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Aims: The aim of this study was to investigate in patients with stable angina the effects on costs of frontline diagnostics by exercise-stress testing (ex-test) vs. coronary computed tomography angiography (CTA)., Methods and Results: In two coronary units at Lillebaelt Hospital, Denmark, 498 patients were identified in whom either ex-test (n = 247) or CTA (n = 251) were applied as the frontline diagnostic strategy in symptomatic patients with a low-intermediate pre-test probability of coronary artery disease (CAD). During 12 months of follow-up, death, myocardial infarction and costs associated with downstream diagnostic utilization (DTU), treatment, ambulatory visits, and hospitalizations were registered. There was no difference between cohorts in demographic characteristics or the pre-test probability of significant CAD. The mean (SD) age was 56 (11) years; 52% were men; and 96% were at low-intermediate pre-test probability of CAD. All serious cardiac events (n = 3) during follow-up occurred in patients with a negative ex-test result. Mean costs per patient associated with DTU, ambulatory visits, and cardiovascular medication were significantly higher in the ex-test than in the CTA group. The mean (SD) total costs per patient at the end of the follow-up were 14% lower in the CTA group than in the ex-test group, € 1510 (3474) vs. €1777 (3746) (P = 0.03)., Conclusion: Diagnostic assessment of symptomatic patients with a low-intermediate probability of CAD by CTA incurred lower costs when compared with the ex-test. These findings need confirmation in future prospective trials.

Background: Non-cardiac aetiologies are common among patients presenting with chest pain., Aim: To determine the cost of non-specific chest pain admissions to a tertiary referral, teaching hospital., Methods: Thrombolysis in myocardial infarction risk (TIMI) risk score, lengths of stay (LOS), investigations and diagnoses were recorded for patients admitted with chest pain. Non-specific chest pain was defined as chest pain where cardiac, pulmonary and gastroesophageal aetiologies were excluded. Costs of admissions were calculated., Results: Of 80 patients, 34 (4%) and 22 (28%) were diagnosed with non-specific chest pain and acute coronary syndrome, respectively. Non-specific chest pain admissions had a mean age of 54 (11; 35-74) years, LOS of 3.8 (2.6; 1-11) days and TIMI risk score of 1.4 (1.5; 0-5). Acute coronary syndrome admissions had a mean age of 67 (14; 43-94) years, LOS of 7.7 (4.3; 2-16) days and TIMI risk score of 3.1 (1.2; 0-5). The mean cost per non-specific chest pain admission was €3,729 (2,378; 1,034-10,468), or 48% of the mean cost per acute coronary syndrome admission of €7,667 (4,279; 1,963-16,071). Bed day costs account for >90% of overall costs. Only 7% of patients were weekend discharges. The mean interval to exercise stress test was 2.7(1.5; 1-7) days., Conclusions: The mean costs of admission and LOS for patients with non-specific chest pain are significant. Extrapolating findings, annual national cost is estimated at approximately €71 million for this cohort, with 73,000 bed days consumed nationally. Delays from admission to tests and low percentage of weekend discharges prolong LOS.

Background: Patterns of noninvasive stress test (ST) and invasive coronary angiography (CA) utilization after percutaneous coronary intervention (PCI) are not well described in older populations., Methods and Results: We linked National Cardiovascular Data Registry CathPCI Registry data with longitudinal Medicare claims data for 250 350 patients undergoing PCI from 2005 to 2007 and described subsequent testing and outcomes. Between 60 days post-PCI and end of follow-up (median 24 months), 49% (n=122 894) received ST first, 10% (n=25 512) underwent invasive CA first, and 41% (n=101 944) had no testing. Several clinical risk factors at time of index PCI were associated with decreased likelihood of downstream testing (ST or CA, P<0.05 for all), including older age (hazard ratio [HR] 0.784 per 10-year increase), male sex (HR 0.946), heart failure (HR 0.925), diabetes mellitus (HR 0.954), smoking (HR 0.804), and renal failure (HR 0.880). Fifteen percent of patients with ST first proceeded to subsequent CA within 90 days of testing (n=18 472/122 894) [corrected]; of these, 48% (n=8831) underwent revascularization within 90 days, compared with 53% (n=13 316) of CA first patients (P<0.0001)., Conclusions: In this descriptive analysis, ST and invasive CA were common in older patients after PCI. Paradoxically, patients with higher risk features at baseline were less likely to undergo post-PCI testing. The revascularization yield was low on patients referred for ST after PCI, with only 7% [corrected] undergoing revascularization within 90 days.

A self-paced treadmill that can simulate overground walking has the potential to improve the effectiveness of treadmill training for gait rehabilitation. We have implemented a self-paced treadmill without the need for expensive equipment such as a motion capture system and an instrumented treadmill. For this, an inexpensive depth sensor, ASUS XtionTM, substitutes for the motion capture system, and a low-cost commercial treadmill is considered as the platform of the self-paced treadmill. The proposed self-paced treadmill is also convenient because the depth sensor does not require markers placed on user's body. Through pilot tests with two healthy subjects, it is quantitatively and qualitatively verified that the proposed self-paced treadmill achieves similar performance as one which utilizes a commercial motion capture system (VICON) as well as an instrumented treadmill.

Background: Diabetic patients have an increased prevalence of atherosclerosis and coronary artery disease. They may also experience higher morbidity and mortality after acute coronary syndrome compared with non-diabetic subjects., Aim: The objective of this study was to determine the presence of silent myocardial ischaemia by treadmill test in asymptomatic diabetic patients and to compare it with age- and sex-matched subjects without diabetes mellitus., Methods: The study design was cross-sectional and the setting was a tertiary care centre. Fifty (42 males, 8 females) asymptomatic patients with diabetes in the age group of 30-70 years were included in the study group and 30 (24 males, 6 females) non-diabetic subjects of comparable age, sex and physical activity were the control group. They were assessed for the presence of silent ischaemia by a standard treadmill test using the Bruce protocol., Results: Twenty-five of 50 diabetic patients showed a positive response to the exercise stress test, while 7 of 30 controls showed stress test positivity (p < 0.05). The stress test positivity showed a female predilection among diabetic patients (50% in diabetic patients and 16.67% in controls; p < 0.05). Diabetic patients with a positive stress test showed higher prevalence of hypertension (36%) and dyslipidaemia (84%) compared with diabetic patients with a negative stress test (12% and 28%, respectively) [p < 0.001]. The controls showed a better exercise capacity compared with diabetic patients; diabetic patients with a negative stress test had better exercise capacity than those with a positive stress test., Conclusions: The treadmill test is a useful, specific, cost-effective, non-invasive tool for detection of silent myocardial ischaemia in asymptomatic diabetic patients.

Aim: Intermittent claudication (IC) in peripheral vascular disease is characterized by lower limb pain appearing on effort. Treatment with PGE1 has been successfully used to manage IC patients. This registry has evaluated safety and costs of PGE1 in the management of IC., Methods: In this study a long-term treatment protocol (LTP), a short-term protocol (STP) and an outpatient (OP), "on-demand" treatment have been compared. A treadmill effort test has been used to evaluate walking distance. The follow up for these three protocols was 40 weeks. PGE1 treatment was associated to a risk reduction plan and to an exercise program., Results: The final analysis has included 252 LTP patients, 223 STP patients and 284 OP patients (total 659 valid cases). A group of 171 comparable patients not treated with PGE1 was used for a parallel comparison. Cardiovascular mortality and morbidity has been evaluated in 731 PGE1 patients completing 24 months of follow up. All protocols have been well tolerated. No side effects were observed. The lower cost has been observed for OP patients. In the long term, mortality and morbidity were lower in patients treated with PGE1 in comparison with patients not treated with PGE1., Conclusion: Considering costs and results (increase in walking distance) and improvement in Karnofsky scale the STP plan appears to be better than LTP for IC patients. The OP, "on-demand" treatment offers further improvements. This last treatment plan is simpler; the plan allows better timing for exercise. The treatment can be used even in non-specialized centers.

