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Cost-Effectiveness Analysis of Diagnostic Strategies for Suspected Pulmonary Embolism Including Helical Computed Tomography

Medical Clinic 1; Division of Medical and Surgical Emergencies; Division of Angiology and Hemostasis; Department of Internal Medicine, Division of Radiodiagnosis; and Department of Radiology, Geneva University Hospital, Geneva, Switzerland

Correspondence and requests for reprints should be addressed to Arnaud Perrier, M.D., Medical Clinic 1, Geneva University Hospital, 24, rue Micheli-du-Crest, CH-1211 Geneva 14, Switzerland. E-mail arnaud.perrier{at}medecine.unige.ch

We performed a formal decision analysis to evaluate the cost-effectiveness of various strategies for pulmonary embolism, including helical computed tomography (CT), and determined the most cost-effective schemes for each clinical probability of pulmonary embolism. Other tests included D-dimer (DD), lower limb venous ultrasound (US), ventilation–perfusion (/) scan, and angiography. Outcome measures were 3-month survival and costs per patient managed. Baseline sensitivity of CT was 70%, corresponding to the performance of single-detector CT, and that figure was raised in sensitivity analysis to account for the expected higher sensitivity of newer multidetector CT scanners. All strategies were compared with a reference strategy, namely the / scan in all patients followed when nondiagnostic by an angiogram. For low clinical probability patients, the most cost-effective strategy was DD, US, and / scan, patients with a nondiagnostic / scan being left untreated. Replacing / scan by CT was also cost-effective. For intermediate and high clinical probability patients, a fourth test must be added, either CT or angiography in patients with nondiagnostic / scan, or angiography in patients with a negative helical CT. When using sensitivity figures above 85% (in the multidetector range), DD, US, and CT became the most cost-effective strategy for all clinical probability categories. Helical CT as a single test was not cost-effective. In summary, including helical CT in diagnostic strategies for pulmonary embolism is cost-effective provided that it is combined with DD and US. In contrast, helical CT as a single test is not cost-effective.

Key Words: pulmonary embolism • fibrin fibrinogen degradation products • ultrasonography, doppler, duplex • tomography scanners, x-ray computed • cost-effectiveness analysis

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