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Cost Effectiveness of Atherosclerosis Screening Daniel B. Mark, MD

Cost Effectiveness of Atherosclerosis Screening Daniel B. Mark, MD Duke Clinical Research Institute No relationships to disclose. The 4 Major Attitudes About Screening for Atherosclerosis: The Cardiac Imaging Expert.

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Cost Effectiveness of Atherosclerosis Screening Daniel B. Mark, MD

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  1. Cost Effectiveness of Atherosclerosis Screening Daniel B. Mark, MD Duke Clinical Research Institute No relationships to disclose

  2. The 4 Major Attitudes About Screening for Atherosclerosis:The Cardiac Imaging Expert

  3. The 4 Major Attitudes About Screening for Atherosclerosis:The Practicing MD

  4. The 4 Major Attitudes About Screening for Atherosclerosis:The Patient

  5. The 4 Major Attitudes About Screening for Atherosclerosis: The Academic Professor

  6. Assessing the Economics of Screening for AtheroscerosisThe Two Key Questions • Is the test strategy good value for $ ? (Cost effectiveness) • Do we have the money to provide it for our pts? ($ in health care budget)

  7. Cost Brings Discipline to the Practice of Medicine

  8. Choosing the Right Tool for the Task

  9. Impact of EBT on CV Risk Profile:Uniformed Services (Army) RCT • 450 consecutive Army personnel, age 39-45 • Randomized to EBT & case management (2 X 2 factorial) • 15% had coronary calcium, mean 10 yr Framingham risk 6% • Over 1 yr, EBT arm showed no change in FRS relative to control O’Malley P et al. JAMA 5/03

  10. Uncoupling of Dx Testing and Outcome:How and Why? • Test provides “significant” new info that does not alter MD decision • MDs do not agree on how to use test results • Indicated therapy not sufficiently effective • Indicated therapy not applied effectively

  11. RCTs of Prevention with Statin Therapy:Overview of 5-year Benefits and Costs  per 1000 pts Costs per pt Deaths 5 4 11 32 MIs 19 26 18 47 Revascs 8 31 47 59 Rx $3700 $4654 $5550 $4680 Offset $100 $524 $1660 $3900 Net $3600 $4130 $3890 $780 1º Prevention WOSCOPS AFCAPS 2º Prevention CARE 4S Mark DB et al. Circ 08/02

  12. Atherosclerosis Imaging in Preventive Cardiology:Will It Break the Bank? The Tragedy of the Medical Commons • If each farmer grazes a few cattle, plenty of grass for all • If each farmer grazes as many cattle as possible, grass rapidly depleted

  13. Screening for Atherosclerosis:The Ultimate Paradox “Everyone wants to go to heaven but no one wants to die.”

  14. Identifying High Risk of Sudden Cardiac Death:A Screening Paradox Total events/year Incidence of SCD/year Gen H-Risk Hx of EF<30% Outpt Gen H-Risk Hx of EF<30% Outpt Pop CAD MI CHF SCD sur Pop CAD MI CHF SCD sur

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