Cost-Effectiveness of Follow-Up of Pulmonary Nodules Incidentally Detected on Cardiac CT Angiography in Patients with Suspected Coronary Artery Disease
Background—Pulmonary nodules (PN) are often incidentally detected during coronary CT angiography (CCTA) which is increasingly used to evaluate patients with chest pain symptoms. However, the efficiency of following up on incidentally detected PN is unknown.
Methods and Results—We determined demographic and clinical characteristics of stable symptomatic patients referred for CCTA in whom incidentally detected PN warranted follow-up. A validated lung cancer simulation model was populated with data from these patients and clinical and economic consequences of follow-up per Fleischner guidelines versus no follow-up were simulated. Of the 3,665 patients referred to CCTA, 591 (16%) had PN requiring follow-up. Mean age of patients with PN was 59±10 years, 66% were male, 67% had ever smoked, and 21% had obstructive CAD. The projected overall lung cancer incidence was 5.8% in these patients, but the majority died from CAD (38%) and other causes (57%). Follow-up of PN was associated with a 4.6% relative reduction in cumulative lung cancer mortality (absolute mortality:FU: 4.33% vs. non-FU: 4.54%), more downstream testing (FU: 2.34 CTs/patient vs. non-FU: 1.01 CTs/patient), and an average increase of quality-adjusted life of seven days. Costs per quality adjusted life year (QALY) gained were $154,700 to follow-up the entire cohort and $129,800/QALY when only smokers were included.
Conclusions—Follow-up of PN incidentally detected in patients undergoing CCTA for chest pain evaluation is associated with a small reduction in lung cancer mortality. However, significant downstream testing contributes to limited efficiency as demonstrated by a high cost per QALY, especially in non-smokers.
- computed tomography angiography
- computer-based model
- comparative effectiveness
- health policy and outcomes research
- Received November 20, 2013.
- Revision received May 9, 2014.
- Accepted June 6, 2014.