{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,10]],"date-time":"2026-04-10T02:20:48Z","timestamp":1775787648636,"version":"3.50.1"},"reference-count":48,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"1","content-domain":{"domain":["www.ahajournals.org"],"crossmark-restriction":true},"short-container-title":["Circulation"],"published-print":{"date-parts":[[1995,1]]},"abstract":"<jats:p>\n            <jats:italic>Background<\/jats:italic>\n            To compare cost-effectiveness and utility of four clinical algorithms to diagnose obstructive coronary atherosclerotic heart disease (CAD), we compared exercise ECG (ExECG), stress single photon emission computed tomography (SPECT), positron emission tomography (PET), and coronary angiography.\n          <\/jats:p>\n          <jats:p>\n            <jats:italic>Methods and Results<\/jats:italic>\n            Published data and a straightforward mathematical model based on Bayes\u2019 theorem were used to compare strategies. Effectiveness was defined as the number of patients with diagnosed CAD, and utility was defined as the clinical outcome, ie, the number of quality-adjusted life years (QALY) extended by therapy after the diagnosis of CAD. Our model used published values for costs, accuracy, and complication rates of tests. Analysis of the model indicates the following results. (1) The direct cost (fee) for each test differs considerably from total cost per \u0394QALY. (2) As pretest likelihood of CAD (pCAD) in the population increases, there is a linear increase in cost per patient tested but a hyperbolic decrease in cost per effect and cost per utility unit, ie, increased cost-effectiveness and decreased cost per utility unit. (3) At pCAD&lt;0.70, analysis of the model indicates that stress PET is the most cost-effective test, with the lowest cost per utility, followed by SPECT, ExECG, and angiography, in that order. (4) Above a threshold value of pCAD of 0.70 (for example, middle-aged men with typical angina), proceeding directly to angiography as the first test showed the lowest cost per effect or utility. This quantitative model has the advantage of estimating a threshold value of pCAD (0.70) at which the rank order of cost-effectiveness and cost per utility unit change. The model also allows substitution of different values for any variable as a way to account for the uncertainties of clinical data, ie, changing costs, test accuracy and risk, etc. This procedure, called sensitivity analysis, showed that the rank order of cost-effectiveness did not change despite changes in several variables.\n          <\/jats:p>\n          <jats:p>\n            <jats:italic>Conclusions<\/jats:italic>\n            (1) Estimation of total costs of diagnostic tests for CAD requires consideration not only of the direct cost of the test per se (eg, test fees) but also of the indirect and induced costs of management algorithms based on the test (eg, cost\/\u0394QALY). (2) It is essential to consider the clinical history (pCAD) when selecting the clinical algorithm to make a diagnosis with the lowest cost per effect or cost per utility unit. (3) Stress PET shows the lowest cost per effect or cost per utility unit in patients with pCAD&lt;0.70. (4) Angiography shows the lowest cost per effect or cost per utility unit in patients with pCAD&gt;0.70.