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      Adenosine-stress cardiac magnetic resonance imaging in suspected coronary artery disease: a net cost analysis and reimbursement implications


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          The health and economic implications of new imaging technologies are increasingly relevant policy issues. Cardiac magnetic resonance imaging (CMR) is currently not or not sufficiently reimbursed in a number of countries including Germany, presumably because of a limited evidence base. It is unknown, however, whether it can be effectively used to facilitate medical decision-making and reduce costs by serving as a gatekeeper to invasive coronary angiography. We investigated whether the application of CMR in patients suspected of having coronary artery disease (CAD) reduces costs by averting referrals to cardiac catheterization. We used propensity score methods to match 218 patients from a CMR registry to a previously studied cohort in which CMR was demonstrated to reliably identify patients who were low-risk for major cardiac events. Covariates over which patients were matched included comorbidity profiles, demographics, CAD-related symptoms, and CAD risk as measured by Morise scores. We determined the proportion of patients for whom cardiac catheterization was deferred based upon CMR findings. We then calculated the economic effects of practice pattern changes using data on cardiac catheterization and CMR costs. CMR reduced the utilization of cardiac catheterization by 62.4%. Based on estimated catheterization costs of € 619, the utilization of CMR as a gatekeeper reduced per-patient costs by a mean of € 90. Savings were realized until CMR costs exceeded € 386. Cost savings were greatest for patients at low-risk for CAD, as measured by baseline Morise scores, but were present for all Morise subgroups with the exception of patients at the highest risk of CAD. CMR significantly reduces the utilization of cardiac catheterization in patients suspected of having CAD. Per-patient savings range from € 323 in patients at lowest risk of CAD to € 58 in patients at high-risk but not in the highest risk stratum. Because a negative CMR evaluation has high negative predictive value, its application as a gatekeeper to cardiac catheterization should be further explored as a treatment option.

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          Exposure to low-dose ionizing radiation from medical imaging procedures.

          The growing use of imaging procedures in the United States has raised concerns about exposure to low-dose ionizing radiation in the general population. We identified 952,420 nonelderly adults (between 18 and 64 years of age) in five health care markets across the United States between January 1, 2005, and December 31, 2007. Utilization data were used to estimate cumulative effective doses of radiation from imaging procedures and to calculate population-based rates of exposure, with annual effective doses defined as low ( 3 to 20 mSv), high (> 20 to 50 mSv), or very high (> 50 mSv). During the study period, 655,613 enrollees (68.8%) underwent at least one imaging procedure associated with radiation exposure. The mean (+/-SD) cumulative effective dose from imaging procedures was 2.4+/-6.0 mSv per enrollee per year; however, a wide distribution was noted, with a median effective dose of 0.1 mSv per enrollee per year (interquartile range, 0.0 to 1.7). Overall, moderate effective doses of radiation were incurred in 193.8 enrollees per 1000 per year, whereas high and very high doses were incurred in 18.6 and 1.9 enrollees per 1000 per year, respectively. In general, cumulative effective doses of radiation from imaging procedures increased with advancing age and were higher in women than in men. Computed tomographic and nuclear imaging accounted for 75.4% of the cumulative effective dose, with 81.8% of the total administered in outpatient settings. Imaging procedures are an important source of exposure to ionizing radiation in the United States and can result in high cumulative effective doses of radiation. 2009 Massachusetts Medical Society
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              Diagnostic performance of stress cardiac magnetic resonance imaging in the detection of coronary artery disease: a meta-analysis.

              The purpose of our study was to conduct an evidence-based evaluation of stress cardiac magnetic resonance imaging (MRI) in the diagnosis of coronary artery disease (CAD). Stress cardiac MRI has recently emerged as a noninvasive method in the detection of CAD, with 2 main techniques in use: 1) perfusion imaging; and 2) stress-induced wall motion abnormalities imaging. We examined studies from January 1990 to January 2007 using MEDLINE and EMBASE. A study was included if it: 1) used stress MRI as a diagnostic test for CAD (> or =50% diameter stenosis); and 2) used catheter X-ray angiography as the reference standard. Thirty-seven studies (2,191 patients) met the inclusion criteria, with 14 datasets (754 patients) using stress-induced wall motion abnormalities imaging and 24 datasets (1,516 patients) using perfusion imaging. Stress-induced wall motion abnormalities imaging demonstrated a sensitivity of 0.83 (95% confidence interval [CI] 0.79 to 0.88) and specificity of 0.86 (95% CI 0.81 to 0.91) on a patient level (disease prevalence = 70.5%). Perfusion imaging demonstrated a sensitivity of 0.91 (95% CI 0.88 to 0.94) and specificity of 0.81 (95% CI 0.77 to 0.85) on a patient level (disease prevalence = 57.4%). In studies with high disease prevalence, stress cardiac MRI, using either technique, demonstrates overall good sensitivity and specificity for the diagnosis of CAD. However, limited data are available regarding use of either technique in populations with low disease prevalence.

                Author and article information

                +49-8026-3932103 , +49-8026-3934631 , pilz@khagatharied.de
                Int J Cardiovasc Imaging
                The International Journal of Cardiovascular Imaging
                Springer Netherlands (Dordrecht )
                4 June 2010
                4 June 2010
                January 2011
                : 27
                : 1
                : 113-121
                [1 ]Department of Cardiology, Clinic Agatharied, Academic Teaching Hospital, University of Munich, Norbert Kerkel Platz, 83734 Hausham, Germany
                [2 ]GE Healthcare, Barrington, IL USA
                [3 ]GE Healthcare, Munich, Germany
                [4 ]Harvard Medical School, Boston, MA USA
                [5 ]Stony Brook University, Stony Brook, NY USA
                [6 ]University of Colorado, Aurora, CO USA
                [7 ]S2 Statistical Solutions, Inc, Cincinnati, OH USA
                © The Author(s) 2010
                : 13 April 2010
                : 21 May 2010
                Original Paper
                Custom metadata
                © Springer Science+Business Media, B.V. 2011

                Cardiovascular Medicine
                adenosine stress,net cost analysis,myocardial perfusion,coronary artery disease,cardiac magnetic resonance imaging


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