관동맥 질환에서 심근 SPECT 의 비용효과

1. 관동맥 질환에서 심근 SPECT의 비용효과 영남대학교 부속병원 핵의학과 조 인 호

2. 건강관리 비용 • 새로운 기술의 발달로 계속 증가 • 전세계의 보건정책 • 질병관리에 드는 비용의 절감 • 비용효과 • 치료 결정에 도움을 주어 환자의 예후를 좋게 할 수 있는 다른 검사들과 비교했을 때, 보다 작은 비용으로 얼마나 많고, 정확한 정보를 제공하는가 ?

3. 심근 SPECT • 관동맥질환의 진단과 예후판정 • 환자의 병력과 운동부하 심전도검사 보다 15-30% 정도 더 높은 정확성 • 게이트 심근 SPECT • 심근관류 검사와 동시에 심근기능평가

4. Incremental prognostic information provided by clinical, exercise, catheterization, and SPECT variables, shown by global Chi square. Iskandrian AS, et al; J Am Coll Cardiol 1993;22:665-670

5. 정상 관류 SPECT • 심장 사건 발생률 : 연간 1% 이하 • 저위험군으로 분류 • 더 이상의 검사는 불필요

6. 심근관류 결손 • 가역적이거나 비가역적 심근관류결손 • 강력한 예후 결정인자 • 관류결손의 크기와 정도 • 심장사건과 비례

7. Annual rates of cardiac death or myocardial infarction by extent and severity of stress myocardial perfusion SECT defect (data from the TriCOR foundation study, N=20,340)

8. 게이트 심근 SPECT • 심근기능의 평가 • 심박출 계수, 심실벽운동 분석, 좌심실 확장기말과 수축기말 용적 • 위험인자 • 부하 후 심실기능저하 • 국소 심근 운동 이상 • 낮은 심박출계수

9. Meta-analysis of the prognostic value of gated and first-pass radionuclide angiography: relationship between peak exercise left ventricular ejection fraction (LVEF) and cardiac outcomes (cardiac death or myocardial infarction).

10. Specificities for detection of CAD using Tl-201 SPECT, Tc-99m MIBI SPECT, and Tc-99m MIBI SPECT with gating. Taillerfer R, et al; J Am Coll Cardiol 1997;29(1):69-77

11. 검사의 이득 • True measure of test • 새로운 정보의 양 • Economic efficiency • Cost per % of new information

12. 환자의 병력 및 운동부하 심전도검사 • 저비용 • 작은 정보 • 심근 SPECT • 비싼 검사비용 • 많은 정보 • Lower cost to achieve a unit of new information

13. 심근 SPECT • 우리나라 현행 수가체계에서 그 자체 또는 운동부하 심전도와 조합 하였을 때 • 검사 전 유병률이 작거나 (0.1이하) 또는 중등도이었을 때 (0.2 – 0.6 까지) 비용효과면에서 가장 우수하다. Lee DS et al; Korean J Nucl Med 2000;34:207-221

14. Cost/QALY of the four diagnostic tactics. Lee DS et al; Korean J Nucl Med 2000;34:207-221

15. 건강관리비용의 사용 • 미국에서 관동맥질환과 관련하여 사용된 비용 : 연간 2,840억 달러 • 진단검사에 든 비용 : 49 % • 진단적인 관동맥 조영술 : 약110만회 • 심근 SPECT : 약 4백만회 • 운동부하 심전도 검사 : 약 6백만회 • 부하심초음파 : 약 75만회 • 진단 검사의 연간 증가율 • 7-12 %

16. Major cardiac services • Estimated overuse ; 23 % • Overuse of cardiac catheterization : 17% • Greater hospital cost • Greater procedural cost