\n          <\/jats:p>","DOI":"10.1161\/01.cir.91.1.54","type":"journal-article","created":{"date-parts":[[2012,6,12]],"date-time":"2012-06-12T00:34:42Z","timestamp":1339461282000},"page":"54-65","update-policy":"https:\/\/doi.org\/10.1161\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":143,"title":["Comparison of Cost-Effectiveness and Utility of Exercise ECG, Single Photon Emission Computed Tomography, Positron Emission Tomography, and Coronary Angiography for Diagnosis of Coronary Artery Disease"],"prefix":"10.1161","volume":"91","author":[{"given":"Randolph E.","family":"Patterson","sequence":"first","affiliation":[{"name":"From the Carlyle Fraser Heart Center, Emory:Crawford Long Hospital, Department of Medicine, Division of Cardiology and Department of Radiology, Emory University School of Medicine, Atlanta, Ga, and Thomas Killip Division of Cardiology, Department of Medicine, Beth Israel Medical Center, Albert Einstein College of Medicine, New York, NY (S.F.H.)."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Robert L.","family":"Eisner","sequence":"additional","affiliation":[{"name":"From the Carlyle Fraser Heart Center, Emory:Crawford Long Hospital, Department of Medicine, Division of Cardiology and Department of Radiology, Emory University School of Medicine, Atlanta, Ga, and Thomas Killip Division of Cardiology, Department of Medicine, Beth Israel Medical Center, Albert Einstein College of Medicine, New York, NY (S.F.H.)."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Steven F.","family":"Horowitz","sequence":"additional","affiliation":[{"name":"From the Carlyle Fraser Heart Center, Emory:Crawford Long Hospital, Department of Medicine, Division of Cardiology and Department of Radiology, Emory University School of Medicine, Atlanta, Ga, and Thomas Killip Division of Cardiology, Department of Medicine, Beth Israel Medical Center, Albert Einstein College of Medicine, New York, NY (S.F.H.)."}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"276","reference":[{"key":"e_1_3_1_1_2","doi-asserted-by":"publisher","DOI":"10.1016\/0002-9149(82)90045-5"},{"key":"e_1_3_1_2_2","first-page":"579","volume":"32","year":"1991","unstructured":"Gould KL. PET perfusion imaging and nuclear cardiology. J Nucl Med. 1991;32:579-606.","journal-title":"J Nucl Med"},{"key":"e_1_3_1_3_2","doi-asserted-by":"publisher","DOI":"10.1056\/NEJM197507312930502"},{"key":"e_1_3_1_4_2","doi-asserted-by":"publisher","DOI":"10.1056\/NEJM197806012982204"},{"key":"e_1_3_1_5_2","doi-asserted-by":"publisher","DOI":"10.1056\/NEJM198811033191805"},{"key":"e_1_3_1_6_2","first-page":"1549","volume":"18","year":"1988","unstructured":"Ellwood P. Special Report: Shattuck Guest Lecture: Outcome management, a technology of patient experience. N Engl J Med. 1988;18:1549-1556.","journal-title":"N Engl J Med"},{"key":"e_1_3_1_7_2","doi-asserted-by":"publisher","DOI":"10.1016\/S0001-2998(78)80017-8"},{"key":"e_1_3_1_8_2","doi-asserted-by":"publisher","DOI":"10.1016\/S0735-1097(84)80214-4"},{"key":"e_1_3_1_9_2","first-page":"707","volume":"30","year":"1989","unstructured":"Gould KL, Goldstein RA, Mullani NA. Economic analysis of clinical positron emission tomography of the heart with rubidium-82. J Nucl Med. 1989;30:707-717.","journal-title":"J Nucl Med"},{"key":"e_1_3_1_10_2","first-page":"1893","volume":"31","year":"1990","unstructured":"Gleason JM, Frick M. The expected value of cash flows in the economic analysis of clinical positron emission tomography of the heart. J Nucl Med. 1990;31:1893-1894. Letter.","journal-title":"J Nucl Med"},{"key":"e_1_3_1_11_2","unstructured":"Weinstein MC Fineberg HV Elstein AS Frazier HS Heuhauser D Neutra RR McNeil BJ. Clinical Decisions and Limited Resources: Clinical Decision Analysis. Philadelphia Pa: WB Saunders; 1980:228-265."},{"key":"e_1_3_1_12_2","unstructured":"Sox HC Jr Blatt MA Higgins MC Martin KI. Medical Decision Making. Boston Mass: Butterworths; 1988:147-201 and 317-336."},{"key":"e_1_3_1_13_2","unstructured":"McKean R. Efficiency in Government Through Systems Analysis. New York NY: John Wiley & Son; 1958:21-96."