Background: Although exercise echocardiography (ExE) of asymptomatic patients early (2 years after percutaneous coronary intervention [PCI] or 5 years after coronary bypass graft surgery [CABG]) after revascularization is considered inappropriate, the appropriateness of later testing is indeterminate. Treatment responses to positive test results in either setting have uncertain outcome implications. We sought to identify whether predictors of increased risk by ExE could lead to interventions that change outcome in asymptomatic patients with previous coronary revascularization., Methods: Exercise echocardiography was performed in 2105 asymptomatic patients (mean [SD] age, 64 [10] years; 310 [15%] were women; 845 [40%] had a history of myocardial infarction; 1143 [54%] had undergone PCI and 962 [46%] had undergone CABG 4.1 [4.7] years prior to the ExE). Ischemia was identified as a new or worsening wall motion abnormality. Patients were followed for a mean (SD) period of 5.7 (3.0) years for cardiac mortality. The association of ischemia during ExE with survival was assessed using Cox proportional hazard models, and an interaction with revascularization was sought., Results: Of 262 patients with ischemia (13%), only 88 (34%) underwent subsequent revascularization. Mortality (97 patients [4.6%]) was associated with ischemia (hazard ratio, 2.10; 95% CI, 1.05-4.19; P=.04) in groups tested both early (P=.03) and late (≥2 years after PCI or ≥ 5 years after CABG) (P=.001). However, the main predictors of outcome were clinical and stress testing findings rather than echocardiographic features. Subgroup analysis showed that asymptomatic patients without diabetes mellitus, with normal ejection fraction (≥50%), and normal exercise capacity (>6 METs [metabolic equivalent for task]) were unlikely to have a positive test result or events. Even high-risk patients did not seem to benefit from repeated revascularization., Conclusions: Asymptomatic patients who undergo ExE after coronary revascularization may be identified as being at high risk but do not seem to have more favorable outcomes with repeated revascularization. From a health economic standpoint, appropriateness of such testing must be carefully reviewed.

Objective: To conduct an economic analysis (EA) of coronary calcium scoring (CCS) using a 0 score, as alternative to stress electrocardiography (sECG) in diagnosing coronary artery disease (CAD)., Method: A decision tree was constructed to compare four strategies for investigation of suspected CAD previously assessed in the formulation of clinical guidelines for the United Kingdom (UK) to two new strategies incorporating CCS. Sensitivity (96%; 95% CI 95.4-96.4%) and specificity (40%; 95% CI 38.7-41.4%) values for CCS were derived from a meta-analysis of 10,760 patients. Other input variables were obtained from a previous EA and average prices for hospital procedures in the UK. A threshold of £30,000/Quality-adjusted Life Year (QALY) was considered cost-effective., Results: Using net monetary benefit calculations, CCS-based strategies were found to be cost-effective compared to sECG equivalents at all assessed prevalence of CAD. Using CCS prior to myocardial perfusion scintigraphy (MPS) and catheter angiography (CA) was found to be cost-effective at pre-test probabilities (PTP) below 30%., Conclusions: Adoption of CCS as an alternative to sECG in investigating suspected stable angina in low PTP population (<30%) would be cost-effective. In patients with PTP of CAD >30%, proceeding to MPS or CA would be more cost-effective than performing either CCS or sECG., Key Points: Coronary calcium scoring (CCS) is useful for assessing coronary artery atherosclerosis It can be performed with multi-detector CT, which is now widely available It plays a role in excluding disease in suspected stable angina Our study assesses its role in this setting as alternative to stress-ECG Adoption of CCS as an alternative to sECG could prove cost-effective.

Context: Coronary computed tomography angiography (CCTA) is a new noninvasive diagnostic test for coronary artery disease (CAD), but its association with subsequent clinical management has not been established., Objective: To compare utilization and spending associated with functional (stress testing) and anatomical (CCTA) noninvasive cardiac testing in a Medicare population., Design, Setting, and Patients: Retrospective, observational cohort study using claims data from a 20% random sample of 2005-2008 Medicare fee-for-service beneficiaries 66 years or older with no claims for CAD in the preceding year, who received nonemergent, noninvasive testing for CAD (n = 282,830)., Main Outcome Measures: Cardiac catheterization, coronary revascularization, acute myocardial infarction, all-cause mortality, and total and CAD-related Medicare spending over 180 days of follow-up., Results: Compared with stress myocardial perfusion scintigraphy (MPS), CCTA was associated with an increased likelihood of subsequent cardiac catheterization (22.9% vs 12.1%; adjusted odds ratio [AOR], 2.19 [95% CI, 2.08 to 2.32]; P < .001), percutaneous coronary intervention (7.8% vs 3.4%; AOR, 2.49 [2.28 to 2.72]; P < .001), and coronary artery bypass graft surgery (3.7% vs 1.3%; AOR, 3.00 [2.63 to 3.41]; P < .001). CCTA was also associated with higher total health care spending ($4200 [$3193 to $5267]; P < .001), which was almost entirely attributable to payments for any claims for CAD ($4007 [$3256 to $4835]; P < .001). Compared with MPS, there was lower associated spending with stress echocardiography (-$4981 [-$4991 to -$4969]; P < .001) and exercise electrocardiography (-$7449 [-$7452 to -$7444]; P < .001). At 180 days, CCTA was associated with a similar likelihood of all-cause mortality (1.05% vs 1.28%; AOR, 1.11 [0.88 to 1.38]; P = .32) and a slightly lower likelihood of hospitalization for acute myocardial infarction (0.19% vs 0.43%; AOR, 0.60 [0.37 to 0.98]; P = .04)., Conclusion: Medicare beneficiaries who underwent CCTA in a nonacute setting were more likely to undergo subsequent invasive cardiac procedures and have higher CAD-related spending than patients who underwent stress testing.

Purpose of Review: Coronary artery disease (CAD) is associated with significant morbidity and mortality. Several noninvasive imaging techniques such as stress echocardiography, stress nuclear studies, computed tomography coronary angiography, and, most recently, stress cardiovascular magnetic resonance (CMR) have enhanced the accuracy and efficiency of evaluation of patients., Recent Findings: The diagnostic capabilities of CMR have increased substantially over the past 20 years due to hardware and software advances. Today, CMR has a number of unique advantages over other imaging modalities - primarily because it provides a view of the entire heart without limitations from inadequate imaging windows or body habitus. Furthermore, along with stress imaging for inducible wall motion or perfusion abnormalities, CMR provides a comprehensive examination with concurrent evaluation of the ejection fraction, aorta, pericardium, and valves all without the inherent risks of radiation administration or contrast exposure., Summary: The purpose of this article is to review the current state of stress CMR for both detection of significant disease and the prognostication of future cardiac events. Clinical data will demonstrate that stress CMR is accurate, with detection in a broad population of patients similar to or better than reported using other noninvasive stress imaging techniques. Moreover, patients with a normal adenosine stress CMR scan have an excellent prognosis on follow-up with no adverse cardiovascular outcomes. Thus, CMR perfusion stress testing has been deemed appropriate for the evaluation of chest pain syndromes in patients with intermediate probability of coronary artery disease (CAD) and for ascertaining the physiologic significance of indeterminate coronary artery lesions.

