Cost-effectiveness of CMR over MPS-SPECT: a systematic review of recent trends for diagnosing CAD

The health economic impacts of cardiovascular magnetic resonance (CMR) imaging and myocardial perfusion scintigraphy by single photon emission computed tomography (MPS-SPECT) as diagnostic modalities are not well understood. This review is based on a wider systematic review and aims to compare CMR and MPS-SPECT as first-line, non-invasive modalities for the diagnosis of symptomatic individuals with a low-to-intermediate pre-test probability (PTP) of coronary artery disease (CAD). We performed a systematic review of MEDLINE and Embase, MEDLINE In-process, the Cochrane Database of Systematic reviews and the Cochrane Central Register of Controlled Trials. Studies from January 1992 to January 2023 were included, if they were based in the UK, France, Germany, Italy, Japan, China, and/or the USA (published in any language). Risk of bias was assessed using the Drummond checklist. Thirteen relevant reports were identified. In the USA, CMR was consistently cost-effective compared with MPS-SPECT for patients with a low-to-intermediate PTP of CAD; resource use and associated costs, as well as total costs, were lower. For patients with a low-to-intermediate PTP of CAD in Europe, CMR was cost-effective in Germany, while in the UK increases in quality-adjusted life-years were found but cost savings were mixed. This review found only 13 reports on the economic benefits of CMR over MPS-SPECT, with just three providing cost-effectiveness outcomes, highlighting the need for further research across different settings and perspectives. Overall, findings suggest that the cost savings from using CMR compared with MPS-SPECT for patients with a low-to-intermediate PTP of CAD support prioritized investment; however, confirmatory research is needed given the limited number of cost-effectiveness analyses identified in this review. Imaging of the heart and its blood vessels is typically used to diagnose coronary artery disease. Non-invasive tests have improved recently. Therefore, doctors are finding them more useful. Global clinical guidelines generally recommend that the choice of imaging test is based on whether patients have a low, intermediate, or high chance of having the disease. This chance is called a patient’s “pre-test probability.” This review compares two non-invasive tests: cardiovascular magnetic resonance (CMR) imaging and myocardial perfusion scintigraphy by single photon emission computed tomography (MPS-SPECT). We looked at which of these tests is better value for money from a payer’s perspective. Thirteen studies in this review compared CMR and MPS-SPECT. The studies were published between 2007 and 2022. CMR was always better value for money than MPS-SPECT for patients with a low or intermediate pre-test probability in the USA and Germany. In the USA, CMR also reduced the need for additional healthcare resource expenses. In the UK, CMR was sometimes better value for money than MPS-SPECT for patients with a low, intermediate, or high pre-test probability. Overall, this review supports CMR as a better value for money option than MPS-SPECT when diagnosing patients with a low or intermediate chance of having coronary artery disease. This should be considered by healthcare providers and funders when reimbursement and investment decisions are being made. However, we only found a small number of studies, so more research is needed.

心血管磁共振（cardiovascular magnetic resonance, CMR）成像与单光子发射计算机断层扫描心肌灌注显像（myocardial perfusion scintigraphy by single photon emission computed tomography, MPS-SPECT）作为冠状动脉疾病诊断手段的卫生经济学影响目前尚未得到充分阐明。本综述基于一项更广泛的系统综述，旨在对比CMR与MPS-SPECT作为一线非侵入式诊断手段，用于诊断预测试概率（pre-test probability, PTP）为低至中度的症状性冠状动脉疾病（coronary artery disease, CAD）患者。本研究检索了MEDLINE、Embase、MEDLINE加工中数据库、Cochrane系统综述数据库及Cochrane对照试验中心注册库，纳入1992年1月至2023年1月期间、基于英国、法国、德国、意大利、日本、中国或美国开展的研究（语言不限）。采用Drummond量表评估研究偏倚风险，最终纳入13篇相关报告。针对预测试概率为低至中度的CAD患者，美国的研究显示CMR相较MPS-SPECT始终具备成本效益，医疗资源消耗、相关成本及总成本均更低；欧洲地区的研究中，德国的结果显示CMR具备成本效益，而英国的研究则发现CMR可提升质量调整生命年，但成本节约情况存在差异。本综述仅检索到13篇探讨CMR相较MPS-SPECT经济学优势的报告，其中仅3篇提供了成本效益结局，凸显了在不同场景与研究视角下开展进一步研究的必要性。总体而言，研究结果表明，针对预测试概率为低至中度的CAD患者，使用CMR相较MPS-SPECT所带来的成本节约支持对其进行优先投入；但鉴于本综述中纳入的成本效益分析数量有限，仍需开展验证性研究。心脏及血管成像通常用于冠心病的诊断，近年来非侵入式检查技术不断进步，临床应用价值日益提升。全球临床指南普遍建议，影像检查的选择应基于患者的疾病发生风险高低，该风险即被称为患者的“预测试概率”。本综述对比了两种非侵入式检查手段：CMR成像与MPS-SPECT，从支付方视角分析二者的性价比。本次纳入的13项研究发表于2007年至2022年之间。针对预测试概率为低至中度的CAD患者，美国与德国的研究均显示CMR的性价比始终优于MPS-SPECT；在美国，CMR还可减少额外医疗资源的消耗。在英国，针对预测试概率为低、中或高度的CAD患者，CMR有时具备更优的性价比。总体而言，本综述支持在诊断预测试概率为低至中度的CAD患者时，选用CMR作为性价比更优的检查手段，医疗服务提供者与资金方在制定报销及投入决策时可参考该结论。但本综述纳入的研究数量有限，仍需开展更多相关研究。