Abstract
OBJECTIVE: Screening for coronary artery disease (CAD) in asymptomatic diabetic patients with two additional atherogenic risk factors has been recommended by the American College of Cardiology/American Diabetes Association, but its cost-effectiveness is yet to be determined. The present study aims to evaluate the cost-effectiveness of screening and determine acceptable strategies.
DESIGN: Cost-effectiveness analysis using a Markov model was performed from a societal perspective to measure the clinical benefit and economic consequences of CAD screening in asymptomatic men with diabetes and two additional atherogenic risk factors. We evaluated cohorts of patients stratified by different age groups, and 10 possible combination pairs of atherogenic risks. Incremental cost-effectiveness of no screening, exercise electrocardiography, exercise echocardiography, or exercise single-photon emission-tomography (SPECT) was calculated. Input data were obtained from the published literature. Outcomes were expressed as U.S. dollars per quality-adjusted life-year (QALY).
MEASUREMENTS AND MAIN RESULTS: Compared with no screening, incremental cost-effectiveness ratio of exercise electrocardiography was $41,600/QALY in 60-year-old asymptomatic diabetic men with hypertension and smoking, but was weakly dominated by exercise echocardiography. Exercise echocardiography was most cost-effective, with an incremental cost-effectiveness ratio of $40,800/QALY. Exercise SPECT was dominated by other strategies. Sensitivity analyses found that results varied depending on age, combination of additional atherogenic risk factors, and diagnostic test performance.
CONCLUSIONS: Incremental cost-effectiveness ratio of CAD screening in asymptomatic patients with diabetes and two or more additional atherogenic risk factors is shown to be acceptable from a societal perspective. Exercise echocardiography was the most cost-effective strategy, followed by exercise electrocardiography.
Similar content being viewed by others
References
Kannel WB, McGee DL. Diabetes and cardiovascular disease. The Framingham study. JAMA. 1979;241:2035–8.
Stamler J, Vaccaro O, Neaton JD, Wentworth D. Diabetes, other risk factors, and 12-yr cardiovascular mortality for men screened in the Multiple Risk Factor Intervention Trial. Diabetes Care. 1993;16:434–44.
Fuller JH. Mortality trends and causes of death in diabetic patients. Diabetes Metab. 1993;19:96–9.
Panzram G. Mortality and survival in type 2 (non-insulin-dependent) diabetes mellitus. Diabetologia. 1987;30:123–31.
Jacoby RM, Nesto RW. Acute myocardial infarction in the diabetic patient: pathophysiology, clinical course and prognosis. J Am Coll Cardiol. 1992;20:736–44.
Fava S, Azzopardi J, Muscat HA, Fenech FF. Factors that influence outcome in diabetic subjects with myocardial infarction. Diabetes Care. 1993;16:1615–8.
Langer A, Freeman MR, Josse RG, Steiner G, Armstrong PW. Detection of silent myocardial ischemia in diabetes mellitus. Am J Cardiol. 1991;67:1073–8.
Rutter MK, McComb JM, Brady S, Marshall SM. Silent myocardial ischemia and microalbuminuria in asymptomatic subjects with non-insulin-dependent diabetes mellitus. Am J Cardiol. 1999;83:27–31.
Koistinen MJ, Huikuri HV, Korhonen UR, et al. Asymptomatic coronary artery disease in diabetes: relation to common risk factors, lipoproteins, apoproteins and apo E polymorphism. Acta Diabetol. 1994;31:210–4.
Naka M, Hiramatsu K, Aizawa T, et al. Silent myocardial ischemia in patients with non-insulin-dependent diabetes mellitus as judged by treadmill exercise testing and coronary angiography. Am Heart J. 1992;123:46–53.
Nesto RW, Watson FS, Kowalchuk GJ, et al. Silent myocardial ischemia and infarction in diabetics with peripheral vascular disease: assessment by dipyridamole thallium-201 scintigraphy. Am Heart J. 1990;120:1073–7.
Consensus development conference on the diagnosis of coronary heart disease in people with diabetes: 10–11 February 1998, Miami, Florida. American Diabetes Association. Diabetes Care. 1998;21:1551–9.
