December 14, 2020
“The moment you begin to wonder if you deserve better, you do.”
As clinicians, we must constantly balance competing demands. While there is shared purpose across so many contributors in healthcare, in some situations there is work to do before alignment can be gained across patients, caregivers, physicians, hospital administrators, insurers, and government regulators. Although all would agree that optimizing patient welfare is paramount, the challenge lies in doing so while remaining cognizant of beneficial or adverse impacts on other stakeholders. Stated more bluntly, what is good for one stakeholder, may not be good for another.
Balancing clinical and economic value is a consistent theme and challenge in healthcare. We are increasingly called on to manage the costs of the care we prescribe and provide, but never to do so to the detriment of patients. As new and better options become available, a clinician’s task to assess the appropriateness, cost, and value of each potential management pathway can become increasingly murky. On rare occasions, however, there are advances which allow optimization of outcomes at lower costs, and in the world of non-invasive cardiology, a recent publication provides an example of just such an advance.
A study from the Massachusetts General Hospital, published in JAMA Network Open, offers a Markov microsimulation-model cost-effectiveness analysis that looks at the clinical and economic values of three specific approaches to diagnosing coronary artery disease (CAD) in patients with stable chest pain.1 For each of the PROMISE trial’s 10,003 enrolled patients, the authors simulated 100 scenarios with varying levels of disease, treatment and outcomes, thereby creating 1,000,300 observations per strategy.
Using this approach, they compared functional cardiac stress testing, (today’s most commonly used approach), to two coronary CTA-driven options: one that relied solely on coronary CTA and a second that added CT-derived lesion-specific physiology through the HeartFlow FFRCT Analysis.
The findings tell us that today we are spending more for worse patient outcomes. In other words, the healthcare system could be paying less and providing better care.
First, and most importantly, the authors considered the clinical effectiveness of the three diagnostic strategies by looking at short- and long-term clinical indicators and outcomes. In the short-term, through 60 days, coronary CTA + HeartFlow improved by 50% the efficiency of selecting patients for invasive testing who then required coronary stenting or bypass procedures. This significant improvement in efficiency was found as 59.6% of patients referred to ICA based on a CTA + HeartFlow pathway went on to revascularization, compared to patients referred to ICA based on CTA alone (53.7% revasc rate) or on stress testing (40.7% revasc rate).
Over the long-term, the authors found that either of the two CTA-first pathways helped identify patients sooner who could benefit from revascularization and at the same time lessened the risk of adverse clinical events such as death or heart attack. This clinical benefit was likely driven by the observation from several trials that identification of any atherosclerotic disease by CTA leads to tailored therapy with medications such as statins.
Next, the authors turned their attention to the cost effectiveness of each pathway. The coronary CTA + HeartFlow strategy was associated with a 10% lifetime cost reduction compared to functional stress testing and a 17% reduction from CTA alone.
The authors also compared the quality adjusted life years (QALY) and incremental cost-effectiveness ratio (ICER) of the three strategies. They found that the coronary CTA + HeartFlow strategy yielded an additional six months of life “in perfect health” compared to stress testing. And when compared to treating symptomatic chest pain patients without any diagnostic testing, stress testing was minimally cost effective ($99,678/QALY) compared to the significant cost effectiveness of CTA + HeartFlow ($36,968/QALY), with CTA alone falling into an intermediate range ($59,436/QALY).
So, what should busy cardiologists, internists and primary care providers take from this work?
First, a front-line pathway utilizing coronary CTA + HeartFlow for evaluation of patients with stable chest pain is one of the rare “dominant” tools in healthcare, namely one which delivers better clinical outcomes at lower costs. Dominant pathways unequivocally align the interests of stakeholders, including patients, providers, and payers.
Second, this pathway is immediate and available. Clinicians can choose to drive a revolution in non-invasive cardiac testing to deliver better outcomes to patients and minimize use and overuse of aging tools that cost our system more and provide less. These tools of yesteryear are making clinicians question if they and their patients deserve a better option, and the answer is a resounding yes.
1. See Karády, et al. JAMA Nework Open 2020. doi.org/10.1001/jamanetworkopen.2020.28312
2. Driessen, et al. J Am Coll Cardiol 2019. Nørgaard, et al. Euro Radiology 2015.