Study Objective: The study aimed to examine time and imaging costs of 2 different imaging strategies for low-risk emergency department (ED) observation patients with acute chest pain or symptoms suggestive of acute coronary syndrome. We compared a "triple rule-out" (TRO) 64-section multidetector computed tomography protocol with nuclear stress testing., Methods: This was a prospective observational cohort study of consecutive ED patients who were enrolled in our chest pain observation protocol during a 16-month period. Our standard observation protocol included a minimum of 2 sets of cardiac enzymes at least 6 hours apart followed by a nuclear stress test. Once a week, observation patients were offered a TRO (to evaluate for coronary artery disease, thoracic dissection, and pulmonary embolus) multidetector computed tomography with the option of further stress testing for those patients found to have evidence of coronary artery disease., Results: We analyzed 832 consecutive observation patients including 214 patients who underwent the TRO protocol. Mean total length of stay was 16.1 hours for TRO patients, 16.3 hours for TRO plus other imaging test, 22.6 hours for nuclear stress testing, 23.3 hours for nuclear stress testing plus other imaging tests, and 23.7 hours for nuclear stress testing plus TRO (P < .0001 for TRO and TRO + other test compared to stress test ± other test). Mean imaging times were 3.6, 4.4, 5.9, 7.5, and 6.6 hours, respectively (P < .05 for TRO and TRO + other test compared to stress test ± other test). Mean imaging costs were $1307 for TRO patients vs $945 for nuclear stress testing., Conclusion: Triple rule-out reduced total length of stay and imaging time but incurred higher imaging costs. A per-hospital analysis would be needed to determine if patient time savings justify the higher imaging costs., (Copyright © 2011 Elsevier Inc. All rights reserved.)

We aimed to evaluate the differences between exercise testing (ET), myocardial perfusion SPECT (MPS) and a combination of ET and MPS based risk assessment as outlined by the guidelines with respect to their "gate-keeper" role to coronary angiography (cath) and the associated diagnostic procedural costs if prognostic considerations, as those proposed by the current guidelines and the recent literature, were taken into account. The Duke-score and the summed difference score (SDS; extent of ischemia) were assessed in 955 consecutive patients referred for MPS combined with ET. According to the guidelines and the available literature, three different algorithms for risk stratification were retrospectively applied: (1) ET based risk stratification and cath if intermediate or high risk Duke-score; (2) MPS based risk stratification and cath if SDS ≥ 8; (3) combined approach with ET as first step and MPS in case of intermediate risk Duke-score. A cath would have been suggested in every patient with either high risk Duke-score or SDS ≥ 8 in patients with intermediate risk Duke-score. The referral rate to cath was 27% according to the ET alone, 13% using MPS, and finally 12% applying the combined risk stratification. The cost of the diagnostic work-up including cath were: 615€, 1,299€, and 598€ per patient, respectively. The coronary angiography referral rate widely depends on the diagnostic modality used for risk stratification and according to the referral criteria provided by the guidelines. In the present study, the use of a stress imaging modality (MPS) and published prognostic data was associated with a lower referral rate to cath as compared to exercise testing alone and thus underlines the advantage of a risk based approach applying stress imaging in patients with intermediate risk Duke-score.

Objectives: We compared analytical approaches to estimate the added value of myocardial perfusion single-photon emission computed tomography (MPS) variables in estimating coronary artery disease (CAD) outcomes., Background: Stress MPS markers of regional ischemia are strong estimators of prognosis. Evidence published to date has not compared analytical methods to establish the added value of stress MPS and to define a clinically meaningful approach to detect improve classification of risk., Methods: A total of 4,575 patients were consecutively and prospectively enrolled in the Myoview Prognosis Registry. Multivariable Cox proportional hazards model were employed to estimate CAD death or myocardial infarction (MI). Risk reclassification methods were also calculated., Results: In risk-adjusted models (including age, sex, presenting symptoms, stress type, CAD history, and risk factors), stress MPS ischemia, rest and post-stress left ventricular ejection fraction (LVEF) (all p < 0.0001) were all significant estimators of CAD death or MI. In this multivariable model, 34% of the model chi-square was contributed by MPS ischemia. In receiver-operating characteristic curve analysis, the area under the curve increased from 0.61 to 0.66 when rest and post-stress LVEF were combined with pre-test CAD likelihood (p < 0.0001), increasing to 0.69 for MPS ischemia (p < 0.0001). The net reclassification improvement (NRI) by adding the Duke Treadmill Score (DTS) to a model including pre-test CAD likelihood was 0.112. The cost per NRI was $57 for the exercise test as compared with an office visit for risk stratification purposes. Further, the NRI by adding MPS ischemia to a model with the DTS and pre-test CAD likelihood was 0.358. The cost per NRI was $615 for the stress MPS as compared with an exercise test., Conclusions: Stress-induced ischemia is independently predictive of near-term CAD outcomes. Analytical approaches that establish the reclassification of events provide a unique approach and may serve as a quality imaging metric for estimation of improved health outcomes for stress MPS as well as for comparison to other imaging modalities., (Copyright © 2010 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Study Objective: We determine whether imaging with cardiac magnetic resonance imaging (MRI) in an observation unit would reduce medical costs among patients with emergent non-low-risk chest pain who otherwise would be managed with an inpatient care strategy., Methods: Emergency department patients (n=110) at intermediate or high probability for acute coronary syndrome without electrocardiographic or biomarker evidence of a myocardial infarction provided consent and were randomized to stress cardiac MRI in an observation unit versus standard inpatient care. The primary outcome was direct hospital cost calculated as the sum of hospital and provider costs. Estimated median cost differences (Hodges-Lehmann) and distribution-free 95% confidence intervals (Moses) were used to compare groups., Results: There were 110 participants with 53 randomized to cardiac MRI and 57 to inpatient care; 8 of 110 (7%) experienced acute coronary syndrome. In the MRI pathway, 49 of 53 underwent stress cardiac MRI, 11 of 53 were admitted, 1 left against medical advice, 41 were discharged, and 2 had acute coronary syndrome. In the inpatient care pathway, 39 of 57 patients initially received stress testing, 54 of 57 were admitted, 3 left against medical advice, and 6 had acute coronary syndrome. At 30 days, no subjects in either group experienced acute coronary syndrome after discharge. The cardiac MRI group had a reduced median hospitalization cost (Hodges-Lehmann estimate $588; 95% confidence interval $336 to $811); 79% were managed without hospital admission., Conclusion: Compared with inpatient care, an observation unit strategy involving stress cardiac MRI reduced incident cost without any cases of missed acute coronary syndrome in patients with emergent chest pain., (Copyright (c) 2010 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.)

Stress single photon emission computed tomographic (SPECT) myocardial perfusion imaging has enjoyed great success over the past several decades as the modality of choice for accurately diagnosing and risk stratifying patients with suspected or known coronary artery disease. Same-day low-dose rest/high-dose stress imaging protocols have generally been widely adopted for this purpose. However, recent studies indicate that rest imaging may be unnecessary in patients with a normal initial stress SPECT. Elimination of the additional imaging would decrease costs, streamline patient evaluations, and reduce radiation exposure. SPECT imaging guidelines should be revised to reflect this new information.