Sox HC Jr, Littenberg B, Garber AM. The role of exercise testing in screening for coronary artery disease. Ann Intern Med. 1989;110:456–69.
Cohn PF. Silent myocardial ischemia. Ann Intern Med. 1988;109:312–7.
Sonnenberg FA, Beck JR. Markov models in medical decision making: a practical guide. Med Decis Making. 1993;13:322–38.
Weinstein MC, Coxson PG, Williams LW, Pass TM, Stason WB, Goldman L. Forecasting coronary heart disease incidence, mortality, and cost: the Coronary Heart Disease Policy Model. Am J Public Health. 1987;77:1417–26.
Anderson KM, Odell PM, Wilson PW, Kannel WB. Cardiovascular disease risk profiles. Am Heart J. 1991;121:293–8.
Hunink MG, Goldman L, Tosteson AN, et al. The recent decline in mortality from coronary heart disease, 1980–1990. The effect of secular trends in risk factors and treatment. JAMA. 1997;277:535–42.
Airaksinen KE. Silent coronary artery disease in diabetes—a feature of autonomic neuropathy or accelerated atherosclerosis? Diabetologia. 2001;44:259–66.
Chaitman BR, Bourassa MG, Davis K, et al. Angiographic prevalence of high-risk coronary artery disease in patient subsets (CASS). Circulation. 1981;64:360–7.
Collins R, Armitage J, Parish S, Sleigh P, Peto R. MRC/BHF Heart Protection Study of cholesterol-lowering with simvastatin in 5963 people with diabetes: a randomised placebo-controlled trial. Lancet. 2003;361:2005–16.
Haffner SM. Dyslipidemia management in adults with diabetes. Diabetes Care. 2004;27(suppl 1):S68-S71.
National Heart, Lung, and Blood Institute. Unpublished tabulation from the public use data tapes, National Health and Nutrition Examination Survey, 1971–1975, 1976–1980, 1988–1994. Hyattsville, Md: National Center for Health Statistics; 1999.
Klesges RC, Debon M, Ray JW. Are self-reports of smoking rate biased? Evidence from the Second National Health and Nutrition Examination Survey. J Clin Epidemiol. 1995;48:1225–33.
Gibbons RJ, Abrams J, Chatterjee K, et al. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina—summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients with Chronic Stable Angina). Circulation. 2003;107:149–58.
Zhang J, Yu KF. What’s the relative risk? A method of correcting the odds ratio in cohort studies of common outcomes. JAMA. 1998;280:1690–1.
Alexander CM, Landsman PB, Teutsch SM. Diabetes mellitus, impaired fasting glucose, atherosclerotic risk factors, and prevalence of coronary heart disease. Am J Cardiol. 2000;86:897–902.
Gianrossi R, Detrano R, Mulvihill D, et al. Exercise-induced ST depression in the diagnosis of coronary artery disease. A meta-analysis. Circulation. 1989;80:87–98.
Fleischmann KE, Hunink MG, Kuntz KM, Douglas PS. Exercise echocardiography or exercise SPECT imaging? A meta-analysis of diagnostic test performance. JAMA. 1998;280:913–20.
Johnson LW, Lozner EC, Johnson S, et al. Coronary arteriography 1984–1987: a report of the Registry of the Society for Cardiac Angiography and Interventions. I. Results and complications. Cathet Cardiovasc Diagn. 1989;17:5–10.
Holmes DR Jr, Holubkov R, Vlietstra RE, et al. Comparison of complications during percutaneous transluminal coronary angioplasty from 1977 to 1981 and from 1985 to 1986: the National Heart, Lung, and Blood Institute Percutaneous Transluminal Coronary Angioplasty Registry. J Am Coll Cardiol. 1988;12:1149–55.
Yusuf S, Zucker D, Chalmers TC. Ten-year results of the randomized controlled trials of coronary artery bypass graft surgery: tabular data compiled by the collaborative effort of the original trial investigators. Part 1 of 2. Online J Curr Clin Trials. 1994; document no. 144.
