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Assessing the cost effectiveness of using prognostic biomarkers with decision models: case study in prioritising
Martin Henriksson1, Stephen Palmer, Ruoling Chen
1Centre for Medical Technology Assessment, Linkoping University, Sweden.
Insights
Prioritizing patients for coronary artery bypass grafting using estimated glomerular filtration rate (eGFR) is cost-effective. This approach improves health outcomes and is more effective than informal prioritization methods.
Area of Science:
- Cardiovascular Medicine
- Health Economics
- Biomarker Research
Background:
- Patients with stable angina awaiting coronary artery bypass grafting (CABG) surgery require effective prioritization.
- Current informal prioritization methods may be suboptimal and potentially harmful.
Purpose of the Study:
- To evaluate the cost-effectiveness of using circulating biomarkers to guide CABG surgery prioritization.
- To compare biomarker-informed strategies against existing non-biomarker approaches.
Main Methods:
- A decision analytical model compared prioritization strategies with and without biomarkers.
- Included routinely assessed (eGFR) and novel (CRP) biomarkers.
- Analyzed data from the Swedish Coronary Angiography and Angioplasty Registry and meta-analyses.
Main Results:
- Prioritization using a risk score with eGFR was the most cost-effective strategy (cost per QALY < £410).
- This strategy yielded 800 QALYs per 100,000 patients at an additional NHS cost of £245,000.
- Strategies involving C-reactive protein (CRP) showed lower QALYs and higher costs.
Conclusions:
- Formal prioritization using routinely assessed biomarkers like eGFR is cost-effective for CABG waiting lists.
- Biomarker-based prioritization significantly improves upon informal methods.
- Relying solely on informal prioritization may negatively impact patient outcomes.
Objective:
To determine the effectiveness and cost effectiveness of using information from circulating biomarkers to inform the prioritisation process of patients with stable angina awaiting coronary artery bypass graft surgery.
Design:
Decision analytical model comparing four prioritisation strategies without biomarkers (no formal prioritisation, two urgency scores, and a risk score) and three strategies based on a risk score using biomarkers: a routinely assessed biomarker (estimated glomerular filtration rate), a novel biomarker (C reactive protein), or both. The order in which to perform coronary artery bypass grafting in a cohort of patients was determined by each prioritisation strategy, and mean lifetime costs and quality adjusted life years (QALYs) were compared.
Data Sources:
Swedish Coronary Angiography and Angioplasty Registry (9935 patients with stable angina awaiting coronary artery bypass grafting and then followed up for cardiovascular events after the procedure for 3.8 years), and meta-analyses of prognostic effects (relative risks) of biomarkers.
Results:
The observed risk of cardiovascular events while on the waiting list for coronary artery bypass grafting was 3 per 10,000 patients per day within the first 90 days (184 events in 9935 patients). Using a cost effectiveness threshold of pound20,000- pound30,000 (euro22,000-euro33,000; $32,000-$48,000) per additional QALY, a prioritisation strategy using a risk score with estimated glomerular filtration rate was the most cost effective strategy (cost per additional QALY was < pound410 compared with the Ontario urgency score). The impact on population health of implementing this strategy was 800 QALYs per 100,000 patients at an additional cost of pound 245,000 to the National Health Service. The prioritisation strategy using a risk score with C reactive protein was associated with lower QALYs and higher costs compared with a risk score using estimated glomerular filtration rate.
Conclusion:
Evaluating the cost effectiveness of prognostic biomarkers is important even when effects at an individual level are small. Formal prioritisation of patients awaiting coronary artery bypass grafting using a routinely assessed biomarker (estimated glomerular filtration rate) along with simple, routinely collected clinical information was cost effective. Prioritisation strategies based on the prognostic information conferred by C reactive protein, which is not currently measured in this context, or a combination of C reactive protein and estimated glomerular filtration rate, is unlikely to be cost effective. The widespread practice of using only implicit or informal means of clinically ordering the waiting list may be harmful and should be replaced with formal prioritisation approaches.
