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

More documents

Recommendations

Info

Assessment of cost-effectiveness evidenceTABLE 43 Cost-effectiveness of presentation troponin testing strategies: population with known CAD, doctoron-demandscenarioStrategy Total costs, £ (95% CI) Total QALYs (95% CI)ICER(£/QALY)No testing 895,440 (887,764 to 903,117) 20,122.36 (20,098.26 to 20,146.46) –Presentation TnT, 10% CV 1,526,705 (1,515,468 to 1,537,942) 20,221.03 (20,196.30 to 20,243.76) 6397Presentation TnT, 99thpercentilePresentation HsTnT, 99thpercentile1,580,066 (1,569,186 to 1,590,946) 20,229.36 (20,205.28 to 20,253.43) 64051,791,928 (1,780,253 to 1,803,603) 20,249.14 (20,224.45 to 20,273.83) 10,71010-hour troponin test 2,024,269 (2,012,991 to 2,035,547) 20,255.68 (20,230.45 to 20,280.91) 35,526TABLE 44 Cost-effectiveness of presentation troponin testing strategies: population with known CAD, twice-dailyward round scenarioStrategy Total costs, £ (95% CI) Total QALYs (95% CI)ICER(£/QALY)No testing 895,440 (887,764 to 903,117) 20,122.36 (20,098.26 to 20,146.46) –Presentation TnT, 10% CV 1,565,347 (1,553,759 to 1,576,935) 20,221.03 (20,196.30 to 20,243.76) 6790Presentation TnT, 99thpercentilePresentation HsTnT, 99thpercentile1,634,789 (1,623,585 to 1,645,992) 20,229.36 (20,205.28 to 20,253.43) 83361,923,076 (1,911,130 to 1,935,023) 20,249.14 (20,224.45 to 20,273.83) 14,57510-hour troponin test 2,423,332 (2,412,088 to 2,434,575) 20,255.68 (20,230.45 to 20,280.91) 76,492TABLE 45 Cost-effectiveness of presentation troponin testing strategies: population with known CAD, once-daily wardround scenarioStrategy Total costs, £ (95% CI) Total QALYs (95% CI)ICER(£/QALY)No testing 895,440 (887,764 to 903,117) 20,122.36 (20,098.26 to 20,146.46) –Presentation TnT, 10% CV 1,591,876 (1,580,221 to 1,603,532) 20,221.03 (20,196.30 to 20,243.76) 7058Presentation TnT, 99thpercentilePresentation HsTnT, 99thpercentile1,671,994 (1,662,038 to 1,683,950) 20,229.36 (20,205.28 to 20,253.43) 96182,012,040 (1,999,995 to 2,024,084) 20,249.14 (20,224.45 to 20,273.83) 17,19110-hour troponin test 2,689,319 (2,678,062 to 2,700,577) 20,255.68 (20,230.45 to 20,280.91) 103,56092NIHR Journals Library
DOI: 10.3310/hta17010 Health Technology Assessment 2013 Vol. 17 No. 1£27,546/QALY, so the 10-hour troponin strategy may be cost-effective for patients without known CAD if adecision can be made and the patient discharged as soon as the 10-hour troponin result is available.The effects of suboptimal diagnosis by the biomarkers were also estimated. The number of adverse events(reinfarctions and deaths) and their proportions for each of the biomarker strategies are shown in Table 46(population without known CAD) and Table 47 (population with known CAD). These tables show theeffect of different testing strategies on clinically relevant outcomes across the whole presenting population.However, clinicians and patients are often more interested to know the risk of adverse outcome in thosedischarged after negative testing. These estimates are given in Table 48 (population without known CAD)and Table 49 (population with known CAD). It should be recognised that the differences in event ratesbetween strategies shown in Tables 46 and 47 and Tables 48 and 49 are, in part, explained by differencesin the populations compared, i.e. lower event rates are in part achieved by positive tests removing those atrisk from the reported population rather than actually preventing adverse events.Tables 46 and 47 show that if patients are discharged without testing, their risk of death and non-fatalMI over the following year are estimated to be around 2.5% and 6%, respectively. We estimated that thevarious testing strategies could reduce these