Skip to main content
SpringerLink
Log in

Costs and clinical outcomes for non-invasive versus invasive diagnostic approaches to patients with suspected in-stent restenosis

  • Original Paper
  • Published:
The International Journal of Cardiovascular Imaging Aims and scope Submit manuscript

Abstract

This study compared costs and clinical outcomes of invasive versus non-invasive diagnostic evaluations for patients with suspected in-stent restenosis (ISR) after percutaneous coronary intervention. We developed a decision model to compare 2 year diagnosis-related costs for patients who presented with suspected ISR and were evaluated by: (1) invasive coronary angiography (ICA); (2) non-invasive stress testing strategy of myocardial perfusion imaging (MPI) with referral to ICA based on MPI; (3) coronary CT angiography-based testing strategy with referral to ICA based on CCTA. Costs were modeled from the payer’s perspective using 2014 Medicare rates. 56 % of patients underwent follow-up diagnostic testing over 2 years. Compared to ICA, MPI (98.6 %) and CCTA (98.1 %) exhibited lower rates of correct diagnoses. Non-invasive strategies were associated with reduced referrals to ICA and costs compared to an ICA-based strategy, with diagnostic costs lower for CCTA than MPI. Overall 2-year costs were highest for ICA for both metallic as well as BVS stents ($1656 and $1656, respectively) when compared to MPI ($1444 and $1411) and CCTA. CCTA costs differed based upon stent size and type, and were highest for metallic stents >3.0 mm followed by metallic stents <3.0 mm, BVS < 3.0 mm and BVS > 3.0 mm ($1466 vs. $1242 vs. $855 vs. $490, respectively). MPI for suspected ISR results in lower costs and rates of complications than invasive strategies using ICA while maintaining high diagnostic performance. Depending upon stent size and type, CCTA results in lower costs than MPI.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Go AS, Mozaffarian D, Roger VL et al (2014) Heart disease and stroke statistics—2014 update: a report from the American Heart Association. Circulation 129(3):e28–e292

    Article  PubMed  Google Scholar 

  2. Cohen DJ, Van Hout B, Serruys PW et al (2011) Quality of life after PCI with drug-eluting stents or coronary-artery bypass surgery. N Engl J Med 364(11):1016–1026

    Article  CAS  PubMed  Google Scholar 

  3. Stenestrand U, James SK, Lindback J et al (2010) Safety and efficacy of drug-eluting vs. bare metal stents in patients with diabetes mellitus: long-term follow-up in the Swedish Coronary Angiography and Angioplasty Registry (SCAAR). Eur Heart J 31(2):177–186

    Article  CAS  PubMed  Google Scholar 

  4. Alfonso F, Byrne RA, Rivero F, Kastrati A (2014) Current treatment of in-stent restenosis. J Am Coll Cardiol 63(24):2659–2673

    Article  PubMed  Google Scholar 

  5. de Graaf FR, Schuijf JD (2010) Evaluation of stents and grafts. EuroIntervention 6(Suppl G):G48–G56

    PubMed  Google Scholar 

  6. Budoff MJ, Dowe D, Jollis JG et al (2008) Diagnostic performance of 64-multidetector row coronary computed tomographic angiography for evaluation of coronary artery stenosis in individuals without known coronary artery disease: results from the prospective multicenter ACCURACY (Assessment by Coronary Computed Tomographic Angiography of Individuals Undergoing Invasive Coronary Angiography) trial. J Am Coll Cardiol 52(21):1724–1732

    Article  PubMed  Google Scholar 

  7. Meijboom WB, Meijs MF, Schuijf JD et al (2008) Diagnostic accuracy of 64-slice computed tomography coronary angiography: a prospective, multicenter, multivendor study. J Am Coll Cardiol 52(25):2135–2144

    Article  PubMed  Google Scholar 

  8. Miller JM, Rochitte CE, Dewey M et al (2008) Diagnostic performance of coronary angiography by 64-row CT. N Engl J Med 359(22):2324–2336

    Article  CAS  PubMed  Google Scholar 

  9. Cademartiri F, Maffie E, Palumbo A et al (2010) CT coronary angiography for the follow-up of coronary stent. Acta Biomed 81(2):87–93

    PubMed  Google Scholar 

  10. Andreini D, Pontone G, Mushtaq S, Pepi M, Bartorelli AL (2010) Multidetector computed tomography coronary angiography for the assessment of coronary in-stent restenosis. Am J Cardiol 105(5):645–655

    Article  PubMed  Google Scholar 

  11. Ronan G, Wolk MJ, Bailey SR et al (2014) ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. J Nucl Cardiol 21(1):192–220

    Article  PubMed  Google Scholar 

  12. Nieman K, Serruys PW, Onuma Y et al (2013) Multislice computed tomography angiography for noninvasive assessment of the 18-month performance of a novel radiolucent bioresorbable vascular scaffolding device: the ABSORB trial (a clinical evaluation of the bioabsorbable everolimus eluting coronary stent system in the treatment of patients with de novo native coronary artery lesions). J Am Coll Cardiol 62(19):1813–1814

    Article  PubMed  Google Scholar 

  13. Wykrzykowska JJ, Arbab-Zadeh A, Godoy G et al (2010) Assessment of in-stent restenosis using 64-MDCT: analysis of the CORE-64 Multicenter International Trial. Am J Roentgenol 194(1):85–92

    Article  Google Scholar 

  14. Nakamura K, Funabashi N, Uehara M et al (2008) Impairment factors for evaluating the patency of drug-eluting stents and bare metal stents in coronary arteries by 64-slice computed tomography versus conventional coronary angiography. Int J Cardiol 130(3):349–356