17. 비용효율 • 검사 후 계속되는 치료의 비용효과 • 검사의 정확성 • 검사비용 • 직접적인 건강개선 효과 • 검사과정으로 초래되는 비용

18. 심근 SPECT ; • 최소의 비용으로 환자 관리방법의 최적화 • 적절한 검사방법의 선택 • 비싼 검사와 치료 빈도 감소 • Identification and early treatment of risk

19. In emergency room • Lower cost venues • Outpatient setting • Evaluation of suspected coronary artery disease • Further testing at positive or nondiagnostic exercise test • Reduce the rate of cardiac catheterization

20. Cost effectiveness of myocardial SPECT in emergency department • Decrease unnecessary hospital admissions in patients with chest pain of nonncardiac origin • High negative predictive value for ruling out the diagnosis of acute cardiac ischemia • Lower the number of patients mistakenly sent home from the ED who have active ischemia or infarction • Reduce missed infarction rate (from 1.8% to 0.1%) • Ziffer J, et al; J Nucl Med 1998;39(5)139P. Abstract

21. Admission to CCUs ultimately not to have acute cardiac ischemia • More than 750,000 patients per year • Weissman et al. • Change treatment strategy : 34/50 patients • Discharge 29 patients • Cost saving = $ 786 per patient • Radensky et al. • Scan strategy in ER with chest pain but nondiagnostic ECGs • Cost saving = $ 900 per patient

22. Overuse of cardiac catheterization : 17% • Greater hospital cost • Greater procedural cost

23. Cost effectiveness of preoperative screening prior to vascular surgery • More advantageous in patients with intermediate pretest probability of CAD • Symptomatic or have a prior CAD history

24. Median Cost/strategy $23,351 $24,826 $27,760 Lower Range $22,967 $24,123 $26,972 Upper Range $24,058 $26,978 $33,930 Routine Screening (% Difference) + 5.9 +15.9 Comparative analysis of preoperative screening strategies. No preoperative Screening Pharmacologic series Imaging Cardiac Catheterization

25. Does Myocardial SPECT of stable angina patients reduce the cost of care compared to direct catheterization? • Comparative costs (1) Direct catheterization strategy (2) Myocardial imaging with selective catheterization screening strategy • Substantial reduction (31-50%) in (2) • Both diagnostic and follow-up costs Shaw LJ, et al; J Am Coll Cardiol 1999;33:661-9

26. Overall diagnostic and follow-up costs of care for direct catheterization and initial stress perfusion imaging are presented. Diagnostic and follow-up costs of care were 30% to 41% higher for patients undergoing direct catheterization. Solid bars = diagnostic cost; open bars = follow-up cost.

27. Rates of cardiac death or myocardial infarction (MI) and coronary revascularization (Revasc) by pretest clinical risk subsets of low, intermediate (Int) and high risk patients. The rates of 1 reversible perfusion defect and cardiac catheterization rates for patients undergoing a noninvasive diagnostic strategy are presented for low, Int, and high risk patients.

28. Threshold for economic efficiency • $ 50,000 / life year saved • Cost effective in stable angina patients • 9,791patients enrolled from 7 hospitals • Intermediate-risk patient • Symptomatic elderly patients • (I.e., age  65 years) • Low-, intermediate- and high-risk patients Shaw LJ, et al; Am Coll Cardiol 1997;29(2 suppl A);137A. abstract

29. Cost effectiveness of stress myocardial perfusion imaging in the economics of noninvasive diagnosis study population. Pretest Cardiac Risk Low Intermediate High Annual Cardiac Death 0.5% 1.5% 4.0% CEA All >$250,000 $29,000 $53,000 Elderly $35,000 $23,000 $43,000 Shaw LJ, et al; Am Coll Cardiol 1997;29(2 suppl A);137A. abstract

30. 심근 SPECT • Identify low-cost patient • Patients with no ischemia • 60 – 80 % of patients with suspected coronary disease • Acute setting • Negative perfusion scan ; 90 % • Limit hospital admission • Identify risk • Early treatment – clinical benefit – improved survival