Yusuf S, Zucker D, Chalmers TC. Ten-year results of the randomized controlled trials of coronary artery bypass graft surgery: tabular data compiled by the collaborative effort of the original trial investigators. Part 2 of 2. Online J Curr Clin Trials. 1994;document no. 145.
Hannan EL, Kilburn H Jr, O’Donnell JF, Lukacik G, Shields EP. Adult open heart surgery in New York State. An analysis of risk factors and hospital mortality rates. JAMA. 1990;264:2768–74.
Romeo F, Rosano GM, Martuscelli E, Valente A, Reale A. Characterization and long-term prognosis of patients with effort-induced silent myocardial ischaemia. Eur Heart J. 1992;13:457–63.
Ekelund LG, Suchindran CM, McMahon RP, et al. Coronary heart disease morbidity and mortality in hypercholesterolemic men predicted from an exercise test: the Lipid Research Clinics Coronary Primary Prevention Trial. J Am Coll Cardiol. 1989;14:556–63.
Laukkanen JA, Kurl S, Lakka TA, et al. Exercise-induced silent myocardial ischemia and coronary morbidity and mortality in middle-aged men. J Am Coll Cardiol. 2001;38:72–9.
Arias E. United States Life Tables, 2002. National Vital Statistics Reports; vol. 51 no. 3. Hyattsville, Md: National Center for Health Statistics.
Beck JR, Kassirer JP, Pauker SG. A convenient approximation of life expectancy (the “DEALE”). I. Validation of the method. Am J Med. 1982;73:883–8.
Beck JR, Pauker SG, Gottlieb JE, Klein K, Kassirer JP. A convenient approximation of life expectancy (the “DEALE”). II. Use in medical decision-making. Am J Med. 1982;73:889–97.
Drummond MF, Pang F. Modeling in economic evaluation. In: Drummond M, McGuire MA, eds. Economic Evaluation in Health Care: Merging Theory with Practice. Oxford, UK: Oxford University Press; 2001.
Yusuf S, Zucker D, Peduzzi P, et al. Effect of coronary artery bypass graft surgery on survival: overview of 10-year results from randomised trials by the Coronary Artery Bypass Graft Surgery Trialists’ Collaboration. Lancet. 1994;344:563–70.
Collaborative overview of randomised trials of antiplatelet therapy—I: prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients. Antiplatelet Trialists’ Collaboration. BMJ. 1994;308:81–106.
Sanmuganathan PS, Ghahramani P, Jackson PR, Wallis EJ, Ramsay LE. Aspirin for primary prevention of coronary heart disease: safety and absolute benefit related to coronary risk derived from meta-analysis of randomised trials. Heart. 2001;85:265–71.
Wilson PW, D’Agostino RB, Levy D, Belanger AM, Silbershatz H, Kannel WB. Prediction of coronary heart disease using risk factor categories. Circulation. 1998;97:1837–47.
Mark DB, Nelson CL, Califf RM, et al. Continuing evolution of therapy for coronary artery disease. Initial results from the era of coronary angioplasty. Circulation. 1994;89:2015–25.
Pocock SJ, Henderson RA, Rickards AF, et al. Meta-analysis of randomised trials comparing coronary angioplasty with bypass surgery. Lancet. 1995;346:1184–9.
Gaspoz JM, Coxson PG, Goldman PA, et al. Cost effectiveness of aspirin, clopidogrel, or both for secondary prevention of coronary heart disease. N Engl J Med. 2002;346:1800–6.
Myocardial infarction and mortality in the coronary artery surgery study (CASS) randomized trial. N Engl J Med. 1984;310:750–8.
Coronary artery surgery study (CASS): a randomized trial of coronary artery bypass surgery. Survival data. Circulation. 1983;68:939–50.
King SB III, Lembo NJ, Weintraub WS, et al. A randomized trial comparing coronary angioplasty with coronary bypass surgery. Emory Angioplasty versus Surgery Trial (EAST). N Engl J Med. 1994;331:1044–50.
Cost-effectiveness of intensive glycemic control, intensified hypertension control, and serum cholesterol level reduction for type 2 diabetes. JAMA. 2002;287:2542–51.
Kuntz KM, Fleischmann KE, Hunink MG, Douglas PS. Cost-effectiveness of diagnostic strategies for patients with chest pain. Ann Intern Med. 1999;130:709–18.
