Cost-effectiveness of diagnostic strategies for patients with chest pain.

BACKGROUND Many noninvasive tests exist to determine whether patients should undergo coronary angiography. The routine use of coronary angiography without previous noninvasive testing is typically not advocated. OBJECTIVE To determine the cost-effectiveness of diagnostic strategies for patients with chest pain. DESIGN Cost-effectiveness analysis. DATA SOURCES Published data. TARGET POPULATION Patients who present with chest pain, have no history of myocardial infarction, and are able to perform an exercise stress test. TIME HORIZON Lifetime. PERSPECTIVE Societal. INTERVENTIONS No testing, exercise electrocardiography, exercise echocardiography, exercise single-photon emission computed tomography (SPECT), and coronary angiography alone. OUTCOME MEASURES Quality-adjusted life expectancy, lifetime cost, and incremental cost-effectiveness. RESULTS OF BASE-CASE ANALYSIS The incremental cost-effectiveness ratio of routine coronary angiography compared with exercise echocardiography was $36,400 per quality-adjusted life-year (QALY) saved for 55-year-old men with typical angina. For 55-year-old men with atypical angina, exercise echocardiography compared with exercise electrocardiography cost $41,900 per QALY saved. If adequate exercise echocardiography was not available, exercise SPECT cost $54,800 per QALY saved compared with exercise electrocardiography for these patients. For 55-year-old men with nonspecific chest pain, the incremental cost-effectiveness ratio of exercise electrocardiography compared with no testing was $57,700 per QALY saved. RESULTS OF SENSITIVITY ANALYSIS On the basis of a probabilistic sensitivity analysis, there is a 75% chance that exercise echocardiography costs less than $50,900 per QALY saved for 55-year-old men with atypical angina. CONCLUSIONS Exercise electrocardiography or exercise echocardiography resulted in reasonable cost-effectiveness ratios for patients at mild to moderate risk for coronary artery disease in terms of age, sex, and type of chest pain. Coronary angiography without previous noninvasive testing resulted in reasonable cost-effectiveness ratios for patients with a high pretest probability of coronary artery disease.