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Cost-effectiveness Targets for Multi–Detector Row CT Angiography in the Work-up of Patients with Intermittent Claudication¹

¹ From the Program for the Assessment of Radiological Technology (ART Program), Dept of Epidemiology and Biostatistics, and Dept of Radiology, Erasmus MC, University Med Center Rotterdam, Dr Molewaterplein 50, Rm Ee21-40B, 3015GE Rotterdam, the Netherlands (K.V., M.C.J.M.K., M.G.M.H.); Dept of Health Policy and Management, Harvard School of Public Health, Boston, Mass (K.M.K., G.S.G., M.G.M.H.); Division of Vascular Surgery, Brigham and Women’s Hosp, Boston, Mass (M.C.D.); and Decision Analysis and Technology Assessment Group, Dept of Radiology, Massachusetts General Hosp, Harvard Med School, Boston, Mass (G.S.G.). From the 2001 RSNA scientific assembly. Received Apr 15, 2002; revision requested Jun 19; revision received Jul 26; accepted Sep 23. Supported in part by the Netherlands Organization for Scientific Research. Address correspondence to K.V. (e-mail: k.visser@erasmusmc.nl).

View larger version (39K): [in a new window]   Figure 1. Flow chart of decision tree. Equivocal test result (*) was defined as a technically inadequate imaging examination or an imaging result that did not enable a treatment plan to be formulated because of the depiction of calcified arterial walls. Two treatment scenarios () were considered: In the first scenario, that of minimally invasive treatment, patients underwent angioplasty if it was feasible; otherwise, they were started on a supervised exercise program. In the second scenario, that of more invasive treatment, patients underwent angioplasty if it was feasible; otherwise they underwent bypass surgery.

View larger version (21K): [in a new window]   Figure 2. Graph illustrates results of base-case analysis: a 60-year-old man. Target values of the costs and sensitivity for detection of significant stenosis of a new imaging modality in the minimally invasive treatment scenario and with a threshold for society’s willingness to pay of $100,000 per QALY gained are plotted. The lines of plotted values represent combinations of costs and sensitivity that would make a new modality cost-effective compared with gadolinium (Gd)-enhanced MR angiography, based on the proportion of patients who would require additional work-up. * = 35% of patients requiring additional work-up, = 20% of patients requiring additional work-up, = 5% of patients requiring additional work-up. CT angiography would be cost-effective compared with MR angiography if the combination of costs and sensitivity for a new modality was to the left of the line. If, however, the combination of costs and sensitivity for CT angiography was to the right of the line, then MR angiography would be more cost-effective.

View larger version (19K): [in a new window]   Figure 3. Graph illustrates results of base-case analysis: a 60-year-old man. Target values of the costs and sensitivity for detection of significant stenosis of a new imaging modality in the more invasive treatment scenario and with a threshold for society’s willingness to pay of $100,000 per QALY gained are plotted. The lines of plotted values represent combinations of costs and sensitivity that would make a new modality cost-effective compared with gadolinium (Gd)-enhanced MR angiography, based on the proportion of patients who would require additional work-up. * = 35% of patients requiring additional work-up, = 20% of patients requiring additional work-up, = 5% of patients requiring additional work-up. CT angiography would be cost-effective compared with MR angiography if the combination of costs and sensitivity of CT angiography was above the line. If, however, the combination of costs and sensitivity of CT angiography was below the line, then the new modality would not be cost-effective.

View larger version (21K): [in a new window]   Figure 4. Alternative case: a 40-year-old man. Target values of the costs and sensitivity for detection of significant stenosis of a new imaging modality in the minimally invasive treatment scenario and with a threshold for society’s willingness to pay of $100,000 per QALY gained are plotted. The lines of plotted values represent combinations of costs and sensitivity that would make a new modality cost-effective compared with gadolinium (Gd)-enhanced MR angiography, based on the proportion of patients who would require additional work-up. * = 35% of patients requiring additional work-up, = 20% of patients requiring additional work-up, = 5% of patients requiring additional work-up. CT angiography would be cost-effective compared with MR angiography if the combination of costs and sensitivity of the new modality was to the left of the line. If, however, the combination of costs and sensitivity of CT angiography was to the right of the line, then MR angiography would be more cost-effective.

View larger version (20K): [in a new window]   Figure 5. Alternative case: a 40-year-old man. Target values of the costs and sensitivity for detection of significant stenosis of a new imaging modality in the more invasive treatment scenario and with a threshold for society’s willingness to pay of $100,000 per QALY gained are plotted. The lines of plotted values represent combinations of costs and sensitivity that would make a new modality cost-effective compared with gadolinium (Gd)-enhanced MR angiography, based on the proportion of patients who would require additional work-up. * = 35% of patients requiring additional work-up, = 20% of patients requiring additional work-up, = 5% of patients requiring additional work-up. CT angiography would be cost-effective compared with MR angiography if the combination of costs and sensitivity of CT angiography was above the line. If, however, the combination of costs and sensitivity of CT angiography was below the line, then the new modality would not be cost-effective.

View larger version (21K): [in a new window]   Figure 6. Alternative case: a 70-year-old man with a history of coronary artery disease. Target values of the costs and sensitivity for detection of significant stenosis of a new imaging modality in the minimally invasive treatment scenario and with a threshold for society’s willingness to pay of $100,000 per QALY gained are plotted. The lines of plotted values represent combinations of costs and sensitivity that would make a new modality cost-effective compared with gadolinium (Gd)-enhanced MR angiography, based on the proportion of patients who would require additional work-up. * = 35% of patients requiring additional work-up, = 20% of patients requiring additional work-up, = 5% of patients requiring additional work-up. CT angiography would be cost-effective compared with MR angiography if the combination of costs and sensitivity of the new modality was to the left of the line. If, however, the combination of costs and sensitivity of CT angiography was to the right of the line, then the new imaging modality would not be cost-effective.