics Discussion Paper Series. York , UK: University of York; 2000. p 1—35.
• Briggs A. Handling uncertainty in economic evaluation and presenting the results. In: Drummond M, McGuire A, eds. Economic Evaluation in Health Care: Merging Theory with Practice. Oxford , UK: Oxford University Press; 2001. p 172—214.
• Briggs AH, Goeree R., Blackhouse G., O'Brien BJ Probabilistic analysis of cost-effectiveness models: choosing between treatment strategies for gastroesophageal reflux disease . Med Decis Making. 2002;22: 290—308 .[Abstract/Free Full Text]
• Iversen GR Bayesian Statistical Inference. Beverly Hills, CA: Sage; 1984.
• Brennan A. Discussed in the Course: ``Probabilistic Sensitivity Analysis in Cost-Effectiveness Modelling.'' Sheffield, UK: Centre for Bayesian Statistics in Health Economics, University of Sheffield; 2004.
• Crystal Ball 2000. v.5.2.2 [homepage on the Internet]. Decisioneering. Available at: www.crystalball.com.
• Fenwick E., Claxton K., Sculpher M. Representing uncertainty: the role of cost-effectiveness acceptability curves . Health Econ. 2001;10: 779—87 .[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• Klocke FJ, Baird MG, Lorell BH, et al. ACC/AHA/ASNC guidelines for the clinical use of cardiac radionuclide imaging—executive summary: a report of the American College of Cardiology/American Heart Association task force on practice guidelines (ACC/AHA/ ASNC committee to revise the 1995 guidelines for the clinical use of cardiac radionuclide imaging) . J Am Coll Cardiol. 2003;42: 1318—33 .[Free Full Text]
• De S., Searles G., Haddad H. The prevalence of cardiac risk factors in women 45 years of age or younger undergoing angiography for evaluation of undiagnosed chest pain . Can J Cardiol. 2002;18: 945—8 .[Web of Science][Medline] [Order article via Infotrieve]
• Michaelides AP, Psomadaki ZD, Dilaveris PE, et al. Improved detection of coronary artery disease by exercise electrocardiography with the use of right precordial leads . N Engl J Med. 1999;340: 340—5 .[Abstract/Free Full Text]
• Jacklin P., Maisey M., West P., Sariklis D., Beech R. Modelling the cost effectiveness of diagnostic pathways for coronary artery disease. Unpublished manuscript; 2002.
• Mowatt G., Brazzelli M., Gemmell H., et al. Systematic review of the prognostic effectiveness of SPECT myocardial perfusion scintigraphy in patients with suspected or known coronary artery disease and following myocardial infarction . Nucl Med Commun. 2005;26: 217—29 .[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• Yusuf S., Zucker D., Peduzzi P., Fisher LD, Takaro T., Kennedy JW, et al. Effect of coronary artery bypass graft surgery on survival: Overview of 10-year results from randomized trials by the coronary artery bypass graft surgery trialists collaboration . Lancet. 1994;344(8922): 563—70 .[CrossRef][Web of Science][Medline] [Order article via Infotrieve]

This version was published on December 1, 2007

Medical Decision Making, Vol. 27, No. 6, 772-788 (2007)
DOI: 10.1177/0272989X07306111


CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    Twitter    What's this?

This article has been cited by other articles:

				R. Chisin Cost-Effectiveness Analysis J. Nucl. Med., March 1, 2009; 50(3): 338 - 339. [Full Text] [PDF]

This Article Abstract Free Full Text (Free PDF) Free Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to Saved Citations Download to citation manager Request Permissions Request Reprints Add to My Marked Citations Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Citing Articles via Scopus Google Scholar Articles by Hernández, R. Articles by Vale, L. Search for Related Content PubMed PubMed Citation Articles by Hernández, R. Articles by Vale, L. Social Bookmarking                         What's this?