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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
DOI: 10.3310/hta17010 Health Technology Assessment 2013 Vol. 17 No. 1TABLE 40 Cost-effectiveness of presentation troponin testing strategies: population without known CAD, doctoron-demandscenarioStrategy Total costs, £ (95% CI) Total QALYs (95% CI) ICER (£/QALY)No testing 965,994 (957,259 to 974,730) 26,226.68 (26,196.77 to 26,256.60) –Presentation TnT,10% CVPresentation TnT,99th percentilePresentation HsTnT,99th percentile10-hour troponintest1,560,351 (1,548,935 to 1,571,768) 26,344.84 (26,317.49 to 26,374.19) 50301,609,760 (1,597,955 to 1,621,564) 26,352.42 (26,323.70 to 26,382.13) 65181,806,910 (1,794,447 to 1,819,373) 26,378.75 (26,350.16 to 26,406.94) 74872,016,540 (2,004,601 to 2,028,749) 26,386.36 (26,358.57 to 26,414.16) 27,546TABLE 41 Cost-effectiveness of presentation troponin testing strategies: population without known CAD, twice-dailyward round scenarioStrategy Total costs, £ (95% CI) Total QALYs (95% CI) ICER (£)No testing 965,994 (957,259 to 974,730) 26,226.68 (26,196.77 to 26,256.60) –Presentation TnT,10% CVPresentation TnT,99th percentilePresentation HsTnT,99th percentile10-hour troponintest1,595,955 (1,584,418 to 1,607,492) 26,344.84 (26,317.49 to 26,374.19) 53311,655,424 (1,653,855 to 1,676,933) 26,352.42 (26,323.70 to 26,382.13) 78451,936,718 (1,924,723 to 1,948,713) 26,378.75 (26,350.16 to 26,406.94) 10,6832,416,409 (2,404,435 to 2,428,383) 26,386.36 (26,358.57 to 26,414.16) 63,034TABLE 42 Cost-effectiveness of presentation troponin testing strategies: population without known CAD, once-dailyward round scenarioStrategy Total costs, £ (95% CI) Total QALYs (95% CI) ICER (£/QALY)No testing 965,994 (957,259 to 974,730) 26,226.68 (26,196.77 to 26,256.60) –Presentation TnT,10% CVPresentation TnT,99th percentilePresentation HsTnT,99th percentile10-hour troponintest1,621,152 (1,609,727 to 1,632,576) 26,344.84 (26,317.49 to 26,374.19) 55441,705,989 (1,694,089 to 1,717,888) 26,352.42 (26,323.70 to 26,382.13) 11,1922,030,901 (2,018,511 to 2,043,290) 26,378.75 (26,350.16 to 26,406.94) 12,3402,705,696 (2,693,761 to 2,717,630) 26,386.36 (26,358.57 to 26,414.16) 88,672© Queen’s Printer and Controller of HMSO 2013. This work was produced by Goodacre et al. under the terms of a commissioning contract issued by the Secretary of Statefor Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journalsprovided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should beaddressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton SciencePark, Southampton SO16 7NS, UK.91
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Health Technology AssessmentVOLUME
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DOI: 10.3310/hta17010 Health Techno
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ContentsAppendix 5 Expected discoun
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BackgroundTABLE 1 Hospital admissio
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Background2. investigation of the c
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BackgroundComputed tomographic coro
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Research questionsiii. the diagnost
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Assessment of diagnostic and progno
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Page 128 and 129: Discussionspecificity were 62% (95%
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Appendix 9Clinical diagnosis of NST
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Appendix 9respectively. Exercise EC
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Appendix 93. Two reviewers will mak
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Appendix 9The methodology used in t
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Appendix 9ES (Information Resources
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Appendix 923. Westwood ME, Whiting
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