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44 Multislice CT in Coronary Heart Disease <strong>KCE</strong> Reports 82<br />
and outpatient hospital costs were calculated. Cost estimates consisted of patient copayments<br />
and hospital reimbursement amounts from insurers and Medicare. The cost in<br />
case of <strong>the</strong> immediate ca<strong>the</strong>terization strategy for 206 patients was simulated by<br />
multiplying <strong>the</strong> unit cost of ca<strong>the</strong>terization by 206. This cost was compared with <strong>the</strong><br />
cost of 206 MSCT coronary angiographies followed by 66 ca<strong>the</strong>terizations.<br />
The results show that <strong>the</strong> cost of <strong>the</strong> direct CCA strategy is $1486 per patient higher<br />
than <strong>the</strong> strategy with MSCT. This is due to ca<strong>the</strong>terisation being more expensive than<br />
MSCT coronary angiography ($2940 versus $544). According to a one-way sensitivity<br />
analysis, MSCT gate-keeping is no longer cost saving if more than 81.5% (instead of 32%)<br />
of <strong>the</strong> patients are sent to CCA after MSCT. In o<strong>the</strong>r words, MSCT coronary<br />
angiography cannot be cost saving in a practice where physician’s referral to coronary<br />
angiography is high, i.e. more than 81.5%.<br />
This study did not <strong>report</strong> patient outcomes. Six patients had a negative CCA after <strong>the</strong>y<br />
had been sent to CCA following an un-interpretable MSCT. The morbidity or mortality<br />
associated with CCA was not included in <strong>the</strong> model. The original population from which<br />
<strong>the</strong> 206 patients with unclear MPS were selected is not described, nor <strong>the</strong> reason for<br />
encounter, even if it may be (unqualified) chest pain. The paper thus illustrates possible<br />
cost-savings under <strong>the</strong> 2005 Alabama particular reimbursement scheme for this hospital<br />
case-mix.<br />
Last year, Otero et al. (2007) published a study aiming at determining <strong>the</strong> maximum<br />
budget neutral reimbursement rate for MSCT if this technique was to become <strong>the</strong><br />
method of choice in acute chest pain imaging in <strong>the</strong> emergency setting. 128 This decision<br />
modelling from <strong>the</strong> Medicare perspective compared 3 alternatives strategies of CAD<br />
diagnosis:<br />
1. MSCT<br />
2. Stress echocardiography (DSE)<br />
3. SPECT (MPS)<br />
Medicare costs and patients’ outcomes were simulated for a cohort of 10 000 patients<br />
without changes on ECG and without cardiac enzyme abnormality. While <strong>the</strong> authors<br />
state that this are patients at intermediate risk, <strong>the</strong>y should actually be considered at<br />
low risk for future cardiovascular events (see chapter 2). The prevalence of CAD in this<br />
population was assumed to be 20% (19% of <strong>the</strong> patients presenting annually to <strong>the</strong><br />
emergency room for chest pain actually have CAD). Three percent of <strong>the</strong> CAD patients<br />
would have an AMI or angina during <strong>the</strong> index hospital admission. The mortality in<br />
those CAD patients after AMI is 7.5% if <strong>the</strong> AMI occurs in hospital and 25% if <strong>the</strong> AMI<br />
occurs outside <strong>the</strong> hospital.<br />
In both alternatives to MSCT, <strong>the</strong> initial emergency test was followed by CCA when<br />
positive, by discharge home when negative and by a 24 hour observation period when<br />
inconclusive in order to decide on doing a CCA or discharging <strong>the</strong> patient. In <strong>the</strong> MSCT<br />
strategy, inconclusive test results on MSCT were followed by stress echocardiography.<br />
Observation after inconclusive MSCT was not an option. Test characteristics were<br />
based on English language literature on 64-SCT and American College of<br />
Cardiology/American Heart Association expert consensus. MSCT sensitivity and<br />
specificity were assumed to be 95% and 90% respectively. Costs included only <strong>the</strong> actual<br />
national Medicare average reimbursements for diagnostics and observation unit fees.<br />
Rates of complications from noninvasive tests were considered negligible and <strong>the</strong>refore<br />
not included. Outcomes studied were deaths, intra- and extra-hospital myocardial<br />
infarction, number of tests performed and observation time needed.<br />
To make <strong>the</strong> costs of <strong>the</strong> MSCT strategy equal to those of <strong>the</strong> strategy with stress<br />
echo, <strong>the</strong> maximum reimbursement for MSCT should amount to $433. To equal <strong>the</strong><br />
costs of <strong>the</strong> MSCT strategy with <strong>the</strong> costs of <strong>the</strong> MPS strategy, <strong>the</strong> maximum amount<br />
should be $990. Three deaths and 19 (in- and out-hospital) AMI were <strong>report</strong>ed as<br />
results of <strong>the</strong> stress echo algorithm, one death and 14 AMI for <strong>the</strong> MPS algorithm and<br />
one death and 8 AMI in <strong>the</strong> case of <strong>the</strong> MSCT algorithm. As for <strong>the</strong> numbers of negative<br />
CCAs, <strong>the</strong>y were respectively 2 352 (stress Echo), 1 060 (MPS) and 266 (MSCT).