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48 Multislice CT in Coronary Heart Disease KCE Reports 82
We challenged the conclusions drawn by Goldstein et al. about the cost-effectiveness of
MSCT compared to standard of care by fully exploring all information provided by their
RCT, including the costs and quality of life effects of invasive angiography,
revascularisations and complications in each diagnostic arm up to 6 months after initial
admission to the emergency department for acute chest pain. We supplemented the
data of the study with data on the quality of life in case of interventional procedures and
applied Belgian health care costs to each of the procedures included in the study. The
full details of this exercise are presented in appendix.
The results showed that, given the limitations of this exercise, the MSCT diagnostic
strategy is on average €479,56 more expensive than the standard of care strategy from
the perspective of the health care payer. Moreover, it leads to a higher loss in QALYs:
0.0016 QALYs are lost in the MSCT arm as compared to 0.00056 QALYs in the
standard of care arm. This is equivalent to about 6 hours of life in perfect health more
lost in the MSCT arm than in the CCA arm. If we neglect the costs of revascularisations
and invasive angiography -as did Goldstein et al. 67 - the costs of the MSCT strategy are
lower than the costs of the standard of care strategy. In that case, we reach the same
conclusion as the authors.
The figures resulting from this exercise should be treated with caution, as the evaluation
was based on data from only one RCT. The patient numbers in each health state were
too small to reliably estimate transition probabilities and make the model more generic.
For instance, none of the patients in the “standard of care”-arm who underwent a late
CCA were revascularised. This might be a coincidence due to the small number of
patients undergoing a late CCA. The RCT was not powered to detect such potential
relevant differences. In real life, with very large patient numbers, the situation might be
different, and some patients might undergo revascularisation if late CCA is positive. To
increase the generalizability of the results, more data on the long term consequences of
both diagnostic interventions would be needed (need for revascularisation, AMI, death).
Data from larger data sets would allow us to define transition probabilities and hence
built a more generic model.
A full economic evaluation would require evidence on the effectiveness of MSCT in real
world in low- to intermediate risk patients. Evidence on diagnostic accuracy in welldefined
patient populations is being built up, meanwhile leaving the assessment of the
impact of MSCT on patient outcomes unevaluated.
Key points
• Published economic evaluations of MSCT to detect CAD in low to
intermediate risk populations are all limited by the gap in evidence
about the clinical effectiveness of MSCT in these populations.
• None of the studies related costs to treatment effects or patient
outcomes. Nevertheless, they are frequently cited to demonstrate
the cost-effectiveness of MSCT relative to the standard of care.
• A basic economic evaluation, based on data from one RCT, showed
that taking treatment or patient outcomes into account might
change the conclusions with respect to the cost-effectiveness of
MSCT.
• However, given the small number of patients in the RCT, firm
conclusions about cost-effectiveness cannot be drawn from this
exercise.
• More trials, sufficiently powered to study differences in relevant
economic and outcome variables, are needed.