Systematic review, meta-analysis and economic modelling of ...

Assessment of cost-effectiveness evidencepatients managed in those locations, whereas patients with suspected ACS were likely to incur the sametrue costs regardless of their location within the hospital.The cost of index admission and treatment for MI and the costs of reinfarction were estimated as oneoffcosts of £3587, based on national tariff for non-elective acute MI without complications. Length ofhospital stay was determined from appropriate data sources, such as the RATPAC trial. 160Lifetime costs of survivors were estimated according to their age and sex, whether or not they had MI, andwhether or not they suffered reinfarction . The lifetime costs for MI patients are estimated using the annualcosts from Ward et al. 157 and the discounted life expectancy of patients with MI were captured fromPolanczyk et al. 156 The cost of reinfarction was estimated as a one-off cost of £3587, based on nationaltariff for non-elective acute MI without complications. 161 The costs are outlined in Tables 38 and 39.Modelling methodologyA model was developed using SIMUL8 software (SIMUL8 Corporation, Boston, MA, USA) to explore thecosts and health outcomes associated with different diagnostic strategies. The analysis was conducted forpatients aged 40–75 years when presenting to the ED. The model takes a lifetime horizon with mean lifeexpectancy based on UK interim lifetables. 158 The economic perspective of the model is the NHS in Englandand Wales with the structure of the model shown in Figure 35. Figure 36 shows the diagnostic pathwayassociated with the 10-hour troponin test in the model, whereas Figure 37 shows the pathway associatedwith the combination of presentation biomarkers and 10-hour troponin testing.Model stabilityThe number of model runs determines the accuracy of the results for estimating the optimal managementstrategy. This uncertainty is a result of the random nature of some events (reinfarction and death) andaccuracy can only be achieved by having sufficient numbers of model runs to account for these randomoccurrences. We ran the model 100 times to estimate the costs and QALYs along with their 95% CIs foreach diagnostic strategy.TABLE 38 Cost estimates used in the modelStrategy Source Estimate (£) 95% CI (£)Admission for MI or reinfarctiontreatmentHospital stay (per hour) for testingNHS reference costs 161 3587 3000 to 4000NHS reference costs for general medical 22 20 to 30ward 161Troponin RATPAC 160 20 18 to 25Other biomarkers RATPAC 160 20 18 to 25TABLE 39 Lifetime costs of patients with MIAge (years) MI cost (£)30–44 4012.545–54 311555–64 221565–74 1530> 75 80088NIHR Journals Library