Objective: Patients without symptoms who have positive stress test results are often referred for diagnostic catheter angiography in an evaluation for coronary artery disease (CAD). The purpose of this study was to use decision tree analysis to determine the cost-effectiveness and radiation dose that would result from performing coronary CT angiography (CTA) before catheterization., Materials and Methods: A decision tree was constructed to compare the false-negative rates, false-positive rates, costs, and radiation exposure of direct referral of patients for cardiac catheterization with the values associated with performing coronary CTA before catheterization. We assumed that patients referred for coronary CTA proceed to catheterization only when significant disease is identified. Costs for coronary CTA and diagnostic catheterization were obtained from the 2009 physician Medicare fee schedule. Sensitivity, specificity, and radiation dose were obtained by literature review., Results: Cost reduction with coronary CTA depends on the prevalence of coronary artery disease, but overall costs are reduced as long as the prevalence is less than 85%. At a 50% prevalence of coronary artery disease, performing coronary CTA before cardiac catheterization results in an average cost saving of $789 per patient with a false-negative rate of 2.5% and average additional radiation exposure of 1-2 mSv., Conclusion: Performing coronary CTA before cardiac catheterization is a cost-effective strategy in the care of patients without symptoms who have positive stress test results when the probability that the patient has significant coronary artery disease is less than 50%. The false-negative rate with this strategy compares favorably with the false-negative rate of stress testing. The use of coronary CTA in this role can avoid many unnecessary cardiac catheterization procedures.

Objectives: The aim of this study was to project clinical outcomes, health care costs, and cost-effectiveness of coronary computed tomography angiography (CCTA), as compared with conventional diagnostic technologies, in the evaluation of patients with stable chest pain and suspected coronary artery disease (CAD)., Background: CCTA has recently been found to be effective in the evaluation of patients with suspected CAD, but investigators have raised concerns related to radiation exposure, incidental findings, and nondiagnostic exams., Methods: With published data, we developed a computer simulation model to project clinical outcomes, health care costs, and cost-effectiveness of CCTA, compared with conventional testing modalities, in the diagnosis of CAD. Our target population included 55-year-old patients who present to their primary care physicians with stable chest pain., Results: All diagnostic strategies yielded similar health outcomes, but performing CCTA-with or without stress testing or performing stress single-photon emission computed tomography-marginally minimized adverse events and maximized longevity and quality-adjusted life-years (QALYs). Health outcomes associated with these strategies were comparable, with CCTA in men and women yielding the greatest QALYs but only by modest margins. Overall differences were small, and performing the most effective test-compared with the least effective-decreased adverse event rates by 3% in men and women. Comparable increases in longevity and QALYs were 2 months and 0.1 QALYs in men and 1 month and 0.03 QALYs in women. CCTA raised overall costs, partly through the follow-up of incidental findings, and when performed with stress testing, its incremental cost-effectiveness ratio ranged from $26,200/QALY in men to $35,000/QALY in women. Health outcomes were marginally less favorable in women when radiation risks were considered., Conclusions: CCTA is comparable to other diagnostic studies and might hold good clinical value, but large randomized controlled trials are needed to guide policy.

The exercise electrocardiogram (ECG) is widely considered the best available test for screening asymptomatic adults without known cardiovascular (CV) disease prior to initiating a vigorous exercise programme due to its prognostic value, widespread availability and low cost. Observational studies have demonstrated an increased relative risk of CV events with positive screening exercise ECG tests in men with diabetes, advanced age, or multiple cardiac risk factors. Recent observational studies have not demonstrated similar prognostic value for exercise ECG testing in asymptomatic healthy women. Despite the predictive ability of exercise ECG testing in several groups, there have been no studies demonstrating a significant impact of screening on morbidity and mortality in completely asymptomatic patients, leading to significant discordance in consensus guidelines on screening. One prospective observational study is ongoing in Italy that may for the first time demonstrate the ability to decrease incident CV events using preparticipation screening exercise ECG testing in adult athletes with targeted exclusion from athletics. Until more conclusive data is available the authors currently recommend screening exercise ECG testing in asymptomatic men with diabetes and asymptomatic men over age 45 with two or more CV risk factors prior to initiating a vigorous exercise programme. Consideration should also be given to screening asymptomatic patients younger than 45 with particularly strong risk factor exposure or elderly patients with fewer than two risk factors.

Background: In a prospective evaluation of 3950 Los Angeles County firefighters who underwent wellness/fitness examinations, 495 firefighters had abnormal treadmill tests and were referred for cardiology evaluation. Cost of the traditional myocardial perfusion imaging (MPI) followed by invasive coronary angiography (ICA) was compared with a method incorporating 64-slice multidetector computed tomography (MDCT) with coronary calcium score (CCS) followed by computed tomographic angiography (CTA) and ICA as indicated., Objective: We compared the costs of 2 methods of predicting coronary artery disease (CAD) by ICA among asymptomatic patients with positive treadmill tests., Methods: A decision-analytic framework was used to compare the net direct costs of CAD diagnosis associated with MDCT versus MPI. In the MDCT arm, all received CCS followed by CTA for those with calcium scores>10 and ICA for those with > or =50% stenosis on CTA. For the MPI arm, results were estimated from prior years' experience, in which firefighters with abnormal treadmill results were referred to ICA., Results: Of 495 firefighters, 131 (26.9%) had abnormal CCS and went to CTA; 40 (8.1%) had > or =50% stenosis on CTA and went to ICA. According to prior years' experience with MPI, 146 (29.5%) would have shown abnormalities requiring ICA. Average cost was $1376/person for MPI versus $503/person for CCS with or without CTA as gatekeeper. All sensitivity analyses showed lower costs for the MDCT pathway compared with MPI., Conclusion: In this firefighter population, the cost of ICA-confirmed diagnosis of CAD is substantially lower with MDCT as gatekeeper than with MPI.

The majority of percutaneous coronary interventions (PCIs) are carried out in nonurgent situations, primarily in patients with stable coronary artery disease. Recent trials have concluded that for patients with stable coronary artery disease, treatment with optimal medical therapy versus optimal medical therapy plus PCI yields equivalent outcomes in terms of morbidity and future risk of myocardial infarction. Since PCI is a procedure with risk, it is important to identify patients for whom the benefit of the procedure outweighs the harms. PCI may be beneficial in certain subgroups, such as patients with moderate-to-severe ischemia on noninvasive testing. Although current guidelines require documentation of ischemia prior to elective PCI and this strategy is cost effective, pre-PCI stress testing appears to be underutilized, potentially leading to PCI being performed in patients who may not derive benefit from the procedure.

FEV(1) is recommended for rating the severity of obstructive and restrictive pulmonary diseases, but it only moderately correlates with quality of life, mortality, and functional status. The 6-min walk test (6MWT) has been increasingly used in clinical practice and research studies as an objective measurement of functional status in patients with moderate-to-severe impairment. This low complexity test measures the distance a patient can quickly walk back and forth in a 30-m (100-foot) corridor in a period of 6 min, referred to as the 6-min walk distance (6MWD). The 6MWD, and in some circumstances oxygen desaturation during the 6MWT, are useful to assess response to medical interventions, to assess prognosis in various conditions, and as a single measurement of functional status. Strictly scripted test instructions and encouragement at baseline and at each minute of exercise is vital to obtain reproducible results. The 6MWT is reported using Current Procedural Terminology code 94620 (simple pulmonary stress test). This code is also appropriate for other simple exercise tests, including oxygen titration (if additional parameters are measured), exercise-induced bronchospasm evaluation using pre- and postexercise spirometry, and exercise prescription for pulmonary rehabilitation. Use of code 94620 to bill for services must be supported by significant documentation.

