Cost-impact of cardiac magnetic resonance imaging with Fast-SENC compared to SPECT in the diagnosis of coronary artery disease in the U.S

Figures & data

Figure 1. Conceptual framework decision tree. (a) Short-term model only; (b) Cost-impact deterministic model comparing expected costs and outcomes of diagnostic strategies for CAD. Abbreviations. CAD, coronary artery disease; SPECT, single-photon emission computed technology; CA, coronary angiography; Fast-SENC, fast strain-encoded cardiac imaging.

Table 1. Clinical for payer-perspective model.

Variables	Base value	Sources
Low CAD prevalence	0.117	^34
CAD imaging modalities
Fast-SENC stress sensitivity rate	96%	^40
Fast-SENC stress specificity rate	88%	^40
SPECT sensitivity rate	70%	^38^,^41^,^42
SPECT specificity rate	76%	^38^,^41^,^42
SPECT + CA sensitivity	100%	^38
Fast-SENC + CA sensitivity	100%	^38
Adverse events
Contra induced nephropathy from CA	3%	^43
PCI related access-site bleeding	0.56%	^44–57
PCI related hematoma	1.63%	^44–57
PCI related retroperitoneal bleeding	0.49%	^44–57
Other PCI-related complication requiring intervention	0.46%	^44–57
Cancer risk from radiation (SPECT)	0.001%	^35
MI 90-day readmission	27.3%	^58
Untreated CA syndrome, major CV event in a year	31%	^59
Death for stable CAD treated patients	2%	^59
Annual death for untreated CA syndrome	13%	^59
Inappropriate PCI in asymptomatic CAD; positive CA	25%	^36

Table 2. Cost input data for payer perspective model.

Variables	Base value	Sources
Imaging costs
Fast-SENC stress test	$453	2017 CMS Fee Schedule
SPECT test	$494	2017 CMS Fee Schedule
SPECT test: Dipyridamole	$6	CMS Fee Schedule^16
SPECT test: Adenosine	$65	CMS Fee Schedule^16
SPECT test: Regadenoson	$214	CMS Fee Schedule^16
Radiopharmaceutical: thallium 201	$165	^16
Radiopharmaceutical: tc-99m	$91	^16
Coronary angiography test	$2,549	2016 Medicare Fee Schedule
Interventional procedure costs
Percutaneous coronary intervention	$12,581	2016 Medicare Fee Schedule
Cost of MI event and PCI intervention	$27,357	HCUP database 2014
Cost of 90-day rehospitalization for acute MI	$14,885	^60
Cost of adverse events
Access-site bleeding	$7,187	^61
Hematoma	$1,848	^61
Retroperitoneal bleeding	$8,849	^61
Other grouped vascular complications	$20,751	^61
Inpatient treatment; major cancers	$122,909	^62
Outpatient treatment; major cancers	$71,830	^62
Cost of false positive patient management	$1,301
Cost of sudden CAD death	$9,078	^63

Abreviations. CAD, coronary artery disease; CMS, The Center for Medicare and Medicaid Services; Fast-SENC, fast strain-encoded cardiac imaging; HCUP, Healthcare Cost and Utilization Project; MI, myocardial infarction; PCI, percutaneous coronary intervention; SPECT, Single-photon emission computed tomography.

Table 3. Input data for the hospital perspective model.

