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

Assessment of cost-effectiveness evidence–10-hour troponinAdmit toobservationarea/wardMeasure troponin10 hours after theworst pain~2 hours ornext roundReviewresultsnegativepositive~1 hourAdmit tohospitalTreatment~1 hourDischargeFIGURE 36 Ten-hour troponin diagnostic strategy.–Troponin and biomarkersMeasurebiomarkercombinationon arrival~2 hrs orbiomarker timeReviewresultsAll biomarkers negativeDischargeEither one/morebiomarkers positiveMeasure troponin10 hours after thearrival of worst pain~2 hrsReviewresultsTroponin positiveAdmit tohospitalAdmit to observationarea or hospital?Troponin negativeDischargeFIGURE 37 Combined biomarker and 10-hour troponin testing diagnostic strategies.Main analysis deterministic resultsThe main analysis compared the presentation troponin strategies in two different populations (no knownCAD and known CAD) and three different scenarios (doctor on demand, twice-daily ward round and oncedailyward round), so a total of six analyses are presented in Tables 40–45.For each scenario the table shows the total costs and total QALYs accrued by the population of 2240patients when each potential strategy is used. As expected, the effectiveness of the strategies (as measuredby the total QALYs) increases in accordance with the strategy sensitivity, whereas the cost of each strategyincreases as specificity decreases. The incremental cost-effectiveness ratio (ICER) reports the additionalcost required using the strategy to accrue one additional QALY compared with the next most effectivealternative. NICE decision-making suggests that a threshold of £20,000–30,000 per QALY is usuallyused, so if the ICER exceeds £20,000–30,000 per QALY then the strategy is unlikely to be consideredcost-effective.The analysis shows that the strategies based on presentation troponin are likely to be considered costeffectivecompared with no testing or the next most effective alternative. Of these strategies, the one usingpresentation HsTnT gains the most QALYs and still has an acceptable ICER, so it appears to be the optimalstrategy. In five out of six scenarios, the ICER for 10-hour troponin testing, compared with presentationHsTnT, exceeds £20,000–30,000 per QALY, so it is unlikely to be considered cost-effective. In onescenario (patients without known CAD and with doctor available on demand) the ICER for 10-hour TnT is90NIHR Journals Library