Economic Outcomes With Anatomical Versus Functional Diagnostic Testing for Coronary Artery Disease

Ann Intern Med. 2016 Jul 19;165(2):94-102. doi: 10.7326/M15-2639. Epub 2016 May 24.


Background: PROMISE (PROspective Multicenter Imaging Study for Evaluation of Chest Pain) found that initial use of at least 64-slice multidetector computed tomography angiography (CTA) versus functional diagnostic testing strategies did not improve clinical outcomes in stable symptomatic patients with suspected coronary artery disease (CAD) requiring noninvasive testing.

Objective: To conduct an economic analysis for PROMISE (a major secondary aim of the study).

Design: Prospective economic study from the U.S. perspective. Comparisons were made according to the intention-to-treat principle, and CIs were calculated using bootstrap methods. ( NCT01174550).

Setting: 190 U.S. centers.

Patients: 9649 U.S. patients enrolled in PROMISE between July 2010 and September 2013. Median follow-up was 25 months.

Measurements: Technical costs of the initial (outpatient) testing strategy were estimated from Premier Research Database data. Hospital-based costs were estimated using hospital bills and Medicare cost-charge ratios. Physician fees were taken from the Medicare Physician Fee Schedule. Costs were expressed in 2014 U.S. dollars, discounted at 3% annually, and estimated out to 3 years using inverse probability weighting methods.

Results: The mean initial testing costs were $174 for exercise electrocardiography; $404 for CTA; $501 to $514 for pharmacologic and exercise stress echocardiography, respectively; and $946 to $1132 for exercise and pharmacologic stress nuclear testing, respectively. Mean costs at 90 days were $2494 for the CTA strategy versus $2240 for the functional strategy (mean difference, $254 [95% CI, -$634 to $906]). The difference was associated with more revascularizations and catheterizations (4.25 per 100 patients) with CTA use. After 90 days, the mean cost difference between the groups out to 3 years remained small.

Limitation: Cost weights for test strategies were obtained from sources outside PROMISE.

Conclusion: Computed tomography angiography and functional diagnostic testing strategies in patients with suspected CAD have similar costs through 3 years of follow-up.

Primary funding source: National Heart, Lung, and Blood Institute.

Publication types

  • Multicenter Study

MeSH terms

  • Aged
  • Chest Pain / etiology
  • Coronary Angiography / economics
  • Coronary Artery Disease / diagnosis*
  • Coronary Artery Disease / diagnostic imaging
  • Coronary Artery Disease / economics*
  • Echocardiography, Stress / economics
  • Electrocardiography / economics
  • Exercise Test / economics
  • Exercise Test / methods
  • Fees, Medical
  • Female
  • Heart Function Tests / economics*
  • Hospital Costs
  • Humans
  • Male
  • Middle Aged
  • Multidetector Computed Tomography / economics*
  • Prospective Studies

Associated data