},{"key":"e_1_3_1_14_2","doi-asserted-by":"publisher","DOI":"10.1016\/S0033-0620(78)80004-8"},{"key":"e_1_3_1_15_2","doi-asserted-by":"crossref","unstructured":"Kent KM Bentivoglio LG Block PS Bourassa MG Cowley MJ Dorros G Detre KM Gosselin AJ Gruentzig AR Kelsey SF Mock MB Mullin SM Passamani ER Myler RK Simpson J Stertzer SH Van Rader MJ Williams DO. Long term efficacy of percutaneous transluminal angioplasty (PTCA): report from the NHLBI registry. Am J Cardiol. 1984;53(suppl C):27C-31C.","DOI":"10.1016\/0002-9149(84)90741-0"},{"key":"e_1_3_1_16_2","doi-asserted-by":"publisher","DOI":"10.1161\/circ.77.4.2964948"},{"key":"e_1_3_1_17_2","doi-asserted-by":"crossref","unstructured":"Frye RL Frommer PL McCallum BD. Consensus development conference on coronary artery bypass: introduction. Circulation. 1982;65(suppl II):II-1-II-2.","DOI":"10.1161\/circ.65.7.6979423"},{"key":"e_1_3_1_18_2","unstructured":"Hurst JW King SB III. The prolongation of life by coronary bypass surgery: the Emory University Hospital experience. In: Hurst JW ed. The Heart: Bypass Surgery for Obstructive Coronary Disease Update II. New York NY: McGraw-Hill; 1980:141-150."},{"key":"e_1_3_1_19_2","doi-asserted-by":"crossref","unstructured":"Cosgrove DM Loop FD Sheldon WC. Results of myocardial revascularization: a 12-year experience. Circulation. 1982;65(suppl II):II-37-II-43.","DOI":"10.1161\/01.CIR.65.7.37"},{"key":"e_1_3_1_20_2","doi-asserted-by":"crossref","unstructured":"Hammermeister KE DeRouen TA Dodge HT. Comparison of survival of medically and surgically treated coronary disease patients in Seattle Heart Watch: a non-randomized study. Circulation. 1982;65(suppl II):II-53-II-59.","DOI":"10.1161\/01.CIR.65.7.53"},{"key":"e_1_3_1_21_2","unstructured":"Hall RJ Elayda MA Gray A Mathur VS Garcia E DeCastro CM Massumi A Cooley DA. Coronary artery bypass: long-term follow-up of 22 284 consecutive patients. Circulation. 1983;68(suppl II):II-20-II-26."},{"key":"e_1_3_1_22_2","doi-asserted-by":"publisher","DOI":"10.1056\/NEJM198411223112102"},{"key":"e_1_3_1_23_2","doi-asserted-by":"publisher","DOI":"10.1016\/0002-9149(87)90841-1"},{"key":"e_1_3_1_24_2","unstructured":"Varnauskas E European Coronary Surgery Study Group. Survival myocardial infarction and employment status in a prospective randomized study of coronary bypass surgery. Circulation. 1985;72(suppl V):V-90-V-101."},{"key":"e_1_3_1_25_2","unstructured":"Killip T Passamani E Davis K the CASS Principal Investigators and Their Associates. The Coronary Artery Surgery Study (CASS): a randomized trial of coronary bypass surgery: eight year follow-up and survival in patients with reduced ejection fraction. Circulation. 1985;72(suppl V):V-102-V-109."},{"key":"e_1_3_1_26_2","doi-asserted-by":"publisher","DOI":"10.1161\/circ.74.6.3536148"},{"key":"e_1_3_1_27_2","doi-asserted-by":"publisher","DOI":"10.1161\/circ.57.1.618399"},{"key":"e_1_3_1_28_2","doi-asserted-by":"publisher","DOI":"10.1016\/S0735-1097(86)80412-0"},{"key":"e_1_3_1_29_2","unstructured":"Lusted LB. Introduction to Medical Decision-Making. Springfield Ill: Charles C Thomas; 1968:1-46."},{"key":"e_1_3_1_30_2","first-page":"1350","volume":"30","year":"1979","unstructured":"Diamond GA, Forrester JS. Analysis of probability as an aid in the clinical diagnosis of coronary artery disease. N Engl J Med. 1979;30:1350-1358.","journal-title":"N Engl J Med"},{"key":"e_1_3_1_31_2","doi-asserted-by":"publisher","DOI":"10.1016\/0735-1097(89)90361-6"},{"key":"e_1_3_1_32_2","doi-asserted-by":"publisher","DOI":"10.1161\/circ.80.1.2661056"},{"key":"e_1_3_1_33_2","unstructured":"Beller GA. Diagnostic accuracy of thallium-201 myocardial perfusion imaging. Circulation. 1991;84(suppl I):I-1-I-6."