After CCTA: More Follow-Up Procedures, Higher Costs
Downstream data for CCTA were compared with those for stress testing.
Coronary computed tomographic angiography （CCTA） is a newer noninvasive anatomical test to detect coronary artery disease （CAD）. In this analysis of Medicare claims data, investigators assessed downstream healthcare use and costs after CCTA or several stress testing modalities in 283,000 patients without CAD-related claims during the previous year.
At 180 days, compared with patients who underwent myocardial perfusion scintigraphy （MPS; the primary stress test used）, patients in the CCTA cohort were more likely to undergo invasive angiography （22.9％ vs. 12.1％）, percutaneous coronary intervention （PCI; 7.8％ vs. 3.4％）, and coronary artery bypass grafting （CABG; 3.7％ vs. 1.3％）; these differences remained significant after adjustment for clinical factors. Compared with a total healthcare cost per patient of US＄24,100 after MPS, costs were higher （+＄4200） for CCTA but lower for stress echocardiography （―＄5000） and exercise electrocardiography （―＄7400）. Overall mortality was similar after CCTA or MPS, although risk for hospitalization for myocardial infarction was lower after CCTA （adjusted odds ratio, 0.60; P＝0.04） and stress echocardiography （AOR, 0.83; P＝0.03） compared with MPS.
COMMENT
In this Medicare population, initial evaluation with CCTA, compared with stress MPS, was associated with higher rates of invasive angiography, PCI, and CABG; in contrast, earlier studies in younger patients had suggested CCTA lowers downstream healthcare use and costs. The effect on rehospitalization for myocardial infarction is tantalizing, but given borderline P values, similar effects after stress echocardiography, and lack of clinical detail in administrative databases, this finding should be considered to be hypothesis-generating. An ongoing randomized trial （the PROMISE study （https://www.promisetrial.org） ） will provide a more robust comparison of outcomes associated with CCTA, MPS, and stress echocardiography.
― Kirsten E. Fleischmann, MD, MPH, Journal Watch General Medicine
Shreibati JB et al. Association of coronary CT angiography or stress testing with subsequent utilization and spending among Medicare beneficiaries.
JAMA 2011 Nov 16; 306:2128.
http://medical.nikkeibp.co.jp/leaf/mem/pub/hotnews/jwhospital/201204/524219.html
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