Cost-effectiveness of 64-slice CT angiography compared to conventional coronary angiography based on a coverage with evidence development study in Ontario

Abstract

Conventional coronary angiography (CCA) is the standard diagnostic for coronary artery disease (CAD), but multi-detector computed tomography coronary angiography (CTCA) is a non-invasive alternative. Methods: A multi-center coverage with evidence development study was undertaken and combined with an economic model to estimate the cost–effectiveness of CTCA followed by CCA vs CCA alone. Alternative assumptions were tested in patient scenario and sensitivity analyses. Results: CCA was found to dominate CTCA, however, CTCA was relatively more cost-effective in females, in advancing age, in patients with lower pre-test probabilities of CAD, the higher the sensitivity of CTCA and the lower the probability of undergoing a confirmatory CCA following a positive CTCA. Conclusions: Results were very sensitive to alternative patient populations and modeling assumptions. Careful consideration of patient characteristics, procedures to improve the diagnostic yield of CTCA and selective use of CCA following CTCA will impact whether CTCA is cost-effective or dominates CCA.

Keywords::

• coronary angiography
• cost-utility analysis
• coverage with evidence development
• economic evaluation
• field evaluation
• 64-slice CT angiography

Acknowledgements

We would like to thank Les Levin and the Evidence Development and Standards Team (formerly the Medical Advisory Secretariat), Health Quality Ontario and the Ontario Health Technology Advisory Committee (OHTAC) for their support and review of this study.

Financial & competing interests disclosure

Funding for this study was provided by the Ontario Ministry of Health & Long-term Care (MOHLTC), which was acquired through the Acute Services Division and also from an independent Health Technology Assessment and Economic Evaluation Program research grant awarded to R Goeree and research team (grant: 06129) at the Programs for Assessment of Technology in Health (PATH) Research Institute, St. Joseph's Healthcare Hamilton. D O’Reilly was a recipient of a Career Scientist Award from the Ontario Ministry of Health and Long-term Care during the conduct of this study. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.

Key issues

• • A total of 169 patients were recruited into the study from four participating centers.

• • The sensitivity and specificity of computed tomography coronary angiography (CTCA) was found to be 83% and 94%, respectively.

• • For the base case patient scenario analysis (i.e., 60-year-old males), and using the pre-test probability of coronary artery disease (CAD) from the coverage with evidence development (CED) study, conventional coronary angiography (CCA) was found to dominate CTCA being slightly less costly and slightly more effective as compared to CTCA. For females, CTCA was cost-effective in lower ages and dominant over CCA in older ages.

• • Pre-test probability was an important variable determining dominance of one strategy over another (CTCA dominating for probabilities under 50% and CCA dominating for probabilities over 50.4%). CTCA is very cost-effective if CTCA sensitivity is above 90%.

• • CTCA dominates CCA if the probability of receiving a confirmatory CCA following a positive CTCA is <50.5%.

• • CCA dominance findings less sensitive in males, less sensitive for CTCA specificity and less sensitive to discount rates.

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Notes