},{"key":"e_1_3_1_34_2","doi-asserted-by":"publisher","DOI":"10.1016\/0002-9149(82)90036-4"},{"key":"e_1_3_1_35_2","doi-asserted-by":"publisher","DOI":"10.1378\/chest.83.1.112"},{"key":"e_1_3_1_36_2","doi-asserted-by":"publisher","DOI":"10.1161\/circ.77.2.3257422"},{"key":"e_1_3_1_37_2","doi-asserted-by":"publisher","DOI":"10.1016\/0735-1097(89)90385-9"},{"key":"e_1_3_1_38_2","first-page":"1168","volume":"31","year":"1990","unstructured":"Van Train KF, Maddahi J, Berman DS, Kiat H, Areeda J, Prigent F, Friedman J, and the Participants of the Multicenter Trial. Quantitative analysis of tomographic stress thallium-201 myocardial scintigrams: a multicenter trial. J Nucl Med. 1990;31:1168-1179.","journal-title":"J Nucl Med"},{"key":"e_1_3_1_39_2","doi-asserted-by":"publisher","DOI":"10.1016\/S0735-1097(10)80055-5"},{"key":"e_1_3_1_40_2","doi-asserted-by":"publisher","DOI":"10.1161\/circ.87.1.8419004"},{"key":"e_1_3_1_41_2","first-page":"1181","volume":"20","year":"1988","unstructured":"Tamaki N, Yonekura Y, Senda M, Yamashita K, Koide H, Saji H, Hashimoto T, Fudo T, Kambara H, Kawai C, Konishi J. Value and limitation of stress thallium-201 single photon emission computed tomography: comparison with nitrogen-13 ammonia positron tomography. J Nucl Med. 1988;20:1181-1188.","journal-title":"J Nucl Med"},{"key":"e_1_3_1_42_2","doi-asserted-by":"publisher","DOI":"10.1161\/circ.79.4.2784361"},{"key":"e_1_3_1_43_2","first-page":"845","volume":"30","year":"1989","unstructured":"Williams BR, Jansen DE, Wong LF, Fiedotin AF, Knopf WD, Toporoff SJ. Positron emission tomography for the diagnosis of coronary artery disease: a non-university experience and correlation with coronary angiography. J Nucl Med. 1989;30:845. Abstract.","journal-title":"J Nucl Med"},{"key":"e_1_3_1_44_2","first-page":"1899","volume":"31","year":"1990","unstructured":"Go RT, Marwick TH, MacIntyre WJ, Saha GB, Neumann DR, Underwood DA, Simpferdorfer CC. A prospective compari- son of rubidium-82 PET and thallium-201 SPECT myocardial perfusion imaging utilizing a single dipyridamole stress in the diagnosis of coronary artery disease. J Nucl Med. 1990;31:1899-1905.","journal-title":"J Nucl Med"},{"key":"e_1_3_1_45_2","doi-asserted-by":"publisher","DOI":"10.1016\/0002-9149(91)90456-U"},{"key":"e_1_3_1_46_2","first-page":"978","volume":"34","year":"1993","unstructured":"Garcia EV, Eisner RL, Patterson RE. What should we expect from cardiac PET? J Nucl Med. 1993;34:978-980.","journal-title":"J Nucl Med"},{"key":"e_1_3_1_47_2","unstructured":"Bruce RA Irving JB. Exercise electrocardiography. In: Hurst JW Logue RB Schlant RC Wenger NK eds. The Heart Arteries and Veins. 4th ed. New York NY: McGraw-Hill; 1978:336-348."},{"key":"e_1_3_1_48_2","doi-asserted-by":"publisher","DOI":"10.1007\/BF02575368"}],"container-title":["Circulation"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.ahajournals.org\/doi\/full\/10.1161\/01.CIR.91.1.54","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2024,5,12]],"date-time":"2024-05-12T15:45:09Z","timestamp":1715528709000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.ahajournals.org\/doi\/10.1161\/01.CIR.91.1.54"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[1995,1]]},"references-count":48,"journal-issue":{"issue":"1","published-print":{"date-parts":[[1995,1]]}},"alternative-id":["10.1161\/01.CIR.91.1.54"],"URL":"https:\/\/doi.org\/10.1161\/01.cir.91.1.54","relation":{},"ISSN":["0009-7322","1524-4539"],"issn-type":[{"value":"0009-7322","type":"print"},{"value":"1524-4539","type":"electronic"}],"subject":[],"published":{"date-parts":[[1995,1]]},"assertion":[{"value":"1994-03-04","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"1994-08-15","order":1,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"1995-01-01","order":2,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}]}}