risks by 0.5–0.7% and 0.9–1.3%, respectively, in patientswithout known CAD and by marginally more in patients with known CAD.Tables 48 and 49 show that the various testing strategies reduce the estimated risk of adverse outcomeafter discharge with a negative assessment but, based on the Mills data, 155 the rate of death and non-fatalMI remained 1.0% and 3.9%, respectively, even after a negative 10-hour troponin result.Table 50 shows the results for the sensitivity analysis using high-sensitivity TnI instead of HsTnT atpresentation. Only the ICERs for presentation TnI and 10-hour troponin testing are shown becauseTABLE 46 Deaths and non-fatal MI at 1 year among patients presenting without known CAD following differenttesting strategies: whole population (n = 1000)Strategy MI DeathsMIs avoided comparedwith no testingLives saved comparedwith no testingNo testing 56.57 24.00 – –Presentation TnT, 10% CV 47.22 18.80 9.45 5.20Presentation TnT, 99th percentile 46.50 18.40 10.07 5.60Presentation HsTnT, 99thpercentile44.49 17.29 12.08 6.7110-hour troponin test 43.97 17.00 12.60 7.00TABLE 47 Deaths and non-fatal MI at 1 year among patients presenting with known CAD following different testingstrategies: whole population (n = 1000)Strategy MI DeathsMIs avoided comparedwith no testingLives saved comparedwith no testingNo testing 58.57 25.60 – –Presentation TnT, 10% CV 48.16 19.81 10.41 5.79Presentation TnT, 99th percentile 47.36 19.36 11.21 6.24Presentation HsTnT, 99thpercentile45.12 18.12 13.45 7.4810-hour troponin test 44.53 17.80 14.04 7.80© 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.93
Page 1:
Health Technology AssessmentVOLUME
Page 7:
DOI: 10.3310/hta17010 Health Techno
Page 10 and 11:
ContentsAppendix 5 Expected discoun
Page 13 and 14:
Page 15 and 16:
Page 17 and 18:
Page 19:
Page 22 and 23:
BackgroundTABLE 1 Hospital admissio
Page 24 and 25:
Background2. investigation of the c
Page 26 and 27:
BackgroundComputed tomographic coro
Page 28 and 29:
Research questionsiii. the diagnost
Page 30 and 31:
Assessment of diagnostic and progno
Page 32 and 33:
Page 34 and 35:
Page 36 and 37:
Page 38 and 39:
Page 40 and 41:
Page 42 and 43:
Page 44 and 45:
Page 46 and 47:
Page 48 and 49:
Page 50 and 51:
Page 52 and 53:
Page 54 and 55:
Page 56 and 57:
Page 58 and 59:
Page 60 and 61:
Page 62 and 63: Assessment of diagnostic and progno
Page 91 and 92: DOI: 10.3310/hta17010 Health Techno
Page 111: DOI: 10.3310/hta17010 Health Techno
Page 128 and 129: Discussionspecificity were 62% (95%
Page 130 and 131: Discussionneed for revascularisatio
Page 132 and 133: Discussionchanges in sensitivity an
Page 134 and 135: Discussionuncertainty about these p
Page 136 and 137: Discussiontroponin assays have bett
Page 138 and 139: ConclusionsSuggested research prior
Page 154 and 155: Appendix 144. heart-type fatty acid
Page 156 and 157: Appendix 1135. interleukin 33.mp. (
Page 158 and 159: Appendix 147. 37 and 45 (529)48. li
Page 164 and 165:
Appendix 313. Fernandez Portales JG
Page 166 and 167:
Appendix 346. Luscher MS, Ravkilde
Page 168 and 169:
Appendix 316. Rao SV, Ohman EM, Gra
Page 171 and 172:
Page 173 and 174:
Page 175 and 176:
Page 177 and 178:
Page 179 and 180:
Page 181 and 182:
Page 183:
Page 187 and 188:
Page 189 and 190:
Page 191 and 192:
Page 193 and 194:
Page 195:
Page 198 and 199:
Appendix 9Clinical diagnosis of NST
Page 200 and 201:
Appendix 9respectively. Exercise EC
Page 202 and 203:
Appendix 93. Two reviewers will mak
Page 204 and 205:
Appendix 9The methodology used in t
Page 206 and 207:
Appendix 9ES (Information Resources
Page 208:
Appendix 923. Westwood ME, Whiting
show all

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

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?