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Cost-effectiveness of presentation versus delayed troponin testing for acute myocardial infarction
Praveen Thokala1, Steve W Goodacre, Paul O Collinson
1School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK.
Insights
Delayed troponin testing for myocardial infarction is unlikely to be cost-effective. High-sensitivity troponin testing at presentation offers the most effective strategy for diagnosing heart attacks efficiently.
Area of Science:
- Cardiology
- Health Economics
Background:
- Myocardial infarction diagnosis relies on timely troponin testing.
- Current guidelines may not reflect the most cost-effective diagnostic strategies.
Purpose of the Study:
- To compare the cost-effectiveness of delayed troponin testing versus presentation troponin testing for myocardial infarction.
- To evaluate different troponin testing strategies within UK acute hospitals.
Main Methods:
- Decision analysis modelling was used to assess cost-effectiveness.
- Secondary data sources informed the model.
- Strategies included delayed troponin testing (10h), standard troponin, high-sensitivity troponin at presentation, and no testing.
Main Results:
- Presentation high-sensitivity troponin testing was the most effective strategy across scenarios, with an ICER below £20,000/QALY.
- Delayed troponin testing was only cost-effective under specific conditions (e.g., rapid discharge, higher willingness-to-pay).
- Sensitivity analysis confirmed presentation high-sensitivity troponin testing (at 3h) as the most cost-effective.
Conclusions:
- Delayed troponin testing is generally not cost-effective compared to presentation high-sensitivity troponin testing.
- Current NICE chest pain guidelines may not align with cost-effective myocardial infarction diagnosis.
Objectives:
To estimate the cost-effectiveness of delayed troponin testing for myocardial infarction compared with troponin testing at presentation.
Design:
Decision analysis modelling of cost-effectiveness using secondary data sources.
Setting:
Acute hospitals in the UK.
Population:
Patients attending hospital with suspected myocardial infarction but a normal or non-diagnostic ECG and no major comorbidities requiring admission.
Interventions:
Delayed troponin testing (10 h after symptom onset) compared with standard and high-sensitivity troponin testing at presentation and no testing. Sensitivity analysis evaluated high-sensitivity troponin testing 3 h after initial assessment.
Main Outcome Measures:
The incremental cost per quality-adjusted life year (QALY) gained by each strategy, compared with the next most effective alternative, and the probability of each strategy being cost-effective at varying willingness-to-pay per QALY gained.
Results:
In all scenarios tested, presentation high-sensitivity troponin testing was the most effective strategy with an incremental cost-effectiveness ratio below the £20 000/QALY threshold. 10 h troponin testing was only likely to be cost-effective if a discharge decision could be made as soon as a negative result was available and the £30 000/QALY threshold was used, or if a lower sensitivity estimate for presentation high-sensitivity troponin was assumed. Sensitivity analysis showed that including high-sensitivity troponin testing at presentation and 3 h in the analysis makes this the most cost-effective strategy.
Conclusions:
Delayed troponin testing is unlikely to be cost-effective compared with high-sensitivity troponin testing at presentation in most scenarios. Current NICE chest pain guidelines do not promote cost-effective care.
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