Alexander Goehler MD,PhD, Presenter: Nothing to Disclose

Thomas Mayrhofer, Abstract Co-Author: Nothing to Disclose

Amit Pursnani MD, Abstract Co-Author: Nothing to Disclose

Heidi Lumish, Abstract Co-Author: Nothing to Disclose

Cordula Barth, Abstract Co-Author: Nothing to Disclose

John T Nagurney, Abstract Co-Author: Nothing to Disclose

Benjamin Chow MD, Abstract Co-Author: Research Grant, General Electric Company Support, TeraRecon, Inc

Quynh Truong MD, Abstract Co-Author: Research Grant, St. Jude Medical, Inc

G. Scott Gazelle MD, PhD, Abstract Co-Author: Consultant, General Electric Company Consultant, Marval Biosciences Inc

Udo Hoffmann MD, Abstract Co-Author: Nothing to Disclose

Coronary computed tomographic angiography (CCTA) is a viable strategy for evaluating acute chest pain in the Emergency Department (ED); however, the long-term health and economic outcomes associated with its improved detection of coronary artery disease (CAD) remain unclear.

We developed a Markov model to compare 30-day and lifetime health and economic outcomes of four competing strategies for evaluation of acute chest pain in the ED: 1) early CCTA, 2) standard of care as observed (SOC) in the Rule Out Myocardial Infarction Using Computed Coronary Angiography (ROMICAT) II trial 3) an expert consensus strategy (guidelines) and 4) an expedited ED protocol with early discharge and diagnostic testing on an outpatient basis. Input parameters included ROMICAT II trial, Ottawa chest pain cohort data and the published literature. The model was validated by closely simulating management as observed in ROMICAT II.

The model predicted length of stay (in hours) of 30.6 for SOC, 23.4 for CCTA, 30.9 for guidelines and 12.3 for expedited discharge. The total associated costs were $4,145, $4,491, $4,064, and $4,064, respectively. Assuming a prevalence of obstructive CAD of 6.3%, SOC correctly identified 43 of 62 patients (68%), CCTA 62 of 63 patients (98%), guidelines 47 of 63 patients (75%), and expedited discharge 29 of 63 patients (46%), with respective revascularization rates of 3.7%, 5.2%, 4.0%, and 2.6%. Over the lifetime, this resulted in quality adjusted life years (QALYs) of 22.95, 23.01, 22.96, 22.92 with lifetime costs of $6,700, $6,900, $6,600, and $4,950, respectively. These differences in QALYs and costs translate into an incremental cost-effectiveness ratio of $37,000/QALY for CCTA versus expedited discharge, with both other strategies being dominated (i.e. inferior).

Though CCTA is associated with greater early testing and revascularization rates, it is cost-effective in the long-term because the benefits of earlier treatment of obstructive CAD outweigh the increase in testing. With about 6 million patients presenting with chest pain to the ED per year, CCTA could result in a gain of about 0.5 million QALYs.

This comparative effectivess analysis demonstrates the dominance of CCTA over alternate strategies in ED triage, offering further support for the expansion of coverage for this service by CMS.

Goehler, A, Mayrhofer, T, Pursnani, A, Lumish, H, Barth, C, Nagurney, J, Chow, B, Truong, Q, Gazelle, G, Hoffmann, U, Effectiveness and Cost-Effectiveness of ED Discharge Strategies for Acute Chest Pain – Expansion of the ROMICAT II Trial.  Radiological Society of North America 2014 Scientific Assembly and Annual Meeting, - ,Chicago IL. http://archive.rsna.org/2014/14015453.html