Real-world clinical and cost analysis of CT coronary angiography and CT coronary angiography-derived fractional flow reserve (FFRCT)-guided care in the National Health Service

J. Graby; R. Metters; S. R. Kandan; D. McKenzie; R. Lowe; K. Carson; B. J. Hudson; J. C. L. Rodrigues

doi:10.1016/j.crad.2021.06.009

Real-world clinical and cost analysis of CT coronary angiography and CT coronary angiography-derived fractional flow reserve (FFR_CT)-guided care in the National Health Service

J. Graby, R. Metters, S. R. Kandan, D. McKenzie, R. Lowe, K. Carson, B. J. Hudson, J. C. L. Rodrigues

Department for Health

Royal United Hospitals Bath NHS Foundation Trust

Research output: Contribution to journal › Article › peer-review

9 Citations (SciVal)

Abstract

AIM: To quantify the real-world clinical and cost impact of computed tomography (CT) coronary angiography (CTCA)-derived fractional flow reserve (FFR_CT) in the National Health Service (NHS). MATERIALS AND METHODS: Consecutive clinical CTCA examinations from September to December 2018 with ≥1 stenosis of ≥25% underwent FFR_CT analysis. The Heart Team reviewed clinical data and CTCA findings, blinded to FFR_CT values, and documented hypothetical consensus management. FFR_CT results were then unblinded and hypothetical consensus management re-recorded. Diagnostic waiting times for management pathways were estimated. A per-patient cost analysis for diagnostic certainty regarding coronary artery disease (CAD) management was performed using 2014–2020 NHS tariffs for pre- and post-FFR_CT pathways. RESULTS: Two hundred and fifty-one CTCAs were performed during the study period. Fifty-seven percent (145/251) had no CAD or stenosis <25%. One study was non-diagnostic. Of the remaining 42% (105/251), two were ineligible for FFR_CT and there was a 5% (5/103) failure rate. FFR_CT led to a change in hypothetical management in 65% (64/98; p<0.001) patients with a functional imaging test cancelled in 17% (17/98) and a diagnostic angiogram cancelled in 47% (46/98). FFR_CT-guided management had a reduced mean time to definitive investigation compared with CTCA alone (28 ± 4 versus 44 ± 4 days; p=0.004). Using the proposed 2020/21 tariff, CTCA + FFR_CT for stenosis ≥50% resulted in a diagnostic pathway £44.97 more expensive per patient than usual care without FFR_CT. CONCLUSIONS: In the real-world NHS setting, FFR_CT-guided management has the potential to rationalise patient management, accelerate diagnostic pathways, and depending on the stenosis severity modelled, may be cost-effective.

Original language	English
Pages (from-to)	862.e19-862.e28
Journal	Clinical Radiology
Volume	76
Issue number	11
Early online date	11 Jul 2021
DOIs	https://doi.org/10.1016/j.crad.2021.06.009
Publication status	Published - 30 Nov 2021

Bibliographical note

Funding Information:
The authors acknowledge the support and contribution of all other members of the Heart Team (Consultant Cardiologists: Dr Richard Mansfield, Dr Jacob Easaw, Dr Daniel Augustine, Dr Antony French, Dr Anu Garg, Dr Ali Khavandi and Cardiology Senior Medical Nurse Practitioners: Samantha Jones, Dawn Ellis and Kady Parke) and all members of the cardiac CT team (Radiographers: Rachel Ferrington, Emma Forster, Carol Fievez, Hayley Loughrey, Emily Lawrence, Lizzie King, Alison Walker, Ian Loxley, Sarah Groves, Tina Weston, Judith Elford, Kathryn Forder, Hazel Rofe, David Ahmed, Patrick Richards, Emily Geraets, Katie Baker, Judith Orr, and Radiology Department Assistants: Sam Swift, Nicola Rudge, Natalie Ovens, Dominique Gage, Andy Davies, Mel Pozniakov, Tina Angell, Kirsty Horseman). We also thank Di Pressdee, CT/MR superintendent, and Rich Wood, PACS manager, for their input.

