The authors of this article make several discrete claims regarding the utility of coronary CT angiography – simply stated right in the title of the article: “Routine coronary computed tomographic angiography reduces unnecessary hospital admissions, length of stay, recidivism rates, and invasive coronary angiography in the Emergency Department triage of chest pain”. And, essentially all the assertions made in this observational, retrospective review are suspect.
Reduces unnecessary hospital admissions:
The article in no fashion addresses “unnecessary” hospital admissions. After all, of their selected cohort of patients, a tiny fraction – 9 of 1,788 – ruled-in for acute MI. A total of 42 underwent revascularization, but this is a measure reflecting only the aggressiveness of their local cardiology groups. It would seem the real problem regarding “unnecessary” admissions is an inability to select patients with appropriate clinical probability for further evaluation.
Reduces length of stay:
There is a less than 1 hour reduction in length of stay only for discharged ED patients. A true accounting of the LOS and congestion of chest pain patients ought to include admitted patients who depart the ED for their hospital observation bed soon after their initial biomarker result – but that would probably make their overall result contrary to their chosen narrative. The reduction in length of stay is also influenced by the authors exclusion of patients who had ED LOS less than 3 hours – as the authors simply decide no adequate evaluation of low-risk chest pain patients could be performed in that timeframe.
Reduces recidivism rates:
The reduction in recidivism rates may have reached statistical significance, but the absolute difference was only 20 patients, most of whom were discharged from the Emergency Department.
Reduces invasive coronary angiography:
There is a reduction in coronary angiography – mostly, from what I can tell, in that the handful of patients with multi-vessel disease detected on CCTA were referred to CABG, and the use of invasive coronary angiography was obviated. The absolute difference was only 19 angiography episodes – an avoidance of a handful of $2000-$3000 procedures at the cost of nearly a thousand $700-$1200 CCTAs.
Finally, their abstract conclusion claims it reduces healthcare resource utilization:
The authors never explicitly define this endpoint – which is probably for the best, as I count 960 non-invasive and 8 invasive tests in their CCTA cohort versus 368 non-invasive and 27 invasive tests in their “standard evaluation” cohort. The admission rate, however, is more than halved from 40% to 14%. A reduction in resource utilization would be contrary to general consensus from trials of CCTA versus standard care.
Most disturbingly, this article reports “Disclosures: none”. However, a simple internet search reveals multiple authors having prior relationships with Siemens and GE Healthcare. Perhaps by some narrowest definition this isn’t untruthful, but it is certainly misleading.
“Routine coronary computed tomographic angiography reduces unnecessary hospital admissions, length of stay, recidivism rates, and invasive coronary angiography in the Emergency Department triage of chest pain”
http://www.ncbi.nlm.nih.gov/pubmed/23684682