Author: Jake Morris MD
This is a summary from Morris et al. Comparative Trends and Downstream Outcomes of Coronary CT Angiography and Cardiac Stress Testing in Emergency Department Patients with Chest Pain: An Administrative Claims Analysis. Academic Emergency Medicine.
Coronary computerized tomography angiography (CCTA) is a rapidly emerging technology for the evaluation of chest pain in the Emergency Department (ED). Numerous large randomized trials (CT-STAT, ACRIN-PA, ROMICAT II, and CT-COMPARE) have demonstrated that CCTA is safe in the assessment of patients at low risk for ACS, and that it significantly speeds up their evaluation in already crowded ED’s.
But does this accelerated evaluation come at a cost? It has been suggested that CCTA, while safe and fast, may lead to more downstream procedures and healthcare utilization. Because CCTA is an anatomical study and not a functional one, what are providers supposed to do if they identify a coronary plaque in a patient with chest pain? Is that plaque causing ACS? Does more testing need to be performed because there are not clear guidelines on how to interpret CCTA results?
To assess how these questions are being answered in the real-world, we performed an administrative claims analysis utilizing a large national claims database (OptumLabs Data Warehouse). We identified over two million ED patients from January 2006 to December 2013 who presented with a primary diagnosis of chest pain. We established patients into cohorts based on whether they received CCTA, myocardial perfusion scan (MPS), stress echocardiography (SE), or treadmill exercise electrocardiogram (TMET) within 72 hours of their ED visit. We assessed whether patients in each group subsequently underwent invasive coronary angiography (ICA), percutaneous coronary intervention (PCI), or coronary artery bypass grafting (CABG). We further evaluated if they were hospitalized, had repeat imaging, or returned to the ED within 30 days.
Trends in Non-invasive Cardiac Testing:
Use of Downstream Resources
What’s the Bottom Line?
CCTA use increased four-fold during the study period and was associated with higher rates of PCI, CABG, repeat noninvasive testing, hospitalization, and return ED visits. This suggests that real-world CCTA use comes at the cost of increased healthcare utilization, and highlights the need for clear guidelines on the use and interpretation of CCTA.
Figure 1. CCTA and functional cardiac stress testing use in Emergency Department patients with chest pain.
Table 5. Associations between CCTA, downstream utilization and acute myocardial infarction after propensity-score matching.
|Propensity model 1||Propensity model 2||Propensity model 3|
|Outcome||CCTA vs MPS||CCTA vs SE||CCTA vs TMET|
|OR*||95% CI||P-value||OR*||95% CI||P-value||OR*||95% CI||P-value|
|Repeat ED Visit||0.95||0.85-1.07||0.43||1.20||1.06-1.36||0.00||1.09||0.97-1.24||0.15|
|Repeat Cardiac Testing||1.68||1.48-1.90||<.0001||3.16||2.72-3.68||<.0001||1.32||1.17-1.48||<.0001|
|Acute Myocardial infarction within 30 days||1.00||0.47-2.12||1.00||1.00||0.47-2.12||1.00||0.82||0.40-1.67||0.59|
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