ASJC Scopus subject areas

Radiology Nuclear Medicine and imaging

Access to Document

10.1016/j.crad.2021.06.009

Cite this

Graby, J., Metters, R., Kandan, S. R., McKenzie, D., Lowe, R., Carson, K., Hudson, B. J., & Rodrigues, J. C. L. (2021). Real-world clinical and cost analysis of CT coronary angiography and CT coronary angiography-derived fractional flow reserve (FFR_CT)-guided care in the National Health Service. Clinical Radiology, 76(11), 862.e19-862.e28. https://doi.org/10.1016/j.crad.2021.06.009

Graby, J, Metters, R, Kandan, SR, McKenzie, D, Lowe, R, Carson, K, Hudson, BJ & Rodrigues, JCL 2021, 'Real-world clinical and cost analysis of CT coronary angiography and CT coronary angiography-derived fractional flow reserve (FFR_CT)-guided care in the National Health Service', Clinical Radiology, vol. 76, no. 11, pp. 862.e19-862.e28. https://doi.org/10.1016/j.crad.2021.06.009

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title = "Real-world clinical and cost analysis of CT coronary angiography and CT coronary angiography-derived fractional flow reserve (FFRCT)-guided care in the National Health Service",

abstract = "AIM: To quantify the real-world clinical and cost impact of computed tomography (CT) coronary angiography (CTCA)-derived fractional flow reserve (FFRCT) in the National Health Service (NHS). MATERIALS AND METHODS: Consecutive clinical CTCA examinations from September to December 2018 with ≥1 stenosis of ≥25% underwent FFRCT analysis. The Heart Team reviewed clinical data and CTCA findings, blinded to FFRCT values, and documented hypothetical consensus management. FFRCT results were then unblinded and hypothetical consensus management re-recorded. Diagnostic waiting times for management pathways were estimated. A per-patient cost analysis for diagnostic certainty regarding coronary artery disease (CAD) management was performed using 2014–2020 NHS tariffs for pre- and post-FFRCT pathways. RESULTS: Two hundred and fifty-one CTCAs were performed during the study period. Fifty-seven percent (145/251) had no CAD or stenosis <25%. One study was non-diagnostic. Of the remaining 42% (105/251), two were ineligible for FFRCT and there was a 5% (5/103) failure rate. FFRCT led to a change in hypothetical management in 65% (64/98; p<0.001) patients with a functional imaging test cancelled in 17% (17/98) and a diagnostic angiogram cancelled in 47% (46/98). FFRCT-guided management had a reduced mean time to definitive investigation compared with CTCA alone (28 ± 4 versus 44 ± 4 days; p=0.004). Using the proposed 2020/21 tariff, CTCA + FFRCT for stenosis ≥50% resulted in a diagnostic pathway £44.97 more expensive per patient than usual care without FFRCT. CONCLUSIONS: In the real-world NHS setting, FFRCT-guided management has the potential to rationalise patient management, accelerate diagnostic pathways, and depending on the stenosis severity modelled, may be cost-effective.",

author = "J. Graby and R. Metters and Kandan, {S. R.} and D. McKenzie and R. Lowe and K. Carson and Hudson, {B. J.} and Rodrigues, {J. C. L.}",

note = "Funding Information: The authors acknowledge the support and contribution of all other members of the Heart Team (Consultant Cardiologists: Dr Richard Mansfield, Dr Jacob Easaw, Dr Daniel Augustine, Dr Antony French, Dr Anu Garg, Dr Ali Khavandi and Cardiology Senior Medical Nurse Practitioners: Samantha Jones, Dawn Ellis and Kady Parke) and all members of the cardiac CT team (Radiographers: Rachel Ferrington, Emma Forster, Carol Fievez, Hayley Loughrey, Emily Lawrence, Lizzie King, Alison Walker, Ian Loxley, Sarah Groves, Tina Weston, Judith Elford, Kathryn Forder, Hazel Rofe, David Ahmed, Patrick Richards, Emily Geraets, Katie Baker, Judith Orr, and Radiology Department Assistants: Sam Swift, Nicola Rudge, Natalie Ovens, Dominique Gage, Andy Davies, Mel Pozniakov, Tina Angell, Kirsty Horseman). We also thank Di Pressdee, CT/MR superintendent, and Rich Wood, PACS manager, for their input. ",

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T1 - Real-world clinical and cost analysis of CT coronary angiography and CT coronary angiography-derived fractional flow reserve (FFRCT)-guided care in the National Health Service

AU - Graby, J.

AU - Metters, R.

AU - Kandan, S. R.

AU - McKenzie, D.

AU - Lowe, R.

AU - Carson, K.

AU - Hudson, B. J.

AU - Rodrigues, J. C. L.

