SHAPE Society

1. Cost Effectiveness of AtherosclerosisCost Effectiveness of Atherosclerosis
ScreeningScreening
Daniel B. Mark, MDDaniel B. Mark, MD
Duke Clinical Research InstituteDuke Clinical Research Institute
No relationships to discloseNo relationships to disclose

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

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

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

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

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

7. Cost Brings Discipline to the Practice of MedicineCost Brings Discipline to the Practice of Medicine

8. Choosing the Right Tool for the TaskChoosing the Right Tool for the Task

10. Impact of EBT on CV Risk Profile:Impact of EBT on CV Risk Profile:
Uniformed Services (Army) RCTUniformed Services (Army) RCT
• 450 consecutive Army personnel, age 39-45450 consecutive Army personnel, age 39-45
• Randomized to EBT & case managementRandomized to EBT & case management
(2 X 2 factorial)(2 X 2 factorial)
• 15% had coronary calcium, mean 10 yr15% had coronary calcium, mean 10 yr
Framingham risk 6%Framingham risk 6%
• Over 1 yr, EBT arm showed no change inOver 1 yr, EBT arm showed no change in
FRS relative to controlFRS relative to control
O’Malley P et al.O’Malley P et al.
JAMA 5/03JAMA 5/03

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

12. RCTs of Prevention with Statin Therapy:RCTs of Prevention with Statin Therapy:
Overview of 5-year Benefits and CostsOverview of 5-year Benefits and Costs
11º Preventionº Prevention
WOSCOPSWOSCOPS
AFCAPSAFCAPS
2º Prevention2º Prevention
CARECARE
4S4S
DeathsDeaths
55
44
1111
3232
MIsMIs
1919
2626
1818
4747
RevascsRevascs
88
3131
4747
5959
RxRx
$3700$3700
$4654$4654
$5550$5550
$4680$4680
OffsetOffset
↓↓$100$100
↓↓$524$524
↓↓$1660$1660
↓↓$3900$3900
NetNet
$3600$3600
$4130$4130
$3890$3890
$780$780
↓↓ per 1000 ptsper 1000 pts Costs per ptCosts per pt
Mark DB et al.Mark DB et al.
Circ 08/02Circ 08/02

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

14. Screening for Atherosclerosis:Screening for Atherosclerosis:
The Ultimate ParadoxThe Ultimate Paradox
““Everyone wants to go toEveryone wants to go to
heaven but no one wantsheaven but no one wants
to die.”to die.”

16. Identifying High Risk of Sudden Cardiac Death:Identifying High Risk of Sudden Cardiac Death:
A Screening ParadoxA Screening Paradox
0.2%
1.5%
5.0%
20.0%
25.0%
0%
5%
10%
15%
20%
25%
30%
300,000
200,000
150,000
100,000
30,000
0
75000
150000
225000
300000
375000
Gen H-Risk Hx of EF<30% OutptGen H-Risk Hx of EF<30% Outpt Gen H-Risk Hx ofGen H-Risk Hx of
EF<30% OutptEF<30% Outpt
Pop CAD MI CHF SCD sur Pop CAD MI CHF SCD surPop CAD MI CHF SCD sur Pop CAD MI CHF SCD sur
Incidence of SCD/yearIncidence of SCD/year Total events/yearTotal events/year