Parameter	SPECT	Fast-SENC stress	Sources
Diagnostic test parameters
Sensitivity	70%	96%	^38^,^41^,^42
Specificity	76%	88%	^38^,^41^,^42
Dobutamine	$3	$3	^16
Adenosine	$65	$65	^16
Regadenoson	$214	$214	^16
CA procedure hospital cost	$2,389	$2,389	Assumption
CA procedure reimbursement	$2,549	$2,549	2016 Medicare Fee Schedule
PCI hospital direct cost	$7,436	$7,436	^64
PCI reimbursement	$12,581	$12,581	2016 Medicare Fee Schedule
Contribution margin per patient PCI	$5,145	$5,145	^64, CMS
Reimbursement parameters
Test reimbursement	$495	$ 453	2017 Medicare Fee Schedule
Radiopharmaceutical reimbursement	$279		2016 Medicare Fee Schedule
Stress agent reimbursement	$94	$ 94	2016 Medicare Fee Schedule
Total cost of ownership
Acquisition cost (one time)	N/A	$40,000	MSI
Maintenance cost (annual)	N/A	$10,000	MSI
Medical equipment lifetime (years)	10	10	Imaging Technology News
Percent cardio SPECT (in hospitals)	0.46	N/A	Imaging Technology News
SPECT studies performed in 2012	8,000,000	N/A	Imaging Technology News
Pharmacological stress agents	1	N/A	Assumption
Total health systems with SPECT (2012)	6,895	N/A	Imaging Technology News
SPECT tests per health system (average)	1,160	1,160	Calculation; Assumption
Imaging modality parameters (per patient)
Time occupying machine (min)	55	20	^16, MSI
Patient prep/supervision time (min)	125	10	^16, MSI
Imaging facility cost/hour	$320	$320	Market research reports
Test inventory (per test)	$0	$150	MSI
Total cost of radiopharmaceutical	$265	$0	^16
Cost of acquiring radiopharmaceutical	$255	$0	^16
Cost of storage	$5	$0	Assumption
Cost of disposal	$5	$0	Assumption
Stress agent cost	$93	$93	^16
Recovery bed time cost per hour	$83	$83	Kaiser

Abbreviations. CA, coronary angiography; CAD, coronary artery disease; CMS, The Center for Medicare and Medicaid Services; Fast-SENC, fast strain-encoded cardiac imaging; MSI, Myocardial Solutions Inc; PCI, percutaneous coronary intervention; SPECT, Single-photon emission computed tomography.

Table 4. Payer model results.

Scenarios	SPECT	Fast-SENC	Difference	Percent difference
Low pretest probability for CAD
Diagnostic cost	$3,157	$2,510	−$647	−20%
Expected cost for year 1	$3,586	$2,567	−$1,019	−28%
Expected cost for year 3	$3,961	$2,617	−$1,344	−34%
Expected cost for year 5	$4,078	$2,632	−$1,446	−35%
Moderate/high pretest probability for CAD
Diagnostic cost	$6,120	$7,025	$905	15%
Expected cost for year 1	$7,953	$7,269	−$684	−9%
Expected cost for year 3	$9,554	$7,483	−$2,072	−22%
Expected cost for year 5	$10,057	$7,550	−$2,507	−25%

Abbreviations. CAD, coronary artery disease; Fast-SENC, fast strain-encoded cardiac imaging; SPECT, Single-photon emission computed tomography.

Table 5. Hospital model results.

Base-case results	SPECT	SPECT	Fast-SENC	Fast-SENC
Non-invasive CAD diagnostic tests:	Procedure	Annual	Procedure	Annual
Non-invasive CAD diagnostic procedure cost	$825	$956,983	$376	$436,396
Number of perfusion imaging procedures a year	1	1,160	1	1,160
Hospital perfusion imaging procedure reimbursement	$867	$1,006,062	$547	$634,408
Hospital contribution margin, non-invasive diagnostic	$42	$49,079	$171	$198,011
Additional test/treatment results	SPECT	Fast-SENC
Additional percutaneous coronary intervention		35
Hospital margin contribution from PCI	$5,145	$5,145
Hospital contribution margin per CA	$39,341	$19,671
Hospital contribution margin per PCI	N/A	$181,594
Added hospital contribution margin (CA and PCI)	$88,420	$399,275

Douglas PS, Hoffmann U, Patel MR, et al. Outcomes of anatomical versus functional testing for coronary artery disease. N Engl J Med. 2015;372:1291–1300.

