Comparison of Cost-Effectiveness of Myocardial Perfusion Imaging Versus other Approaches: Predictions by a Model

Abstract

A 63-year old, obese lady is seen by her doctor because of atypical chest pain (Figure 9-1) (see Color Plates section). She has a history of diabetes, hypertension, and mildly elevated cholesterol levels, and her electrocardiogram (ECG) is consistent with left ventricular hypertrophy. Her private physician believes in performing the cheapest, least invasive test first. He orders a stress ECG ($330). The ECG is positive (1.5 mm of horizontal ST depression) at 6 min of a modified stress test. Because there is a history of hypertension and left ventricular hypertrophy on ECG, the significance of the “abnormality” on the stress ECG is questioned by the physician, who then decides a radionuclide stress test might add more certainty to the diagnosis. Exercise ²⁰¹Tl SPECT imaging ($1200) is then performed, but the presence of attenuation caused by breast tissue causes an “equivocal” interpretation. At this point, cardiac catheterization is performed ($4800) and the patient is found to have normal coronary arteries at a total cost of $6330 for all three procedures. Had this physician obtained a positron emission tomography (PET) MPI after the equivocal ²⁰¹Tl, the negative result would have saved 53% or $3300 ($6330–$3000). If a PET had been obtained in this woman as the first test, the savings would have been 72% or $4530.