Systematic Review of the Health-Economic Impact of Diagnostic Modality Selection for Patients with Coronary Artery Disease

OBJECTIVES: While the clinical case for non-invasive modalities for cardiac imaging in the diagnosis and management of coronary artery disease (CAD) is becoming more established, the economic consequences are less well defined. This study assessed the health-economic consequences of non-invasive versus invasive modality selection in symptomatic individuals with low, intermediate, or high risk of known or unknown CAD, stable or unstable.

METHODS: A systematic review (SR) of original articles or errata, published between 1992-January 2023, was conducted. The search was performed in Embase, Medline, and Cochrane databases. Literature from UK, France, Germany, Italy, Japan, China, and the USA was in-scope. The UK National Health Service Economic Evaluation Database and Database of Abstract of Reviews and Effects were searched manually (PROSPERO: CRD42022384183).

This analysis restricted inclusion to head-to-head studies comparing a non-invasive (coronary computed tomography angiography [CCTA], myocardial perfusion scintigraphy by single-photon emission computed tomography [MPS-SPECT], cardiac magnetic resonance imaging [CMR], exercise electrocardiography [ExECG], positron emission tomography [PET], and stress echocardiography [SE]) to an invasive (invasive coronary angiography [ICA]) modality.

RESULTS: Twenty-three studies were identified for extraction and analysis, of which 17 provided cost-effectiveness data and six reported costs and resource usage. Consistently, non-invasive modalities (including CCTA and CMR) were cost effective versus ICA in CAD diagnosis in low-to-intermediate risk patients. Where high-risk patients were included, results were more mixed. The main driver of cost effectiveness was cost savings. Resource use and cost studies also demonstrated savings for non-invasive modalities versus ICA. Results were consistent across studies with healthcare system, societal or hospital perspectives.

CONCLUSIONS: This SR demonstrates that, further to the clinical rationale for using non-invasive modalities (e.g., CCTA, CMR) in the diagnosis and management of CAD, this strategy is consistently cost effective and cost saving in low-to-intermediate risk patients, irrespective of the healthcare setting.