N1 - Funding Information: The authors acknowledge the support and contribution of all other members of the Heart Team (Consultant Cardiologists: Dr Richard Mansfield, Dr Jacob Easaw, Dr Daniel Augustine, Dr Antony French, Dr Anu Garg, Dr Ali Khavandi and Cardiology Senior Medical Nurse Practitioners: Samantha Jones, Dawn Ellis and Kady Parke) and all members of the cardiac CT team (Radiographers: Rachel Ferrington, Emma Forster, Carol Fievez, Hayley Loughrey, Emily Lawrence, Lizzie King, Alison Walker, Ian Loxley, Sarah Groves, Tina Weston, Judith Elford, Kathryn Forder, Hazel Rofe, David Ahmed, Patrick Richards, Emily Geraets, Katie Baker, Judith Orr, and Radiology Department Assistants: Sam Swift, Nicola Rudge, Natalie Ovens, Dominique Gage, Andy Davies, Mel Pozniakov, Tina Angell, Kirsty Horseman). We also thank Di Pressdee, CT/MR superintendent, and Rich Wood, PACS manager, for their input.

PY - 2021/11/30

Y1 - 2021/11/30

N2 - AIM: To quantify the real-world clinical and cost impact of computed tomography (CT) coronary angiography (CTCA)-derived fractional flow reserve (FFRCT) in the National Health Service (NHS). MATERIALS AND METHODS: Consecutive clinical CTCA examinations from September to December 2018 with ≥1 stenosis of ≥25% underwent FFRCT analysis. The Heart Team reviewed clinical data and CTCA findings, blinded to FFRCT values, and documented hypothetical consensus management. FFRCT results were then unblinded and hypothetical consensus management re-recorded. Diagnostic waiting times for management pathways were estimated. A per-patient cost analysis for diagnostic certainty regarding coronary artery disease (CAD) management was performed using 2014–2020 NHS tariffs for pre- and post-FFRCT pathways. RESULTS: Two hundred and fifty-one CTCAs were performed during the study period. Fifty-seven percent (145/251) had no CAD or stenosis <25%. One study was non-diagnostic. Of the remaining 42% (105/251), two were ineligible for FFRCT and there was a 5% (5/103) failure rate. FFRCT led to a change in hypothetical management in 65% (64/98; p<0.001) patients with a functional imaging test cancelled in 17% (17/98) and a diagnostic angiogram cancelled in 47% (46/98). FFRCT-guided management had a reduced mean time to definitive investigation compared with CTCA alone (28 ± 4 versus 44 ± 4 days; p=0.004). Using the proposed 2020/21 tariff, CTCA + FFRCT for stenosis ≥50% resulted in a diagnostic pathway £44.97 more expensive per patient than usual care without FFRCT. CONCLUSIONS: In the real-world NHS setting, FFRCT-guided management has the potential to rationalise patient management, accelerate diagnostic pathways, and depending on the stenosis severity modelled, may be cost-effective.

AB - AIM: To quantify the real-world clinical and cost impact of computed tomography (CT) coronary angiography (CTCA)-derived fractional flow reserve (FFRCT) in the National Health Service (NHS). MATERIALS AND METHODS: Consecutive clinical CTCA examinations from September to December 2018 with ≥1 stenosis of ≥25% underwent FFRCT analysis. The Heart Team reviewed clinical data and CTCA findings, blinded to FFRCT values, and documented hypothetical consensus management. FFRCT results were then unblinded and hypothetical consensus management re-recorded. Diagnostic waiting times for management pathways were estimated. A per-patient cost analysis for diagnostic certainty regarding coronary artery disease (CAD) management was performed using 2014–2020 NHS tariffs for pre- and post-FFRCT pathways. RESULTS: Two hundred and fifty-one CTCAs were performed during the study period. Fifty-seven percent (145/251) had no CAD or stenosis <25%. One study was non-diagnostic. Of the remaining 42% (105/251), two were ineligible for FFRCT and there was a 5% (5/103) failure rate. FFRCT led to a change in hypothetical management in 65% (64/98; p<0.001) patients with a functional imaging test cancelled in 17% (17/98) and a diagnostic angiogram cancelled in 47% (46/98). FFRCT-guided management had a reduced mean time to definitive investigation compared with CTCA alone (28 ± 4 versus 44 ± 4 days; p=0.004). Using the proposed 2020/21 tariff, CTCA + FFRCT for stenosis ≥50% resulted in a diagnostic pathway £44.97 more expensive per patient than usual care without FFRCT. CONCLUSIONS: In the real-world NHS setting, FFRCT-guided management has the potential to rationalise patient management, accelerate diagnostic pathways, and depending on the stenosis severity modelled, may be cost-effective.

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