Introduction: Of all stress tests done in low risk Emergency Department observation units (OU), a small, but significant number may be reported as positive or indeterminate. The objective of this study is to quantify the prevalence and costs associated with positive and indeterminate stress tests that result in negative cardiac catheterization., Methods: Retrospective observational cohort study over 9 months. All patients undergoing the chest pain protocol who got cardiac stress testing in the OU were eligible for inclusion. Cost data were derived from an institutional activity-based cost system utilizing actual costs. Chart review was completed on all patients with positive and indeterminate stress tests and a randomly chosen sample of those with negative stress tests., Results: Of the 1194 patients who met the inclusion criteria, 1084 (90.8%) had a negative stress test. Sixty-two (5.2%) had a positive stress test, and 48 (4.0%) had an indeterminate stress test. Of all 59 patients who underwent catheterization, 41 (69.5%) were negative cardiac catheterizations. The prevalence among all OU stress test patients of positive or indeterminate stress tests with subsequent negative cardiac catheterization was 41/1194 (3.4%; 95% CI 2.5%-4.6%). The prevalence of significant coronary artery disease at cardiac catheterization was 18/1194 (1.5%; 95% CI 1.0%-2.4%). Patients with a positive or indeterminate stress test who had a negative catheterization incurred increased OU costs ($1385 vs. $1,039, P = 0.012), total costs ($7298 vs. $1562, P < 0.001) and length of inpatient stay (1.83 days vs. 0.00 days) when compared with those who had a negative stress test., Conclusion: The probability of going to the OU and having a positive or indeterminate stress test resulting in a subsequent negative catheterization was double the probability of having a stress test result in catheterization that detected significant coronary artery disease. These patients incurred 5 times the total cost when compared with those patients with negative stress testing. Further investigation is warranted to determine alternative risk stratification methods for these low risk chest pain patients with positive stress tests.

Aim: To select optimal methods of coronary heart disease (CHD) diagnosis in patients with different CHD probability using cost-effect analysis., Material and Methods: The trial included 102 patients admitted to hospital because of suspected CHD. The initial CHD probability was determined according to G.A. Diamond table. CHD diagnosis was made with application of Holter ECG monitoring (88 patients), treadmill test (67 patients), dobutamine stress echocardiography (echo-CG, 31 patients), stress single photon emission computed tomography (SPECT, 30 patients), multislice computed tomography (MSCT) with contrast study of coronary arteries (14 patients). Non-invasive tests were followed by coronaroangiography. The cost-effect method was used for analysis of the above methods cost efficacy., Results: MSCT specificity was 96%, specificity of the other methods - 70-75%. SPECT was most sensitive (96%), Holter ECG monitoring was the least sensitive (49%). Efficacy of all the diagnostic tests was maximal in moderate probability of CHD. In spite of its moderate specificity and sensitivity, treadmill test was the cheapest and, therefore, most cost effective in all the groups. Specification of CHD probability by 1% required 17.4 roubles in low risk groups, 9.4 and 24.7 roubles in moderate and high risk, respectively., Conclusion: CHD diagnosis should be started with treadmill test.

Background: Cardiopulmonary exercise testing is a noninvasive and cost-effective technique that adds significant value to the assessment and management of a variety of symptoms and diseases. The penetration of this testing in medical practice may be limited by perceived operational and financial barriers., Procedure: This article reviews coding and supervision requirements related to both simple and complex pulmonary stress testing. A program evaluation and review technique diagram is used to describe the work flow process. Data from our laboratory are used to generate an income statement that separates fixed and variable costs and calculates the contribution margin. A cost-volume-profit (break-even) analysis is then performed., Results: Using data from our laboratory including fixed and variable costs, payer mix, reimbursements by payer, and the assumption that the studies are divided evenly between simple and complex pulmonary stress tests, the break-even number is calculated to be 300 tests per year. A calculator with embedded formulas has been designed by the author and is available on request., Conclusions: Developing a cardiopulmonary exercise laboratory is challenging but achievable and potentially profitable. It should be considered by a practice that seeks to distinguish itself as a quality leader. Providing this clinically valuable service may yield indirect benefits such as increased patient volume and increased utilization of other services provided by the practice. The decision for a medical practice to commit resources to managerial accounting support requires a cost-benefit analysis, but may be a worthwhile investment in our challenging economic environment.

Objectives: To assess the acceptability and feasibility of functional tests as a gateway to angiography for management of coronary artery disease (CAD), the ability of diagnostic strategies to identify patients who should undergo revascularisation, patient outcomes in each diagnostic strategy, and the most cost-effective diagnostic strategy for patients with suspected or known CAD., Design: A rapid systematic review of economic evaluations of alternative diagnostic strategies for CAD was carried out. A pragmatic and generalisable randomised controlled trial was undertaken to assess the use of the functional cardiac tests: angiography (controls); single photon emission computed tomography (SPECT); magnetic resonance imaging (MRI); stress echocardiography., Setting: The setting was Papworth Hospital NHS Foundation Trust, a tertiary cardiothoracic referral centre., Participants: Patients with suspected or known CAD and an exercise test result that required non-urgent angiography., Interventions: Patients were randomised to one of the four initial diagnostic tests., Main Outcome Measures: Eighteen months post-randomisation: exercise time (modified Bruce protocol); cost-effectiveness compared with angiography (diagnosis, treatment and follow-up costs). The aim was to demonstrate equivalence in exercise time between those randomised to functional tests and those randomised to angiography [defined as the confidence interval (CI) for mean difference from angiography within 1 minute]., Results: The 898 patients were randomised to angiography (n = 222), SPECT (n = 224), MRI (n = 226) or stress echo (n = 226). Initial diagnostic tests were completed successfully with unequivocal results for 98% of angiography, 94% of SPECT (p = 0.05), 78% of MRI (p < 0.001) and 90% of stress echocardiography patients (p < 0.001). Some 22% of SPECT patients, 20% of MRI patients and 25% of stress echo patients were not subsequently referred for an angiogram. Positive functional tests were confirmed by positive angiography in 83% of SPECT patients, 89% of MRI patients and 84% of stress echo patients. Negative functional tests were followed by positive angiograms in 31% of SPECT patients, 52% of MRI patients and 48% of stress echo patients tested. The proportions that had coronary artery bypass graft surgery were 10% (angiography), 11% (MRI) and 13% (SPECT and stress echo) and percutaneous coronary intervention 25% (angiography), 18% (SPECT) and 23% (MRI and stress echo). At 18 months, comparing SPECT and stress echo with angiography, a clinically significant difference in total exercise time can be ruled out. The MRI group had significantly shorter mean total exercise time of 35 seconds and the upper limit of the CI was 1.14 minutes less than in the angiography group, so a difference of at least 1 minute cannot be ruled out. At 6 months post-treatment, SPECT and angiography had equivalent mean exercise time. Compared with angiography, the MRI and stress echo groups had significantly shorter mean total exercise time of 37 and 38 seconds, respectively, and the upper limit of both CIs was 1.16 minutes, so a difference of at least 1 minute cannot be ruled out. The differences were mainly attributable to revascularised patients. There were significantly more non-fatal adverse events in the stress echo group, mostly admissions for chest pain, but no significant difference in the number of patients reporting events. Mean (95% CI) total additional costs over 18 months, compared with angiography, were 415 pounds (-310 pounds to 1084 pounds) for SPECT, 426 pounds (-247 pounds to 1088 pounds) for MRI and 821 pounds (10 pounds to 1715 pounds) for stress echocardiography, with very little difference in quality-adjusted life-years (QALYs) amongst the groups (less than 0.04 QALYs over 18 months). Cost-effectiveness was mainly influenced by test costs, clinicians' willingness to trust negative functional tests and by a small number of patients who had a particularly difficult clinical course., Conclusions: Between 20 and 25% of patients can avoid invasive testing using functional testing as a gateway to angiography, without substantial effects on outcomes. The SPECT strategy was as useful as angiography in identifying patients who should undergo revascularisation and the additional cost was not significant, in fact it would be reduced further by restricting the rest test to patients who have a positive stress test. MRI had the largest number of test failures and, in this study, had the least practical use in screening patients with suspected CAD, although it had similar outcomes to stress echo and is still an evolving technology. Stress echo patients had a 10% test failure rate, significantly shorter total exercise time and time to angina at 6 months post-treatment, and a greater number of adverse events, leading to significantly higher costs. Given the level of skill required for stress echo, it may be best to reserve this test for those who have a contraindication to SPECT and are unable or unwilling to have MRI. Further research, using blinded reassessment of functional test results and angiograms, is required to formally assess diagnostic accuracy. Longer-term cost-effectiveness analysis, and further studies of MRI and new generation computed tomography are also required.

