For patients with suspected coronary artery disease (CAD), computed tomographic angiography (CTA) and functional diagnostic testing strategies have similar costs through 3 years of follow up. Results of this prospective economic study are published in Annals of Internal Medicine.
Chest pain is a common reason for patients to seek medical care and a challenge for doctors who must diagnose the cause. Typically, clinicians rely on health history and noninvasive tests to assess for CAD, such as CTA and functional stress tests. The recent PROMISE (PROspective Multicenter Imaging Study for Evaluation of Chest Pain) trial examined the effect of these different diagnostic testing strategies for CAD on patient outcomes and found little difference between them. A planned secondary aim of PROMISE was to conduct an economic analysis to assess cost differences between the approaches.
Researchers analyzed economic data for 9,649 patients enrolled in PROMISE between July 2010 and September 2013. They looked at cost of the initial outpatient testing strategy, hospital-based costs, and physician fees for the first 90 days and then estimated out to 3 years. The data showed that an initial CTA strategy had costs similar to those of a functional stress testing strategy, but patterns of care differed. Patients in the CTA group had less follow-up noninvasive testing and more invasive catheterization and revascularization. After 90 days, the choice of test had little effect on differential costs.
According to the author of an accompanying editorial, the PROMISE economic analysis is disappointing because it lacks data on treatment costs associated with heart disease. Stable ischemic heart disease therapeutic management includes a focus on symptom control, lifestyle modification, and targeted risk factor modifying treatments, which may impart a heavy economic burden on many patients. The author suggests further research to determine the value of symptom-guided treatment without diagnostic testing as a way to eliminate the commonplace finding of “testing begetting more testing.”