 PubMed Web of Science ®Google Scholar

Korosoglou G, Gitsioudis G, Voss A, et al. Strain-encoded cardiac magnetic resonance during high-dose dobutamine stress testing for the estimation of cardiac outcomes: comparison to clinical parameters and conventional wall motion readings. J Am Coll Cardiol. 2011;58:1140–1149.

 PubMed Web of Science ®Google Scholar

Boldt J, Leber AW, Bonaventura K, et al. Cost-effectiveness of cardiovascular magnetic resonance and single-photon emission computed tomography for diagnosis of coronary artery disease in Germany. J Cardiovasc Magn Reson. 2013;15:30.

 PubMed Web of Science ®Google Scholar

Sanders GD, Patel MR, Chatterjee R. et al. Noninvasive technologies for the diagnosis of coronary artery disease in women: future research needs. Rockville, MD: Agency for Healthcare Research and Quality (US); 2013.

 Google Scholar

George RT, Mehra VC, Chen MY, et al. Myocardial CT perfusion imaging and SPECT for the diagnosis of coronary artery disease: a head-to-head comparison from the CORE320 multicenter diagnostic performance study. Radiology. 2015;274:626.

 PubMed Web of Science ®Google Scholar

Tavakol M, Ashraf S, Brener SJ. Risks and complications of coronary angiography: a comprehensive review. Glob J Health Sci. 2012;4:65–93.

 PubMedGoogle Scholar

Berrington de Gonzalez A, Kim KP, Smith-Bindman R, et al. Myocardial perfusion scans: projected population cancer risks from current levels of use in the United States. Circulation. 2010;122:2403–2410.

 PubMed Web of Science ®Google Scholar

Chen HY, Tisminetzky M, Yarzebski J, et al. Decade-long trends in the frequency of 90-day rehospitalizations after hospital discharge for acute myocardial infarction. Am J Cardiol. 2016;117:743–748.

 PubMed Web of Science ®Google Scholar

Papafaklis MI, Mavrogiannis MC, Stone PH. Identifying the progression of coronary artery disease: prediction of cardiac events. Cont Cardiol Edu. 2016;2(2):105–114.

 Google Scholar

Bradley SM, Spertus JA, Kennedy KF, et al. Patient selection for diagnostic coronary angiography and hospital-level percutaneous coronary intervention appropriateness: insights from the National Cardiovascular Data Registry. JAMA Intern Med. 2014;174:1630–1639.

 PubMed Web of Science ®Google Scholar

Henzlova MJ, Duvall WL, Einstein AJ, et al. ASNC imaging guidelines for SPECT nuclear cardiology procedures: stress, protocols, and tracers. J Nucl Cardiol. 2016;23:606–639.

 PubMed Web of Science ®Google Scholar

Khera R, Jain S, Pandey A, et al. Comparison of readmission rates after acute myocardial infarction in 3 patient age groups (18 to 44, 45 to 64, and >/=65 Years) in the United States. Am J Cardiol. 2017;120:1761–1767.

 PubMedGoogle Scholar

Resnic FS, Arora N, Matheny M, et al. A cost-minimization analysis of the angio-seal vascular closure device following percutaneous coronary intervention. Am J Cardiol. 2007;99:766–770.

 PubMed Web of Science ®Google Scholar

Fitch K, Iwasaki K, Pyenson B. Cost drivers of cancer care: a retrospective analysis of medicare and commercially insured population claim data 2004–2014. Milliman Report. 2016.

 Google Scholar

Wittels EH, Hay JW, Gotto AM. Jr. Medical costs of coronary artery disease in the United States. Am J Cardiol. 1990;65:432–440.

 PubMed Web of Science ®Google Scholar

Karmpaliotis D, Lembo N, Kalynych A, et al. Development of a high-volume, multiple-operator program for percutaneous chronic total coronary occlusion revascularization: procedural, clinical, and cost-utilization outcomes. Cathet Cardiovasc Intervent. 2013;82:1–8.

 PubMed Web of Science ®Google Scholar