Background and Aim: Coronary heart disease (CHD) is the most common cause of death in the United Kingdom, accounting for more than 120,000 deaths in 2001, among the highest rates in the world. This study reports an economic evaluation of single photon emission computed tomography myocardial perfusion scintigraphy (SPECT) for the diagnosis and management of coronary artery disease (CAD)., Methods: Strategies involving SPECT with and without stress electrocardiography (ECG) and coronary angiography (CA) were compared to diagnostic strategies not involving SPECT. The diagnosis decision was modeled with a decision tree model and long-term costs and consequences using a Markov model. Data to populate the models were obtained from a series of systematic reviews. Unlike earlier evaluations, a probabilistic analysis was included to assess the statistical imprecision of the results. The results are presented in terms of incremental cost per quality-adjusted life year (QALY)., Results: At prevalence levels of CAD of 10.5%, SPECT-based strategies are cost-effective; ECG-CA is highly unlikely to be optimal. At a ceiling ratio of Pound 20,000 per QALY, SPECT-CA has a 90% likelihood of being optimal. Beyond this threshold, this strategy becomes less likely to be cost-effective. At more than Pound 75,000 per QALY, coronary angiography is most likely to be optimal. For higher levels of prevalence (around 50%) and more than a Pound 10,000 per QALY threshold, coronary angiography is the optimal decision., Conclusions: SPECT-based strategies are likely to be cost-effective when risk of CAD is modest (10.5%). Sensitivity analyses show these strategies dominated non-SPECT-based strategies for risk of CAD up to 4%. At higher levels of prevalence, invasive strategies may become worthwhile. Finally, sensitivity analyses show stress echocardiography as a potentially cost-effective option, and further research to assess the relative cost-effectiveness of echocardiography should also be performed.

This study compared the cost-effectiveness of dobutamine-atropine stress echocardiography (DASE) and electrocardiographic exercise testing (EET) implemented in emergency department accelerated diagnostic protocols for the early stratification of low-risk patients presenting with acute chest pain (ACP). One hundred ninety-nine patients with ACP, nondiagnostic electrocardiographic results, and negative biomarker results were randomized to DASE (n = 110) or EET (n = 89) <6 hours after emergency department presentation. Patients with negative risk assessment results were immediately discharged and followed for 2 months. Ninety patients (82%) in the DASE arm and 78 (88%) in the EET arm were discharged after the diagnosis of nonischemic ACP. The mean lengths of stay in the hospital were 23 +/- 12 and 31 +/- 23 hours in the DASE and EET arms, respectively (p = 0.01). No 2-month follow-up events occurred in DASE patients, and the event rate was significantly higher in EET patients (0% vs 11%, p = 0.004). The DASE strategy showed lower costs compared with the EET strategy at 1-month ($1,026 +/- $250 vs $1,329 +/- $1,288, p = 0.03) and 2-month ($1,029 +/- 253 vs $1,684 +/- $2,149, p = 0.005) follow-up. In conclusion, early DASE in emergency department triage of low-risk patients with ACP is safe and reduces costs of care compared to EET.

Background: Screening for coronary artery disease (CAD) in asymptomatic diabetic patients with atherogenic risk factors is recommended by the American College of Cardiology/American Diabetes Association. It is not clear whether these guidelines apply to the Japanese population with a different epidemiology of CAD. This study evaluates the applicability of the U.S. guidelines to Japan, taking account of cost-effectiveness., Design: A cost-effectiveness analysis using a Markov model was performed to measure the clinical benefit and cost of CAD screening in asymptomatic patients with diabetes and additional atherogenic risk factors. We evaluated cohorts of patients stratified by age, gender, and atherogenic risks. The incremental cost-effectiveness of not screening, exercise electrocardiography, exercise echocardiography, and exercise single-photon emission-tomography (SPECT) was calculated. The data used were obtained from the literature. Outcomes are expressed as US dollars per quality-adjusted life year (QALY)., Results: Compared with not screening, the incremental cost-effectiveness ratio (ICER) of exercise electrocardiography was $31,400/QALY for 60-year-old asymptomatic diabetic men, and 46,600 for 65-year-old women with hypertension and smoking. The ICER of exercise echocardiography was $31,500/QALY and of SPECT was $326,000/QALY, compared with the next dominant strategy. Sensitivity analyses found that these results varied according to age, gender, the combination of additional atherogenic risk factors, and the frequency of screening., Conclusion: From a societal perspective the U.S. guidelines on screening for CAD in high risk diabetic patients are applicable to the Japanese population. However, the population subjected to screening should be carefully selected to obtain greatest benefit from screening.

Background: Exercise electrocardiography (ETT) is frequently used in patients with suspected coronary artery disease (CAD). Single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) improves diagnostic stratification. There are no randomized trials comparing ETT and MPI. We hypothesized that first-line MPI would be effective and cost-saving versus ETT., Methods and Results: We randomized 457 outpatients with stable chest pain and suspected CAD to either treadmill electrocardiography or MPI. The post-test likelihood incorporated the pretest likelihood and the test result, with clinically driven testing. The primary endpoint was cost to diagnosis based on institutional and National Institute for Clinical Excellence costs. MPI significantly reduced the intermediate post-test likelihood of CAD (30% for ETT vs 3% for MPI, P < .0001) and further investigations (71% for ETT vs 16% for MPI, P < .0001). Despite the reduction in downstream resource utilization after MPI, mean costs were not different between the 2 initial strategies: 490.44 pounds sterling (95% confidence interval, 453.80-527.08) for ETT versus 512.41 pounds sterling (95% confidence interval, 481.41-543.41) for MPI. MPI cost was no different from ETT cost in patients with an intermediate or high pretest likelihood (P = not significant). ETT was less expensive in low-risk patients., Conclusions: In this study there was no difference in cost to diagnosis between initial ETT and MPI. In low-likelihood patients ETT was less costly, whereas there was no cost difference in intermediate- or high-likelihood patients.

Objective: The purpose of the study was to validate the X-ray-based attenuation correction technique applied to post-stress myocardial perfusion single photon emission computed tomography (SPECT)., Materials and Methods: Fifty-six patients with clinically suspected ischemic heart disease and no history of myocardial infarction or coronary revascularization were studied. All patients underwent a myocardial perfusion SPECT after exercise (38) or pharmacological stress (18). Mean clinical follow-up time was 18.6 months. Studies were assessed after reconstruction using the filtered back projection technique and after application of the X-ray-based attenuation correction technique, and the results obtained were related to the final clinical diagnosis., Results: Eleven uncorrected studies were normal, while 45 studies showed perfusion defects. After attenuation correction, absence of significant perfusion defects was observed in 24 cases (42.9 % of all cases), and ischemic heart disease was finally ruled out in 22 cases. A greater study normalization rate was seen in men (p = 0.048; odds ratio = 2,923), but this fact was not shown to be significantly correlated to the following variables: pre-test probability of ischemic heart disease, body mass index greater than 30, presence of cardiovascular risk factors or otherwise, and age., Conclusions: Application of the X-ray-based attenuation correction technique would have allowed for obviating the conduct of a resting perfusion study in 42.9 % of patients without apparently changing the diagnostic safety of the test. This fact was seen more frequently in men. This method seems to be both safe and time- and cost-effective.

