Cost-Minimization analysis for cardiac revascularization in 12 healthcare systems based on the EuroCMR/SPINS registries
Authors: Moschetti K , Kwong RY , Petersen SE , Lombardi M , Garot J , Atar D , Rademakers FE , Sierra-Galan LM , Mavrogeni S , Li K , Lara Fernandes J , Antiochos P , Bruder O , Marholdt H , Schwitter J 
Published: July 2021

Abstract

Funding Acknowledgements
Type of funding sources: Private company. Main funding source(s): EuroCMR registry (Life Sciences GE Healthcare, Medtronic Inc., Minneapolis MN, USA; Novartis International AG, Basel, Switzerland; Siemens Healthcare, Erlangen, Germany), SPINS registry (Siemens Healthineers, Erlangen, Germany; Bayer AG, Leverkusen, Germany)

Background
Coronary artery disease (CAD) is a major contributor to the public health burden. Stress perfusion cardiac magnetic resonance (CMR) has an excellent accuracy to detect CAD, but data on its cost effectiveness are scarce.

Purpose
To compare the costs of a CMR-guided strategy vs 2 invasive strategies based on 2 large international CMR registries.

Methods
In the EuroCMR registry (n = 3’647, 59 centers, 18 countries) and the US-based SPINS registry (n = 2’349, 13 centers, 11 states) costs were calculated for 12 healthcare systems (8 Europe, US, 2 Latin America, 1 Asia). They included diagnostic examinations (CMR, X-ray coronarography (CXA) with/without FFR), revascularizations, and complications during a 1-year follow-up. Endpoints in both registries were all-cause and cardiovascular (CV) death, sudden cardiac death (SCD), aborted SCD, non-fatal myocardial infarction (nf-MI), and stroke. 7 sub-group analyses covered low to high-risk cohorts. Patients with ischemia-positive CMR underwent CXA and revascularization (percuteneous and surgical intervention) at the treating physician’s discretion (=CMR + CXA-strategy). In the hypothetical invasive CXA + FFR-strategy, costs were calculated for an initial CXA and an FFR in vessels with ≥50% stenoses assuming the same proportion of revascularizations/complications as in the CMR + CXA-strategy and FFR positive rates as given in the literature. In the CXA-only strategy, costs included CXA and revascularizations of ≥50% stenoses.

Results
Revascularizations were performed in 8.0% and 6.2% (p &lt; 0.01) of SPINS and EuroCMR patients, respectively. Consistent cost savings were observed for the CMR + CXA strategy vs CXA + FFR in all 12 healthcare systems ranging from 42 ± 20% and 52 ± 15% in the low-risk EuroCMR and SPINS patients with atypical chest pain (CV-death and nf-MI 0.4-0.7%/y), respectively, to 31 ± 16% in the high-risk SPINS patients (CV-death and nf-MI 3.2%/y) with known CAD (p &lt; 0.0001 vs 0 in all groups, Fig 1/2). Cost savings were even higher vs CXA-only with 63 ± 11%, 73 ± 6%, and 52 ± 9%, respectively (p &lt; 0.0001 vs 0 in all groups, Fig 2).

Conclusions
In 12 healthcare systems, a CMR + CXA-strategy yielded consistent moderate to high cost savings compared to a hypothetical CXA + FFR-strategy over the entire spectrum of risk. Cost savings were consistently high vs a CXA-only strategy for all risk groups.
Figure 1: SPINS refers to the subgroup of patients with suspected CAD (n = 1’530), EuroCMR (= suspected CAD; n = 3’647). EuroCMR vs SPINS ns. Countries per region are listed in alphabetical order.
Figure 2: Top: CMR + CXA vs CXA + FFR: ANOVA: overall p = 0.0017, * vs EuroCMR typ angina: p &lt; 0.005 (Scheffe post-hoc testing). Bottom: CMR + CXA vs CXA-only: ANOVA overall p &lt; 0.0001, * vs SPINS with CAD and vs EuroCMR typ A: p &lt; 0.0001; † vs SPINS with CAD: p &lt; 0.03; ‡ vs EuroCMR typ A: p &lt; 0.0001; § vs SPINS with CAD: p &lt; 0.002; ║ vs EuroCMR typ: p &lt; 0.002 (Scheffe post-hoc tesing)