Acute chest pain is one of the most common reasons patients visit hospital emergency departments. Increasingly over the past five years, coronary CT angiography (CCTA) is performed to rule out the presence of coronary artery disease (CAD). Its function as a “gatekeeper” is expensive, and a number of studies have been published to analyze its overall cost effectiveness. A study published in the July-August issue of the Journal of Cardiovascular Computed Tomography shows that when CCTA is performed, the need for subsequent tests is reduced and cost of care is lower.
The study analyzes the costs of treating over 1,500 consecutive patients in a 7.5 year period at Brooke Army Medical Center in San Antonio, TX. The cost of treating patients at military hospitals tends to be lower than at civilian ones because most clinical and support staff are salaried and there are no physician fee-for-service incentives. Lead Author Dustin M. Thomas, M.D., of the cardiology service at Brooke Army Medical Center in San Antonio, TX, and co-authors made the presumption that the management of patients who present with chest pain is comparable to treatment of patients treated in the private sector. They conducted an analysis to evaluate the effect of CAD burden on subsequent chest pain clinical evaluation, subsequent cardiac testing, and the direct costs of care after the initial CCTA exam. Only direct costs were included, and estimates were made using the 2014 Medicare and Medicaid Services Physician and Hospital Fee Schedule. The cost for an inpatient admission was based on the 2014 national average of Medicare payments for a chest pain admission to a civilian hospital.
A total of 1,518 consecutive symptomatic adult patients were referred for CCTA at Brooke Army Medical Center from January 2005 to July 2012. They were followed for a median of 12 months and some as much as two years. The patients were categorized by CCTA-identified stenosis into three cohorts: patients with obstructive coronary artery disease (CAD), with non-obstructive CAD, and not having CAD.
Approximately 10% of the patients were diagnosed with CAD. They were referred for invasive coronary angiography (ICA) performed with complete revascularization at the discretion of their cardiologists and received additional care provided based on published guidelines and the outcome of the ICA results. Patients with non-obstructive CAD (44.2%) were referred for management of modifiable cardiovascular risk factors at a cardiology clinic, and the remainder (45.4%) were told to see a primary care physician if they experienced additional chest-related symptoms.
Only 174 patients presented for chest pain reevaluation within 12 months following their initial CCTA exam. They included 91 patients with non-obstructive CAD, 52 patients with no CAD, and 31 patients with obstructive CAD. Nineteen of the 31 patients with obstructive CAD were referred for ICA. The remaining 12 patients underwent additional noninvasive testing. The authors reported that once patients were selected to undergo additional testing, there was no difference among the groups with regard to the average number of tests ordered. Forty-two patients with non-obstructive CAD had at least one additional test, as did 18 patients with no-CAD.
The authors reported that nearly two thirds of patients with no CAD and nearly half of the patients with non-obstructive CAD identified at the time of the initial CCTA were able to avoid hospital admission and repeat testing in follow-up. The median cost of treatment at Brooke Army Medical Center for a patient with obstructive CAD following the CCTA was $5,832. The cost of a patient with non-obstructive CAD was almost $3,000 less, at $2,951, and for patients with no CAD, a median of $235 with a range of no additional expenses to $2,880.
Study reconfirms overall cost savings in treatment with use of CCTA. Appl Radiol.