Cardiac troponins are markers used to diagnose acute myocardial infarction, but their value in guiding management in low- to intermediate-risk patients is not well established. Using a randomized design, the authors compared a strategy using stress testing with blinded troponins vs a troponin I-guided strategy for risk stratification and management of 241 patients with intermediate-risk unstable angina. Fewer stress-tested patients required coronary care unit admission and repeat hospitalization for acute coronary syndrome, at a lower cost. There was no significant difference in rates of death and myocardial infarction due to acute coronary syndrome at 6 months' follow-up. For patients with intermediate-risk acute coronary syndrome, stress testing is as safe as, and more cost-effective than, a troponin I-guided strategy. Patients with marginal troponin I elevations can safely undergo stress testing. Further studies combining stress testing and a troponin I-guided strategy are warranted.

Objective: To evaluate the applicability of the incremental (shuttle) walk test in patients with chronic obstructive pulmonary disease and compare the performance of those patients on the shuttle walk test to that of the same patients on the encouraged 6-minute walk test., Methods: A cross-sectional study was conducted, in which 24 patients with chronic obstructive pulmonary disease were selected. In random order, patients were, after an initial practice period, submitted to a shuttle walk test and an encouraged 6-minute walk test., Results: The patients obtained a higher heart rate (expressed as a percentage of that predicted based on gender and age) on the encouraged 6-minute walk test (84.1 +/- 11.4%) than on the shuttle walk test (76.4 +/- 9.7%) (p = 0.003). The post-test sensation of dyspnea (Borg scale) was also higher on the encouraged 6-minute walk test. On average, the patients walked 307.0 +/- 89.3 meters on the shuttle walk test and 515.5 +/- 102.3 meters on the encouraged 6-minute walk test (p < 0.001). There was a good correlation between the two tests in terms of the distance walked (r = 0.80, p < 0.001)., Conclusion: The shuttle walk test is simple and easy to implement in patients with chronic obstructive pulmonary disease. The encouraged 6-minute walk test produced higher post-test heart rate and greater post-test sensation of dyspnea than did the shuttle walk test.

Background: The purpose of this report is to present a model of physicians in full-time clinical practice participating as investigators in multicenter clinical trials, sponsored by a pharmaceutical or medical device company., Methods: This gas-exchange substudy was conducted as a pilot study to establish the feasibility of the 10-member EXERcise testing group of the Duke University Cooperative Cardiovascular Society (EXERDUCCS) consortium to perform a complex multicenter trial using cardiopulmonary exercise testing. An active interchange of information was established involving the principal investigator for the substudy, a dedicated full-time project coordinator, a medical director of the overall EXERDUCCS network site, the project coordinator for the sponsor, and all the participating EXERDUCCS investigators and coordinators., Results: The sponsor set as a goal of enrollment of 6 subjects per site, and 8 of the 10 sites met this goal. As a result of the successful enrollment and completion of the study and substudy by the EXERDUCCS sites, the sponsor subsequently increased the payment stipends to the sites to compensate for the extra work and expense incurred., Conclusions: This cooperative experience accomplished several goals: (1) it allowed a complex clinical trial to be successfully completed in a time frame which would not have been possible using only single unconnected sites; (2) it educated the physician-investigators (and their personnel) in exercise cardiopulmonary; and (3) it prepared the sites for future clinical trials involving this methodology.

Background and Purpose: In-hospital rehabilitation can improve recovery of patients after surgery, but also contributes to the high costs of the German health system. Therefore, the possibility of a telemedically monitored rehabilitation at home as an alternative to an in-hospital rehabilitation was evaluated in a pilot study., Patients and Methods: In an open trial, 100 patients performed an ambulatory rehabilitation after heart surgery under coverage of telemedical monitoring for 3 months. 70 patients performed a regular conventional in-hospital rehabilitation for 3 weeks. Physical performance, quality of life (questionnaire), complications, and costs were assessed and compared between the two groups., Results: 6 and also 12 months after surgery, maximal physical performance was significantly increased by 46-54 W in both study groups compared to their baseline value. Moreover, physical and psychological quality of life had increased in both study groups compared to baseline values. However, only in the ambulatory group all items had increased with statistical significance. Fewer insults of angina pectoris were reported during follow-up in the ambulatory group compared to the in-hospital group (p < 0.01). Total costs of the rehabilitation were 59% lower in the ambulatory group compared to the in-hospital group., Conclusion: An ambulatory rehabilitation improves physical performance, quality of life, and is safe and cheap. The data of this study indicate that rehabilitation at home can be established instead of an in-hospital rehabilitation for patients after heart surgery.

Suppliers who are better informed than purchasers, such as physicians treating insured patients, often have discretion over what to provide. I show how, when the purchaser observes what is supplied but neither the recipient type nor the actual cost incurred, optimal provision differs from what would be efficient if the purchaser had full information, weather or not the supplier can extract informational rent. The analysis is applied to, among other things, data on tests for coronary artery disease and to Medicare diagnosis-related groups defined by the treatment given, not just the diagnosis, illustrating the biases in provision that result.

Background: The results of diagnostic tests often have a profound impact on the way patients view their health. Decision analyses and clinical guidelines do not routinely consider this, in part because methods are not well developed for measuring the value of testing to patients., Objectives: To measure the value of stress testing to patients with chest pain suggestive of coronary artery disease (CAD) and to improve methods for measuring the value of diagnostic information., Methods: The authors conducted a prospective cohort study of patients with chest pain who were referred from 44 primary care practices for treadmill testing (N = 320). Current health status, perceived life expectancy, anxiety, uncertainty, and preferences for current health states were measured before and 1 week after testing and receipt of the results. Patients also reported the diagnosis given by their physicians after testing. The authors used paired t tests to assess changes before and after testing., Results: Perceived life expectancy lengthened, anxiety decreased, and uncertainty decreased 1 week after exercise testing, compared to before (P < 0.01). For many patients, sytoms were less bothersome after testing than before. There were few changes in perceptions of current health status, as measured by the SF-36. The authors found evidence of reassurance among patients who reported that CAD had been excluded and no evidence of psychological harm among patients who reported a new CAD diagnosis., Conclusions: Patients experienced measurable psychological benefits from noninvasive diagnostic testing for CAD. Similar measurements should be standard components of diagnostic test evaluation.

Objective: To determine whether stress imaging for patients who are unsuitable for exercise treadmill testing (ETT) as part of a chest pain unit (CPU) triage strategy resulted in incremental benefit in clinical outcomes and relative costs compared with patients randomized to routine hospital admission., Patients and Methods: Clinical outcomes and medical resource utilization were examined at the Mayo Clinic in Rochester, Minn, for 212 intermediate-risk patients with unstable angina randomized to a CPU and compared with 212 patients randomized to routine admission from November 21, 1995, to March 18, 1997. Patients in stable condition in the CPU underwent ETT; if patients were unsuitable for ETT, stress imaging was performed. Costs for CPU evaluation and outcomes were assessed during a 6-month follow-up., Results: During the observation period, 60 patients (28%) were admitted to the hospital. Of the 152 remaining patients, 125 (82%) underwent ETT (91 had normal results), and 27 (18%) underwent stress imaging (3 had normal results). Patients with normal ETT or stress imaging results had no primary events at 6-month follow-up. Patients admitted to the hospital who underwent stress imaging had an insignificantly higher 6-month event rate compared with patients who underwent ETT (16.7% vs 8.1%; P=.38). The standardized resource-based relative-value units (RBRVUs) for patients who underwent ETT and stress imaging during follow-up were 19.4 and 56.4 RBRVUs, respectively, compared with 51.4 (ETT) and 52.1 (stress imaging) RBRVUs for similar numbers of patients randomized to routine admission., Conclusions: Exercise treadmill testing safely stratified most intermediate-risk patients with unstable angina and was less costly than routine admission. Patients not suitable for ETT are likely to have abnormal stress imaging results. They represent a higher-risk cohort that could be routinely admitted to the hospital without reducing the effectiveness of the CPU strategy.