Lave JR, Pashos CL, Anderson GF, et al. Costing medical care: using Medicare administrative data. Med Care. 1994;32:JS77-JS89.
Stinnett AA, Mittleman MA, Weinstein MC, Kuntz KM, Cohen DJ, Williams LW. The cost-effectiveness of dietary and pharmacologic therapy for cholesterol reduction in adults. In: Gold MR, Siegel JE, Russell LB, Weinstein MC, eds. Cost-effectiveness in Health and Medicine. New York, NY: Oxford University Press; 1996:349–91.
Russell MW, Huse DM, Drowns S, Hamel EC, Hartz SC. Direct medical costs of coronary artery disease in the United States. Am J Cardiol. 1998;81:1110–5.
Drug Topics Red Book. Montvale, NJ: Medical Economics Company, Inc; 1998.
Drug Topics Red Book. Montvale, NJ: Medical Economics Company, Inc; 2003.
Johannesson M, Jonsson B, Kjekshus J, Olsson AG, Pedersen TR, Wedel H. Cost effectiveness of simvastatin treatment to lower cholesterol levels in patients with coronary heart disease. Scandinavian Simvastatin Survival Study Group. N Engl J Med. 1997;336:332–6.
Weinstein MC, Siegel JE, Gold MR, Kamlet MS, Russell LB. Recommendations of the Panel on Cost-effectiveness in Health and Medicine. JAMA. 1996;276:1253–8.
Nease RF Jr, Kneeland T, O’Connor GT, et al. Variation in patient utilities for outcomes of the management of chronic stable angina. Implications for clinical practice guidelines. Ischemic Heart Disease Patient Outcomes Research Team. JAMA. 1995;273:1185–90.
Tsevat J, Goldman L, Soukup JR, et al. Stability of time-tradeoff utilities in survivors of myocardial infarction. Med Decis Making. 1993;13:161–5.
Brown ML, Fintor L. Cost-effectiveness of breast cancer screening: preliminary results of a systematic review of the literature. Breast Cancer Res Treat. 1993;25:113–8.
Littenberg B, Garber AM, Sox HC Jr. Screening for hypertension. Ann Intern Med. 1990;112:192–202.
Coppleson LW, Brown B. The prevention of carcinoma of the cervix. Am J Obstet Gynecol. 1976;125:153–9.
Fletcher RH, Fletcher SW, Wagner EH. Diagnosis. In: Satterfield TS, Taylor C, eds. Clinical Epidemiology. Philadelphia, Pa: Lippincott Williams & Wilkins; 1996:43–74.
Hunink M, Glasziou P, Siegel J, et al. Constrained Resources. Decision Making in Health and Medicine: Integrating Evidence and Values. Cambridge, UK: Cambridge University Press; 2001.
Turner RC, Millns H, Neil HA, et al. Risk factors for coronary artery disease in non-insulin dependent diabetes mellitus: United Kingdom Prospective Diabetes Study (UKPDS: 23). BMJ. 1998;316:823–8.
Mak KH, Moliterno DJ, Granger CB, et al. Influence of diabetes mellitus on clinical outcome in the thrombolytic era of acute myocardial infarction. GUSTO-I Investigators. Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries. J Am Coll Cardiol. 1997;30:171–9.
Bacci S, Villella M, Villella A, et al. Screening for silent myocardial ischaemia in type 2 diabetic patients with additional atherogenic risk factors: applicability and accuracy of the exercise stress test. Eur J Endocrinol. 2002;147:649–54.
Cohn PF, Fox KM, Daly C. Silent myocardial ischemia. Circulation. 2003;108:1263–77.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Hayashino, Y., Nagata-Kobayashi, S., Morimoto, T. et al. Cost-effectiveness of screening for coronary artery disease in asymptomatic patients with type 2 diabetes and additional atherogenic risk factors. J GEN INTERN MED 19, 1181–1191 (2004). https://doi.org/10.1111/j.1525-1497.2004.40012.x
Issue Date:
DOI: https://doi.org/10.1111/j.1525-1497.2004.40012.x