Cost analysis of initial computed tomography angiography vs cardiac catheterization

Journal of Cardiovascular Computed Tomography (2007) 1, 124

Letters to the Editor Cost analysis of initial computed tomography angiography vs cardiac catheterization The report by Cole et al1 is an interesting and provocative cost analysis of potential savings using a strategy of coronary computed tomography angiography (CCTA) before cardiac catheterization in patients with equivocal or mildly abnormal nuclear stress tests. I believe, however, that the analysis is basically flawed because the strategy 1 group assumes that all the study patients go on to cardiac catheterization. The authors themselves appear to recognize that this is certainly never the case in reality. If, in the absence of CCTA utilization, only a fraction of patients with equivocal or mildly abnormal nuclear scans would ordinarily go on to cardiac catheterization, “real-world” cost savings do not occur. In fact, I would suspect that the 100% CCTA strategy would be far more expensive compared with a more typical, historical strategy of cardiac catheterization utilization in the patients described. Stephen Fleet, MD Lahey Clinic Department of Cardiology One Essex Center Drive Peabody, MA 01960 USA E-mail: [email protected] doi:10.1016/j.jcct.2007.08.006

Reference 1. Cole JH, Chunn VM, Morrow JA, Buckley RS, Phillips GM: Cost implications of initial computed tomography angiography as opposed to catheterization in patients with mildly abnormal or equivocal myocardial perfusion scans. J Cardiovasc Comput Tomogr. 2007;1:21– 6.

laboratory at a number of institutions. In fact, as shown in our sensitivity analysis, we believe that the mean cost savings we present are quite conservative estimates. We also welcome dialogue on the topic and are happy to respond to Dr. Fleet’s comments. It is certainly true that if all persons with abnormal nuclear studies proceeded to CCTA, the cost implications would be different (although there is some evidence that cost savings may still occur even in that situation1). However, such an analysis is not the point of our study. The cost model in our study analyzes the cost implications for persons who are referred for additional testing. The question is whether catheterization or CCTA and selective catheterization are a more cost-saving strategy for these persons. As we point out, this population represented only 6% of all nuclear studies at our center, even though about 15% of studies are typically classified as either mildly abnormal or equivocal. In our experience, referred patients for CCTA are persons with ongoing symptoms (who otherwise almost always go on to catheterization) or those in whom the referring physician considers it important to establish whether coronary atherosclerosis exists. A major challenge with CCTA is going to be the development of appropriate clinical algorithms for its use. We encourage continued research in this area and are happy to have participated in the first stages of the discussion. Jason H. Cole, MD, MSc Division of Cardiology, Department of Medicine, University of South Alabama College of Medicine 3715 Dauphin Street, Suite 4400 Mobile, AL 36608 USA E-mail: [email protected] doi:10.1016/j.jcct.2007.08.007

In Reply to Dr. Fleet

Reference

As clinicians experienced in the use of cardiac computed tomography (CT) my coauthors and I are very confident that coronary CT angiography (CCTA) is already functioning in an appropriate role as “gatekeeper” to the catheterization

1. Sola S, Fu ZA, Obuchowski NA, Garcia MJ: Cost savings of a strategy using coronary CT angiography vs. cardiac catheterization to evaluate patients with an abnormal stress test. J Cardiovasc Comput Tomogr 2007;1:S1.

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