Pulmonary embolism: v/q scanning combined with serial IPG was most cost-effective.

Clinical bottom line (level 1b)

  1. Of the options considered, ventilation-perfusion scanning followed by serial IPG if non-diagnostic, was the most cost-effective way of diagnosing pulmonary embolism.
Hull et al: Archives of Internal Medicine 1996; 156: 68-72
Expires October 2003

The study

cost-effectiveness analysis
Setting: six teaching hospitals, USA

decision-analysis of PIOPED study (prospective study of 662 patients (50% male; mean age 56) with suspected pulmonary embolism referred for ventilation-perfusion scan

  • Viewpoint: third party, eg. HMO or NHS purchaser
  • Benefit assessment: recurrent venous thromboembolism, bleeding or death
  • Resources and costs: from Midwest urban hospital: direct cost of investigations and treatment cost if a positive result
  • Sensitivity analysis: varied cost of hospital stay, investigations, prevalence of PE, false positives for ultrasound or IPG
    • Options considered:
      • 1.ventilation-perfusion scan; if non-diagnostic, pulmonary angiogram
      • 2. ventilation-perfusion scan; if non-diagnostic, had single ultrasound scan. If positive, anticoagulated. If negative had pulmonary angiogram
      • 3. ventilation-perfusion scan; if non-diagnostic, had single IPG scan. If positive, anticoagulated. If negative had pulmonary angiogram
      • 4. ventilation-perfusion scan; if non-diagnostic, had serial ultrasound scan if good cardiopulmonary reserve. If poor cardiopulmonary reserve, had a pulmonary angiogram
      • 5. ventilation-perfusion scan; if non-diagnostic, had serial IPG if good cardiopulmonary reserve. If poor cardiopulmonary reserve, had a pulmonary angiogram

    The evidence

    intervention cost
    1. v/q scan alone: cost per patients requiring treatment (US $) 14421
    1. v/q scan alone: cost per patient correctly withheld treatment (US $) 5978
    2. single ultrasound scan: cost per patient requiring treatment (US $) 14407
    2. single ultrasound scan: cost per patient correctly withheld treatment (US $) 6016
    3. single IPG: cost per patient requiring treatment (US $) 14047
    3. single IPG: cost per patient correctly withheld treatment (US $) 5865
    4. serial ultrasound scans: cost per patient requiring treatment (US $) 13842
    4. serial ultrasound scans 4745
    5. serial IPG: cost per patient requiring treatment (US $) 12639
    5. serial IPG: cost per patient correctly withheld treatment (US $) 4333

    Effect of sensitivity analysis: IPG remained most cost-effective following the sensitivity analysis. Other rankings varied according to the costs of investigation or treatment.

    Comments

    1. The authors did not look at venography, CT scanning or MRI as alternatives to serial IPG.

    Citation

    1. Hull RD, Feldstein W, Stein PD, et al: Cost-effectiveness of pulmonary embolism diagnosis. Archives of Internal Medicine 1996; 156: 68-72
    Contributor: Chris Ball and Clare Wotton, October 2000
    Reviewer:

    Clinical Question.
    Patient suspected pulmonary embolism
    Intervention or Exposure various diagnostic tests
    Outcome most cost-effective