Short Attention Span Summary
Coronary CTA use has increased in frequency and is associated with increased subsequent "PCI, CABG, repeat non-invasive testing, hospitalization, and return ED visits." This test for CAD seems to beget more testing and invasive procedures without improving the outcome, which begs the question - is CCTA the wisest non-invasive way to evaluate patients presenting to the ED with chest pain?
Acad Emerg Med. 2016 May 7. doi: 10.1111/acem.13005. [Epub ahead of print]
1Mayo Medical School, Mayo Clinic College of Medicine, Rochester, MN.
2Division of Emergency Medicine Research, Department of Emergency Medicine, Mayo Clinic, Rochester, MN.
3Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, MN.
4Division of Healthcare Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN.
5Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN.
6Optum Labs, Cambridge, MA.
7Department of Cardiology, Mayo Clinic, Rochester, MN.
8Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN.
Coronary computerized tomography angiography (CCTA) is a rapidly emerging technology for the evaluation of chest pain in the Emergency Department (ED). We assessed trends in CCTA use and compared downstream healthcare utilization between CCTA and cardiac stress testing modalities.
Using administrative claims data (Optum Labs Data Warehouse) from over 100 million geographically diverse privately insured and Medicare Advantage enrollees across the U.S., we identified 2,047,799 ED patients from January 2006 to December 2013 who presented with chest pain and had a CCTA or cardiac stress test within 72 hours. Cohorts were established based on CCTA or functional stress testing (myocardial perfusion scintigraphy [MPS], stress echocardiogram [SE], or treadmill exercise electrocardiogram [TMET]) performed within 72 hours of the ED visit. We tracked subsequent invasive cardiac procedures (invasive coronary angiography [ICA], percutaneous coronary intervention [PCI], and coronary artery bypass grafting [CABG]), repeat noninvasive testing, return ED visits, hospitalization, and the rate of acute myocardial infarction (AMI) within 30 days. We used propensity-score matching to adjust for coronary artery disease (CAD) risk factors, Charlson-Deyo comorbidity index, and baseline differences between patients selected for CCTA or cardiac stress testing. Logistic regression was used to measure adjusted associations between testing modality and outcomes.
During the study period, CCTA use increased from 0.8% to 4.5% of all cardiac testing within 72-hours, a change of 434% (P for trend < .001), while rates of other cardiac stress testing modalities decreased (-22% for TMET [P< .001]; -11% for SE [P= .11]; -6% for MPS [P= .04]. After matching, there was no difference in the 30-day rate of AMI between testing modalities. Compared to myocardial perfusion scintigraphy, CCTA was associated with higher rates of PCI (odds ratio [OR]=1.25, 95% confidence interval [CI] 1.04-1.51), and CABG (OR=1.47; 95% CI, 1.03-2.13). Compared to stress echocardiography and treadmill stress testing, CCTA was associated with more invasive procedures, hospitalizations, return ED visits, and repeat noninvasive testing.
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 article is protected by copyright. All rights reserved.
This article is protected by copyright. All rights reserved.
PMID: 27155236 [PubMed - as supplied by publisher]