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76 Multislice CT in Coronary Heart Disease KCE Reports 82 FLOW CHART Economic evaluations Potentially relevant citations identified: 290 Studies retrieved for more detailed evaluation: 52 Relevant studies: 2 Based on title and abstract evaluation, citations excluded: 238 Reasons: High-Risk population 1 EBCT, MSCT
KCE Reports 82 Multislice CT in Coronary Heart Disease 77 CHALLENGING THE ECONOMIC CONCLUSIONS OF GOLDSTEIN ET AL. Several international articles refer to the paper by Goldstein et al. 67 to claim costeffectiveness of MSCT. In this appendix, we challenge the economic conclusions of the authors, by fully using their findings to assess the economic benefit of the technology. This analysis was a simple exercise to evaluate the validity of the economic conclusions drawn from the Goldstein study. Not too much weight should be given to the precise figures resulting from this exercise, as the initial clinical trial was not set up to do an economic evaluation. Patient numbers were too small for instance to draw firm conclusions about the therapeutic impact of MSCT or the standard of care as defined in the study. In the study, the number of invasive treatments was higher in the MSCT arm than in the standard of care arm (6 versus 1). This might be due to coincidence. However, in the absence of better data, applying these crude figures in the economic model has an important impact on the costs and effects of the initial diagnostic strategy. Because of the limited value of the precise figures resulting from this evaluation, the evaluation has been put in appendix. It substantiates, however, the argument that erroneous conclusions about the economic benefit of MSCT might be drawn if based only on an RCT that was not initially set up to assess economic benefit of this technology. METHODOLOGY Design The principles of the methodological guidelines for pharmacoeconomic evaluations in Belgium were applied in this excercise. 161 Three outcome studies were identified in the clinical literature review, one being a randomised controlled trial comparing a diagnostic strategy with MSCT with standard of care (serial ECGs + cardiac biomarkers + MPS). 67 The study was a cost-outcome description, drawing conclusions about the economic benefits, defined as the difference between median costs of MSCT and standard of care. For the evaluation of the incremental costs and effects of a diagnostic strategy with MSCT and a standard diagnostic strategy in patients with chest pain, we used the data from this RCT. In contrast to the authors of the study, we decided to extrapolate the economic results to include the costs of invasive angiography, revascularisations and complications up to 6 months after initial admission to the emergency department for acute chest pain. The basic idea is that the cost-effectiveness of MSCT depends not only on the costs and effects of the diagnostic strategy, but also the costs and effects of its sequelae, i.e. the changes in therapeutic behaviour and the consequent impact on patient outcomes. Therefore, it is insufficient to consider only the technique’s diagnostic accuracy (sensitivity and specificity) in an economic evaluation. An economic evaluation should also incorporate the technique’s effect on patients’ outcomes (life years gained or quality-adjusted life years gained). The design of our economic evaluation is a piggy-back economic evaluation, based on a data from one RCT. A decision tree was constructed based on the observed movements of patients in that RCT. In that sense, the decision tree is a limited representation of the expected reality, as the number of patients in the RCT was limited and not all branches of a more realistic model could be filled with data from the trial. However, with the limited data available in literature, it was unfortunately unrealistic to fill a decision tree that included all possible real-life scenarios. The economic evaluation was performed in Microsoft® Excel 2002, using @RISK 4.5.5 for the bootstrapping.
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