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58 Multislice CT in Coronary Heart Disease KCE Reports 82 Table 17: Reimbursement for a MSCT coronary angiography in different countries (2008) Country Anatomic localisation precision Technology specification Implicit assimilation Explicit exclusion Physician Fee (€) USA CT coronary angiography Some insurers Some insurers Some insurers +/- 75€ CAN Thorax CT No Some regions No +/- 75€ AUS (CT angiography - not coronary) No No Yes € 0 EN CT, one area, pre and post contrast No Yes No +/- 160€ NL Thorax CT No Yes No +/- 64€ D Thorax CT No Yes No +/- 80€ F CT heart and vessel angiography No Yes No +/- 25€ Belgium Thorax CT No Yes No +/- 120€ The non invasive CT coronary angiography is only considered as such in two countries: the United States and Australia. It can be reimbursed in some states of USA under specific conditions while the reimbursement was not allowed in Australia (until now but will be in a few months). In other countries, there is no specific reimbursement for CT coronary angiography. USA is the only country, amongst the countries reviewed, where some local health insurers refer to a number of slices as a condition for the payment of cardiac CT. In Australia and France, CT reimbursement depends on the age of the CT unit used: the older the machine, the lower the fee. In France, this amount is not a physician fee but a technical amount covering infrastructure and overheads. The link with the equipment age is double-edged as it is an incentive to renew old CT installations but, on the other hand, it might drive costs and push hospitals to acquire brand new technology while clinical evidence does not support its use (yet). Key points • The initial investment cost of a MSCT scanner ranges from €850 000 (64-SCT scanner) to €2 million (scanner with higher number of detectors). Additionally, the cost for software for the coronary applications amounts to 20% of the device cost. The postprocessing software is €100 000 and its updating €20 000 per year. The yearly maintenance cost is €100 000. • Amongst the 240 Belgian CT scanners, 75% were already MSCT scanners (in 2005) from which 45% with more than 16 detectors. About 20% of the Belgian hospitals are doing cardiac CT. • Currently the MSCT coronary angiography is reimbursed to the Belgian radiologist under a conventional thoracic or abdominal CT INAMI/RIZIV fee-for-service amounting to €121.4. • The MSCT coronary angiography is only specifically coded in two countries: in the United States where some states reimburse it under specific conditions and in Australia where it will reimbursed in the coming months. • Like in Belgium, the procedure is charged under a generic CT code in Québec, England, the Netherlands, Germany and France.
KCE Reports 82 Multislice CT in Coronary Heart Disease 59 7 PATIENT ISSUES 7.1 TRUE NEGATIVE TEST RESULT A true-negative test result (TN) will benefit the patient if it can reassure him or her concerning a pre-existing worry in a way that is less demanding than other tests. A potential for MSCT to reassure patients with chest pain has been anticipated, thus contributing to an improvement in QoL. According to estimates by Diamond and Forrester, patients with atypical chest pain have a low probability for angiographic significant CAD. 7 (appendix) Depending on age and gender, the estimate varies between 0.8 and 28.1%. With a normal exercise test, the probability for angiographic significant CAD in this population is between 0.2 and 8.2%. 7 The diagnostic accuracy of MSCT in patients with this low pre-test probability of CAD has not been studied so far. 150 Moreover, according to Bayesian reasoning, the usefulness of further testing in these low probability patients is limited by the large number of false postive results. If we (unrealistically) would extrapolate the diagnostic performance of MSCT from intermediate and high risk populations 66 to a population with a pre-test probability of 5%, of 100 patients tested, 13 would have a positive result of which 9 would be false positives. Instead of reassuring 100 patients, MSCT would induce anxiety in 13 patients out of 100, without any proven benefit in terms of clinical outcomes. Patients with chest pain that is probably not cardiac in origin, should decide for themselves what level of diagnostic certainty they want, at what cost in monetary terms and in terms of discomfort and risk incurred by additional downstream procedure(s), i.e. radiation exposure, risk of false positives, risk of useless revascularisation, etc. They should moreover be aware that a zero-risk will be never attainable. A TN can have an adverse effect when it leads the patient to be less cautious when symptoms appear or when generally accepted lifestyle measures become neglected by it, 151 e.g. a patient may wish not to quit smoking because he or she currently tests negative for CAD or lung cancer. 7.2 FALSE NEGATIVE TEST RESULT A false-negative test result (FN) would give the individual false reassurance, and he or she may ignore signs of early disease which would cause a delay in diagnosis and treatment. 151 Coronary artery imaging can also be misleading by its semiquantitative nature, merely reporting a luminal narrowing being less or more than 50%. This is an oversimplification because coronary lesions
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