    Article  PubMed  Google Scholar 

  15. Sheth T, Dodd JD, Hoffmann U et al (2007) Coronary stent accessability by 64 slice multi-detector computed tomography. Catheter Cardiovasc Interv 69(7):933–938

    Article  PubMed  Google Scholar 

  16. Groeneveld PW (2012) How drug-eluting stents illustrate our health system’s flawed relationship with technology: comment on “use of drug-eluting stents as a function of predicted benefit”. Arch Intern Med 172(15):1152–1153

    Article  PubMed  Google Scholar 

  17. Chinnaiyan KM, Raff GL, Goraya T et al (2012) Coronary computed tomography angiography after stress testing: results from a multicenter, statewide registry, ACIC (Advanced Cardiovascular Imaging Consortium). J Am Coll Cardiol 59(7):688–695

    Article  PubMed  Google Scholar 

  18. Pontone G, Andreini D, Bartorelli AL et al (2012) Radiation dose and diagnostic accuracy of multidetector computed tomography for the detection of significant coronary artery stenoses: a meta-analysis. Int J Cardiol 160(3):155–164

    Article  PubMed  Google Scholar 

  19. Moscucci M (2002) Frequency and costs of ischemic and bleeding complications after percutaneous coronary interventions: rationale for new antithrombotic agents. J Invasive Cardiol 14(Suppl B):55B–64B

    PubMed  Google Scholar 

  20. Bell GW, Edwardes M, Dunning AM et al (2010) Periprocedural safety of 64-detector row coronary computed tomographic angiography: results from the prospective multicenter ACCURACY trial. J Cardiovasc Comput Tomogr 4(6):375–380

    Article  PubMed  Google Scholar 

  21. Hospital Outpatient Prospective Payment System. Centers for Medicare & Medicaid Services website. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1589-FC.html?DLPage=1&DLSort=2&DLSortDir=descending. Accessed Aug 2014

  22. Consumer Price Index. Bureau of Labor Statistics website (2014). http://data.bls.gov/cgi-bin/surveymost?cu

  23. Schiele TM (2005) Current understanding of coronary in-stent restenosis. Pathophysiology, clinical presentation, diagnostic work-up, and management. Z Kardiol 94(11):772–790

    Article  CAS  PubMed  Google Scholar 

  24. Berman DS, Hachamovitch R, Shaw LJ et al (2006) Roles of nuclear cardiology, cardiac computed tomography, and cardiac magnetic resonance: assessment of patients with suspected coronary artery disease. J Nucl Med 47(1):74–82

    PubMed  Google Scholar 

  25. Shaw LJ, Min JK, Hachamovitch R et al (2010) Cardiovascular imaging research at the crossroads. JACC Cardiovasc Imaging 3(3):316–324

    Article  PubMed  Google Scholar 

  26. Berman DS, Abidov A, Hachamovitch R et al (2009) Comparative roles of cardiac CT and nuclear cardiology in assessment of the patient with suspected coronary artery disease. J Invasive Cardiol 21(7):352–358

    PubMed  Google Scholar 

  27. Nallu K, Yang DC, Swaminathan RV, Kim LK, Feldman D (2013) Innovations in drug-eluting stents. Panminerva Med 55(4):345–352

    CAS  PubMed  Google Scholar 

  28. Balla S, Aggarwal K, Nistala R (2010) Bioabsorbable coronary stents—are these the next big thing in coronary angioplasty? Recent Pat Cardiovasc Drug Discov 5(2):86–90

    Article  CAS  PubMed  Google Scholar 

  29. Serruys PW, Chevalier B, Dudek D et al (2015) A bioresorbable everolimus-eluting scaffold versus a metallic everolimus-eluting stent for ischaemic heart disease caused by de-novo native coronary artery lesions (ABSORB II): an interim 1-year analysis of clinical and procedural secondary outcomes from a randomised controlled trial. Lancet 385(9962):43–54

Download references

Funding sources

This study was funded by Abbott Vascular. This study was also funded, in part, by the Dalio Institute of Cardiovascular Imaging, the Michael J. Wolk Foundation and a grant from the National Institutes of Health (NIH R01HL118019).

Author information

Authors and Affiliations

  1. Department of Radiology, Weill Cornell Medical College, New York, NY, USA

    James K. Min

  2. Dalio Institute of Cardiovascular Imaging, NewYork-Presbyterian Hospital and the Weill Cornell Medical College, 413 E. 69th Street, Suite 108, New York, 10021, NY, USA

    James K. Min

  3. Abbott Vascular, Santa Clara, CA, USA

    James T. Hasegawa & Susanne F. Machacz

  4. Xcenda, Palm Harbor, FL, USA

    Ken O’Day

Authors
  1. James K. Min
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. James T. Hasegawa
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Susanne F. Machacz
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Ken O’Day
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to James K. Min.

Ethics declarations

Conflict of interest

Dr. James K. Min serves as a consultant to Abbott Vascular and HeartFlow, Inc.; GE Healthcare; and serves on the medical advisory board of GE Healthcare and Arineta. James T. Hasegawa, Susanne F. Machacz, Ken O’Day declare that they have no conflict of interest.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Min, J.K., Hasegawa, J.T., Machacz, S.F. et al. Costs and clinical outcomes for non-invasive versus invasive diagnostic approaches to patients with suspected in-stent restenosis. Int J Cardiovasc Imaging 32, 309–315 (2016). https://doi.org/10.1007/s10554-015-0758-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10554-015-0758-z

Keywords

Search

Navigation