Randomized comparison of chest pain evaluation with FFR CT or standard care: Factors determining US costs.

Background: FFR _CT assesses the functional significance of lesions seen on CTCA, and may be a more efficient approach to chest pain evaluation. The FORECAST randomized trial found no significant difference in costs within the UK National Health Service, but implications for US costs are unknown. The purpose of this study was to compare costs in the FORECAST trial based on US healthcare cost weights, and to evaluate factors affecting costs.
Methods: Patients with stable chest pain were randomized either to the experimental strategy (CTCA with selective FFR _CT ), or to standard clinical pathways. Pre-randomization, the treating clinician declared the planned initial test. The primary outcome was nine-month cardiovascular care costs.
Results: Planned initial tests were CTCA in 912 patients (65%), stress testing in 393 (28%), and invasive angiography in 94 (7%). Mean US costs did not differ overall between the experimental strategy and standard care (cost difference +7% (+$324), CI -12% to +26%, p ​= ​0.49). Costs were 4% lower with the experimental strategy in the planned invasive angiography stratum (p for interaction ​= ​0.66). Baseline factors independently associated with costs were older age (+43%), male sex (+55%), diabetes (+37%), hypertension (+61%), hyperlipidemia (+94%), prior angina (+24%), and planned invasive angiography (+160%). Post-randomization cost drivers were coronary revascularization (+348%), invasive angiography (267%), and number of tests (+35%).
Conclusions: Initial evaluation of chest pain using CTCA with FFR _CT had similar US costs as standard care pathways. Costs were increased by baseline coronary risk factors and planned invasive angiography, and post-randomization invasive procedures and the number of tests. Registration at ClinicalTrials.gov (NCT03187639).
Competing Interests: Declaration of competing interest MAH reports a research grant for FORECAST from HeartFLow. KF has received fees and/or travel expenses from Servier, AstraZeneca, Celixir, Taurx, UCB and Broadview Ventures. He was a Director of Vesalius Trials Ltd. GM reports grants from HeartFlow & Bayer, and support by a NIHR Research Professorship (2017-08-ST2-007). CB is employed by the University of Glasgow, which holds consultancy and research agreements for his work with Abbott Vascular, AstraZeneca, Boehringer Ingelheim, Causeway Therapeutics, Coroventis, Genentech, GSK, HeartFlow, Menarini, Neovasc, Siemens Healthcare, and Valo Health. CB receives research funding from the British Heart Foundation (RE/18/6134217). PSD reports a grant from HeartFlow. NC reports unrestricted research grants from HeartFlow, Boston Scientific, Beckmann Coulter; consultancy/speaker fees from Abbott, HeartFlow, Boston Scientific, Phillips; travel sponsorship from Haemonetics, Abbott, Medtronic, Biosensors, and Edwards. All other authors report no relationships with industry.
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