Rationale and Objectives
The aims of the study were: 1) to assess the baseline health-related quality of life (HRQOL) of patients with coronary artery disease (CAD) using the standard gamble; 2) to evaluate and compare patients’ preference for catheter versus computed tomography (CT) coronary angiography using the wait tradeoff (WTO) and rating scales; and 3) to calculate test disutility for catheter and CT coronary angiography.
Materials and Methods
Thirty patients with CAD who underwent both CT and catheter angiography were interviewed by telephone within 6 months of testing. Patients were asked about their baseline symptoms and quality of life, their experience preparing for both CT and catheter angiography, their desire to undergo CT or catheter angiography, and immediate treatment versus having a waiting period between test results and treatment for a hypothetical “ideal test” with no side effects. Test disutility for CT and catheter angiography were calculated and compared.
Results
The mean and median baseline HRQOL utility values were 0.72 and 0.91. The patients were willing to wait a mean (median) time of 12 (3) days after the ideal test for the test results to avoid undergoing CT angiography. They were willing to wait a mean (median) of 7 (3) days after the ideal test for test results, to avoid undergoing catheter angiography. There was no significant difference between waiting times or between patients’ rating for their experience preparing for the two tests. Test disutility for CT angiography was 1.30 quality-adjusted life days (QALD) versus 2.16 QALD for catheter angiography ( P > .05).
Conclusion
There was no significant difference in patient preference and test disutility between CT and catheter angiography in our small series. Future rigorously planned and adequately powered studies are required to confirm these findings in larger patient populations.
Coronary computed tomography angiography (CCTA) is a relatively new imaging technique for the diagnosis of coronary artery disease (CAD). Compared to catheter coronary angiography (CCA), which is the gold standard for diagnosing CAD, CCTA is less invasive and has a lower complication rate , with reported sensitivities of 98% to 100% and specificities of 82% to 89% . In the emergency room setting, CCTA has been shown to save cost when used in the workup of low- and intermediate-risk patients with chest pain with negative serial enzymes in the absence of electrocardiogram changes to indicate ischemia.
Both CCA and CCTA have associated morbidity that may adversely affect the short-term quality of life of patients, which may impact patient preferences for a specific test. For example, catheter angiography can be associated with pain, discomfort, and restricted activity during and after the procedure . For CCA and CCTA, medications are administered such as nitroglycerin usually for both, and a beta-blocker or other heart rate–lowering medication for CCTA before the exam is performed; patients have to hold their breath for a short time during contrast administration, and particularly with CCTA because of the peripheral venous injection, may feel flushed and warm after the injection of contrast material, or for either test, experience a contrast reaction.
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Methods
Patient Selection
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Baseline HRQOL Utility Values in Patients with CAD
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Patient Preference for CCTA versus CCA
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WTO
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DRS
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Measuring Test Disutility
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Statistical Analyses
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Results
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Table 1
Patient Profile: Symptoms and Treatment
Category Number (%) of Patients Total number of patients 30 Confirmed coronary artery disease 23 (77) Reason for referral Historical finding Hypertension 14 (47) Hyperlipidemia 16 (53) Diabetes Mellitus 6 (20) Cardiomyopathy 2 (7) Percutaneous coronary intervention 2 (7) Valve disease/surgery 5 (17) Coronary artery bypass grafting 5 (17) Positive findings on other tests 8 (27) Current symptoms None 4 (13) Chest pain 17 (57) Shortness of breath 7 (23) Atypical or noncardiac chest pain 3 (10) Fatigue 5 (17) Palpitations 2 (7) Treatment history Lifestyle changes 22 (73) Cholesterol-lowering medication 10 (33) Antihypertensive medication 8 (27) Angiotensin-converting enzyme inhibitors 7 (23) Platelet inhibitors 9 (30) Nitrates 2 (7) Beta-blockers 8 (27) Calcium channel blockers 3 (10) Anticoagulants 4 (13) Percutaneous coronary intervention: stenting 1 (3) Percutaneous coronary intervention: angioplasty 4 (13) Bypass grafting 4 (13) Valve surgery 3 (10) Other 5 (17) Autoimplantable cardiodefibrillator insertion 1 (3) Embolization right coronary artery to atrial fistula 1 (3) Permanent pacemaker insertion 3 (10)
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Table 2
Patient Preference: Comparison of Catheter Angiography and CT Angiography, Wait Tradeoff and Direct Rating Scale
Catheter Angiography CT Angiography_P_ Value ∗ Wait time, mean ± SD (median) 7 ± 10 (3) 12 ± 16 (3) .26 Rating scale score, mean ± SD (median) † −4.1 ± 2.5 (−4.5) −3.4 ± 2.0 (−3) .42 Disutility (based on population utility values) in QALD 0.84 1.44 .26 Disutility (based on our study utility values) in QALD 1.30 2.16 .29
CT, computed tomography; QALD, quality-adjusted life days; SD, standard deviation.
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Table 3
Correlation Coefficients for WTO Results and DRS Scores
Catheter Angiography WTO CT Angiography WTO Catheter Angiography DRS CT angiography WTO 0.77 ( P < .001) NA Catheter angiography DRS −0.38 ( P = .04) −0.31 ( P = .08) NA CT angiography DRS 0.0 ( P = .71) 0.12 ( P = .51) 0.002 ( P = .99)
CT, computed tomography; DRS, direct rating scale; NA, not available; WTO, wait-tradeoff.
P values = Spearman coefficient.
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Discussion
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Limitations
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Implications
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Acknowledgment
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Appendix 1
Patient Preferences Survey Instrument
Paper standard gamble
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Appendix 2
Patient Preferences Survey Instrument
WTO (Wait-Tradeoff)
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Computed tomography coronary angiography version
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Cardiac catheterization version
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Appendix 3
Patient Preferences Survey Instrument
Direct rating scale
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CT coronary angiography
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10987654321Most negative experienceOptimal health 10
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Optimal health
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Direct rating scale
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Catheter angiography
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10987654321Most negative experienceOptimal health 10
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Optimal health
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