Risk stratification for coronary artery disease in multi-ethnic populations: Are there broader considerations for cost efficiency?

Figure 4 Theoretical Considerations for Future Cost-Efficiency. Three avenues for cost-efficacy analysis within a health cluster are identified. (1) Referral: the PTP gives a rough guide as to first choice of diagnostic test. High demand for evaluation raises an argument for observational studies for the best point of initial PTP work-up e.g. with GP supported education or early cardiology review; (2) Diagnostics: the combination of patient factors, cost and availability dictates stress echocardiography be the first choice of imaging modality, however more understanding of other modalities should also be encouraged; (3) Clinical Evaluation: this area is most likely to influence lifetime CAD cost-efficiency. Avenues to explore are: (a) patients and primary care preventive education after findings of minor CAD and/or with intermediate and high risk criteria factors; (b) patients at increased risk of recurrent chest pains and readmission e.g. vasospastic angina; (c) risk models for screening and follow-up of various ethnicities and demographies at different stages of epidemiological transition; (d) combinations of primary, specialist and tertiary care management models: the long term patient specific and health system goals once the work-up for CAD is initiated, aside from actual diagnosis of definite CAD, is prevention of disease progression or risk of future disease and preventing cost-ineffective utility of health resources especially unnecessary diagnostics and hospital beds. Physician Choice: includes any combination of investigation based on additional characteristics deemed to alter risk of accuracy of EST. Ca: Calcium; CAD: Coronary artery disease; CTCA: Computerized tomography coronary angiography; ESE/SE: Exercise stress echocardiography; PTP: Pretest probability; SPECT: Single photon emission computerized tomography.