Cost-utility of computed tomography in patients with atypical chest pain clinically referred for invasive coronary angiography: randomised controlled trial

Abstract

Background Computed tomography (CT) is as safe as invasive coronary angiography (ICA) in the incidence of major adverse cardiovascular events in patients with atypical chest pain. However, the cost-utility of CT and ICA in healthcare after long-term follow-up is still unknown. Methods A prespecified cost-utility analysis (CUA) of 329 patients with atypical chest pain from a single-centre randomised trial compared CT and ICA. The CUA was conducted from the health sector perspective up to a 3-year follow-up using quality-adjusted life years (QALYs) from the EQ-5D-3L questionnaire. Costs were obtained from each individual’s outpatient and inpatient billing data and included cardiovascular medications, hospitalisations, emergency visits, cardiologist visits, and cardiac examinations. The analysis implemented 500 multiple imputations and 1000 bootstrapping iterations per imputed dataset, followed by calculating the net monetary benefit (NMB). Results There was no significant difference in mean QALYs at either 1-year (CT: 0.69 (95% CI: 0.66–0.72); ICA: 0.71 (95% CI: 0.68–0.74); difference: −0.02 (−0.06 to 0.03)) or 3-year follow-up (CT: 2.09 (95% CI: 2.00–2.17); ICA: 2.11 (95% CI: 2.02–2.19); difference: −0.02 (95% CI: −0.14 to 0.12)), while the mean cost per patient was significantly lower in the CT compared with the ICA at both 1-year (difference (€): −1647.8, 95% CI: −2198.3 to 1093.3) and at 3-year follow-ups (difference (€): −1543.3, 95% CI: −2228.0 to −830.0). At a willingness-to-pay of €20,000/QALY, the mean incremental NMB of CT over ICA was €1256.5 (164.8–2331.8) at 1-year and €1202.0 (95% CI: −1378.7 to −3961) at 3-year follow-ups. Conclusion A CT-first strategy for the management of patients with atypical angina or chest pain was more cost-effective than a direct ICA strategy. Trial registration ClinicalTrials.gov NCT00844220. Key Points Question What is the cost-effectiveness of using CT compared to invasive coronary angiography (ICA) for diagnosing coronary artery disease in patients with atypical chest pain? Findings A CT-first diagnostic strategy was €1543 less costly per patient over a 3-year follow-up, yielding similar quality-adjusted life years compared to ICA. Clinical relevance CT offers a cost-effective, non-invasive alternative to ICA for patients with atypical chest pain, reducing healthcare costs significantly without compromising patient-reported outcomes or quality of life. Graphical Abstract