Objective: Screening for coronary artery disease (CAD) in asymptomatic diabetic patients with two additional atherogenic risk factors has been recommended by the American College of Cardiology/American Diabetes Association, but its cost-effectiveness is yet to be determined. The present study aims to evaluate the cost-effectiveness of screening and determine acceptable strategies., Design: Cost-effectiveness analysis using a Markov model was performed from a societal perspective to measure the clinical benefit and economic consequences of CAD screening in asymptomatic men with diabetes and two additional atherogenic risk factors. We evaluated cohorts of patients stratified by different age groups, and 10 possible combination pairs of atherogenic risks. Incremental cost-effectiveness of no screening, exercise electrocardiography, exercise echocardiography, or exercise single-photon emission-tomography (SPECT) was calculated. Input data were obtained from the published literature. Outcomes were expressed as U.S. dollars per quality-adjusted life-year (QALY)., Measurements and Main Results: Compared with no screening, incremental cost-effectiveness ratio of exercise electrocardiography was $41,600/QALY in 60-year-old asymptomatic diabetic men with hypertension and smoking, but was weakly dominated by exercise echocardiography. Exercise echocardiography was most cost-effective, with an incremental cost-effectiveness ratio of $40,800/QALY. Exercise SPECT was dominated by other strategies. Sensitivity analyses found that results varied depending on age, combination of additional atherogenic risk factors, and diagnostic test performance., Conclusions: Incremental cost-effectiveness ratio of CAD screening in asymptomatic patients with diabetes and two or more additional atherogenic risk factors is shown to be acceptable from a societal perspective. Exercise echocardiography was the most cost-effective strategy, followed by exercise electrocardiography.

Accurate and safe diagnostic testing provides the crucial link between detection and optimal management of coronary artery disease (CAD). Noninvasive diagnostic testing for CAD may be less accurate in women than in men. Many noninvasive diagnostic modalities are available for this purpose. An exercise tolerance test provides an assessment of functional capacity and has the advantages of wide availability and low initial cost. However, exercise echocardiography may be the most cost-effective method for the initial assessment of coronary artery disease in intermediate-risk women owing to its higher sensitivity and specificity. Recent studies with electron-beam computed tomography reveal that women with no coronary calcification are very unlikely to have obstructive CAD. In symptomatic women with an intermediate likelihood of CAD, either an exercise treadmill test or exercise echocardiography is appropriate for initial screening and can provide useful prognostic information. Alternatively, an electron-beam computed tomographic scan with a 0 calcium score may spare many women with atypical chest pain or equivocal findings on an exercise tolerance test from undergoing more expensive stress imaging studies or coronary angiography. For high-risk symptomatic women, a more aggressive approach involving coronary angiography appears to be the preferred initial diagnostic strategy.

Background: Coronary heart disease is the leading cause of morbidity and mortality in the United States. Exercise tolerance testing has been proposed as a means of better identifying asymptomatic patients at high risk for coronary heart disease events., Purpose: To review the evidence on the use of exercise tolerance testing to screen adults with no history of cardiovascular disease for coronary heart disease., Data Sources: The MEDLINE database from 1966 through February 2003, hand-searching of bibliographies, and expert input., Study Selection: Eligible studies evaluated the benefits or harms of exercise tolerance testing when added to traditional risk assessment for adults with no known history of cardiovascular events., Data Extraction: One reviewer extracted information from eligible articles into evidence tables, and another reviewer checked the tables. Disagreements were resolved by consensus., Data Synthesis: No study has directly examined the effect of screening asymptomatic patients with exercise tolerance testing on coronary heart disease outcomes or risk-reducing behaviors or therapies. Multiple cohort studies demonstrate that screening exercise tolerance testing identifies a small proportion of asymptomatic persons (up to 2.7% of those screened) with severe coronary artery obstruction who may benefit from revascularization. Several large prospective cohort studies, conducted principally in middle-aged men, suggest that exercise tolerance testing can provide independent prognostic information about the risk for future coronary heart disease events (relative risk with abnormal exercise tolerance testing, 2.0 to 5.0). However, when the risk for coronary heart disease events is low, most positive findings will be false and may result in unnecessary further testing or worry. The risk level at which the benefits of additional prognostic information outweigh the harms of false-positive results is unclear and requires further study., Conclusions: Although screening exercise tolerance testing detects severe coronary artery obstruction in a small proportion of persons screened and can provide independent prognostic information about the risk for coronary heart disease events, the effect of this information on clinical management and disease outcomes in asymptomatic patients is unclear.

Objectives: We sought to evaluate the prognostic and cost implications of stress myocardial perfusion single-photon emission computed tomography (SPECT), or MPS, in patients with a high pretest likelihood (>0.85) of coronary artery disease (CAD) with no previous CAD., Background: Sparse data are available regarding the prognostic performance characteristics of MPS in this patient group., Method: We followed up 1,270 consecutive patients with no previous revascularization or myocardial infarction (MI), with a pre-exercise tolerance test (ETT) likelihood of CAD > or =0.85, who underwent exercise or adenosine stress MPS (follow-up 94.4% complete; 2.2 +/- 1.2 years; 60 hard events [5.9%, 2.6%/year]). Risk adjustment of survival data was done using Cox proportional hazards analysis. Costs per reclassification of risk were calculated using assumed costs and threshold analyses., Results: In patients treated medically after MPS, normal MPS had a low risk of cardiac death and hard events (0.6% and 1.3% per year, respectively). With increasing extent and severity of MPS defects, the risk of both cardiac death and hard events increased significantly (p < 0.05). Cox models indicated that the addition of MPS data resulted in incremental prognostic value over pre-MPS data (chi-square increase 48 to 87, p < 0.0001). Compared with strategies of initial referral to ETT in patients able to exercise, initial referral to MPS appeared to be a more cost-effective strategy. Similarly, compared with a strategy of direct referral to catheterization in patients with a high likelihood of CAD, initial referral to MPS is a cost-saving approach., Conclusions: In patients with a high likelihood of CAD but without known CAD, stress MPS yields incremental value and achieves risk stratification in a cost-effective manner. The current results support a strategy of initial stress imaging in this patient cohort, as a reasonable alternative to direct referral to catheterization or initial ETT.

We evaluated clinical and economic outcomes of diagnostic strategies on the basis of pharmacologic stress echocardiography (PhSE) versus exercise electrocardiography test (EET) in 527 patients with chest pain (274 women; age 59 +/- 10 years) who underwent both EET and PhSE. We investigated 3 strategies, ie, coronary angiography: after positive EET (strategy 1); after positive PhSE (strategy 2); or after a positive PhSE performed after a positive EET (strategy 3). A patient was correctly identified if he or she had negative test results and no events, or had positive test results and abnormal coronaries. The cost per patient correctly identified was calculated as the ratio between the cost of each strategy and the number of patients correctly identified. The accuracy in correctly identifying the patients was 78%, 92%, and 91% with strategies 1, 2, and 3, respectively. The cost of each patient correctly identified was 1572 US dollars, 1097 US dollars, and 1081 US dollars with strategies 1, 2, and 3, respectively. In conclusion, PhSE-based strategies are cost-effective versus EET.