ACC: Consider 'cost efficiency' for echo and chronic CAD

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CHICAGO--When it comes to cost effectiveness, echocardiography and chronic coronary artery disease (CAD), consider rethinking the terminology. That was one message from a March 25 presentation at the American College of Cardiology’s 61st annual scientific session.

“There are no good cost-effectiveness data on echo in chronic CAD, and by that I mean established CAD,” said Pamela S. Douglas, MD, of the Duke University Medical Center in Durham, N.C. She noted that previous evaluations looked at the initial diagnosis of a patient with symptoms and efforts to determine whether the symptoms were due to CAD or not. “But once the patient has received a diagnosis of CAD, there are very few studies as to what sort of diagnostic testing needs to be done on those patients, what the value of that testing might be and the cost relative to the value.”

As an option, she suggested thinking in terms of cost efficiency, which she defined as achieving a desired goal such as making a diagnosis or excluding CAD at a reduced or minimum cost. “That is an additional way to think about value from imaging and chronic disease,” she said.

Douglas looked back at previous meta-analysis research comparing echo and other modalities that was later used for a cost-effectiveness analysis. The findings favored echo for cost effectiveness but she pointed out that there were limitations, especially in contemporary practice. Those included  the use of old technology, wide ranges at the time in the estimated disease prevalence, an anatomic gold standard for ischemia testing, vastly different reimbursement rates from today’s and analytic shortcomings.

Importantly, she added, the analysis was test-based rather than an episode of care. She discussed preliminary data based on another study comparing nuclear and echo testing that found patient profiles and downstream testing varied by modality. For instance, 6.3 percent of patients in the echo group had additional stress testing versus 1.1 percent in the nuclear group.

“There were differences in downstream use of testing and intervention, depending on the initial test, which in turn depends on the patient population,” Douglas said. “It becomes very difficult to model cost effectiveness or cost minimization with this kind of heterogeneity,”

She listed a number of reasons to order echo such as restenosis or risk stratification, and added that cost is a factor when evaluating appropriate use criteria. “All of these things may add value in CAD but we have very little information on what the cost effectiveness might be,” she said. “We do know that repeat testing is common.”

To illustrate the challenge of calculating costs, she offered 2012 Medicare fee schedule for stress echo and stress nuclear in the office and in the hospital. “If I look at a stress echo versus a stress nuclear in the office, it is less than half as much,” she said. “If I look in the hospital, it is about two-thirds as much. But if I compare a stress echo in the hospital with stress nuclear in the office, all of a sudden echo is more expensive.

“How are we supposed to make sense of that?” she asked. “That is one of the real barriers to figuring out cost effectiveness in testing because it is such an unlevel and changing playing field.”

She concluded that cost efficiency may be a better target, but it depends on the goals for imaging, the population tested, the cost of the test, the costs of episodes of care and it implies that the image is for an appropriate use.