Cost-effectiveness of presentation and delayed troponin testing for acute myocardial infarction
- Praveen Thokala1,
- Steve W Goodacre1,
- Paul O Collinson2,
- John W Stevens1,
- Nicholas L Mills3,
- David E Newby3,
- Francis Morris4,
- Jason Kendall5,
- Matt D Stevenson1
- 1School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
- 2Department of Chemical Pathology, St George's Hospital, London, UK
- 3University/British Heart Foundation Centre for Cardiovascular Science, Edinburgh, UK
- 4Sheffield Teaching Hospitals, Sheffield, UK
- 5North Bristol NHS Trust, Bristol, UK
- Correspondence to Professor Steve Goodacre, Professor of Emergency Medicine, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK;
Contributors PT created the decision analysis model and undertook the analysis. SG conceived and designed the study, and drafted the paper. JWS provided meta-analysis data and expert statistical input. PC provided expert clinical chemistry input. NM and DN provided expert cardiology input and outcome data. FM and JK provided expert emergency medicine input. MS provided expert modelling advice. All the authors contributed to redrafting the paper and approved the final draft. SG is guarantor for the paper.
- Accepted 3 July 2012
- Published Online First 3 August 2012
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.
- Myocardial infarction
- cardiac biomarkers
- quality of care and outcomes
- delivery of care
- myocardial ischaemia and infarction
- acute coronary syndrome
- natriuretic peptides
- troponin T
- coronary artery disease
- air pollution
- progenitor cells
- coronary angioplasty
- intravascular ultrasound
- coronary vasomotion
- endogenous fibrinolysis
- platelet activation
All authors, external and internal, had full access to all the data (including statistical reports and tables) in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis.
Funding The project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment (HTA) Programme (number 09/22/21) and sponsored by the University of Sheffield. The study funders had no role in study design; in the collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication. The researchers were independent of the study funders. The British Heart Foundation support NLM (FS/10/024) and DEN (CH/09/002).
Disclaimer The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR HTA.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.