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78 Multislice CT in Coronary Heart Disease KCE Reports 82 Structure of the decision tree A simple decision tree was constructed, where the numbers of patients moving from one intervention to another were derived directly from the RCT. The structure of the decision tree is presented in Figure 6. Figure 6: Structure of the decision tree for the economic model no re-admission (within 6 months) 59 discharge 6 immediate discharge 67 re-admission: alive revascularisation PCI ECG+blood 8 1 1 1 CCA 1 death further testing 0 2 SPECT Discharge MSCT 1 1 99 PCI 3 revascularisation 5 alive CABG 8 2 no revascularisation 3 CCA Chest pain 8 death 0 Further testing alive no revascularisation 32 3 3 CCA 3 death SPECT 0 24 Discharge 21 no re-admission (within 6 months) 87 discharge immediate discharge 1 95 alive no revascularisation 4 4 re-admission: SoC 8 CCA 4 death Further testing 0 Standard of care 98 7 SPECT Discharge 3 3 Analytic technique revascularisation PCI 1 1 alive 3 CCA no revascularisation 3 2 death 0 Because outcome in terms of mortality is not different between the two diagnostic arms in the study, an analysis of the “cost-per-life year gained” based on these data would ultimately boil down to a cost-minimisation analysis. However, invasive angiography, PCI and CABG have a demonstrated impact on the quality of life of patients undergoing this procedure. Therefore, it is worth looking at the QALY gains or losses of the two diagnostic work-up paths being compared. A cost-utility approach is therefore performed, calculating the incremental cost-per-QALY gained associated with MSCT as compared to standard of care.
KCE Reports 82 Multislice CT in Coronary Heart Disease 79 Perspective Target population The perspective taken is that of the Belgian health care payer, including both the National Institute for Health and Disability Insurance (RIZIV/INAMI) and the patients. For the calculation of the costs of the two diagnostic work-up arms, we calculate the total reimbursement by the RIZIV/INAMI and add, if applicable, the patients’ out-ofpocket expenses. The target population of our model is as in the RCT: adult patients with acute chest pain who are deemed at low risk for coronary events after and initial work-up in the emergency department (ECG, biomarkers). Population characteristics in both groups are presented in Table 20: Table 20: Patient characteristics in the two diagnostic groups MSCT Group Standard of Care group P-value N=99 N=98 Age, mean in yrs 47 50 0.08 Male, % 43 57 0.05 Body Mass Index 28 28 0.78 Hypertension, % 39 38 0.88 Diabetes, % 8.2 12.2 0.35 Family history of early coronary disease, % 40 44 0.56 Current smoker, % Goldman Riley criteria, % 15 20 0.35 0 very low risk 100 99 1 1 low risk 0 1 2 moderate risk Source: Goldstein et al. 0 0 67 Comparator Costs The comparator to MSCT angiography is ”standard of care” as defined by Goldstein et al. (2007). This includes noninvasive coronary tests, i.e. serial electrocardiograms and cardiac biomarkers at 0, at 4 and at 8 hours and rest-stress MPS. Common procedures to both diagnostic arms were the electrocardiograms and cardiac biomarkers at 0 and at 4 hours. Patients were randomised if both of these were normal. Therefore, the difference in primary diagnostic protocol between the ”intervention”, i.e. MSCT, and the comparator, i.e. ”standard of care”, is one cardiac biomarker and SPECT as part of the initial diagnostic strategy in the ”standard of care” group. According to the Belgian pharmacoeconomic guidelines only included direct health care costs should be included in the base-case cost analysis. Indirect costs of productivity losses were not included. Initial diagnostic strategy The costs of the initial diagnostic strategy were calculated on the basis of the prevailing reimbursement tariffs and out-of-pocket expenses of the procedures associated with the strategy. For MSCT angiography no reimbursement tariff exists (yet). Therefore, we used the reimbursement and patients’ out-of-pocket expenses for „chest CT“, which are the tariffs actually applied for MSCT. Usually other costs are associated with procedures than the costs of the procedure itself. For example, when a patient enters an emergency department and gets a MSCT angiography after which he is immediately discharged, the hospital can charge other costs to the RIZIV/INAMI such as a physician’s fee.
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