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Assessment of cost-effectiveness evidencethe other strategies are all less effective than these two strategies so, using the £20,000/QALY or£30,000/QALY threshold, one or other of these two strategies would always be optimal. The pointestimates from our meta-analysis suggested that the ADVIA Ultra high-sensitivity TnI assay had lowersensitivity than the Roche HsTnT assay. This may be due to random error, patient selection or choice ofthreshold, but the difference in point estimates provides the opportunity to explore whether the 10-hourtroponin strategy is more cost-effective than a less-sensitive presentation strategy. The ICERs in Table 50suggest that this is the case, although the 10-hour troponin strategy would still only be optimal in onescenario (doctor on demand, patients without known CAD) if the £20,000/QALY were used and would beoptimal in three of the six scenarios if the £30,000/QALY threshold were used.TABLE 48 Deaths and non-fatal MI at 1 year among patients (n = 1000) presenting without known CAD followingdifferent testing strategies: strategy-negative patients only aStrategyProportion of MI indischarged patientswithout treatment aProportion ofdeaths in dischargedpatients withouttreatment aImprovement inproportion of MI indischarged patientsover no testingImprovement inproportion ofdeaths in dischargedpatients over notestingNo testing 0.0566 0.0240 – –PresentationTnT, 10% CVPresentationTnT, 99thpercentilePresentationHsTnT, 99thpercentile10-hourtroponin test0.0438 0.0138 0.0128 0.01020.0427 0.0130 0.0139 0.01100.0398 0.0106 0.0168 0.01340.0390 0.0100 0.0176 0.0140a Includes TN, FP and FN patients.TABLE 49 Deaths and non-fatal MI at 1 year among patients (n = 1000) presenting with known CAD followingdifferent testing strategies: strategy-negative patients onlyStrategyProportion of MI indischarged patientswithout treatment aProportion ofdeaths in dischargedpatients withouttreatment aImprovement inproportion of MI indischarged patientsover no testingImprovement inproportion ofdeaths in dischargedpatients over notestingNo testing 0.0586 0.0256 – –PresentationTnT, 10% CVPresentationTnT, 99thpercentilePresentationHsTnT, 99thpercentile10-hourtroponin test0.0444 0.0143 0.0142 0.01130.0432 0.0133 0.0154 0.01230.0399 0.0107 0.0187 0.01490.0390 0.0100 0.0196 0.0156a Includes TN, FP and FN patients.94NIHR Journals Library
DOI: 10.3310/hta17010 Health Technology Assessment 2013 Vol. 17 No. 1Table 51 shows the results for the sensitivity analysis in which a strategy of measuring high-sensitivitytroponin at presentation and 3 hours later is included alongside the other strategies used in the mainanalysis. Again, only the ICERs for the 3-hour strategy and 10-hour troponin testing are shown becausethe other strategies are all less effective than these two strategies and will not be optimal if either a£20,000/QALY or £30,000/QALY threshold is used. The ICERs in Table 51 show that the 3-hour strategy isthe most cost-effective strategy at either the £20,000/QALY or £30,000/QALY threshold, whereas the ICERfor the 10-hour troponin strategy substantially exceeds both thresholds in all scenarios.The final deterministic diagnostic analysis estimated the cost-effectiveness of adding an alternativebiomarker to troponin alone. This analysis was limited to patients without known CAD using the twicedailyward round scenario. Estimates of presentation troponin sensitivity and specificity were based onthe primary study that evaluated the relevant biomarker. This provided the best estimate of the effect ofadding the biomarker but means that we are not always comparing the biomarker combination to theoptimal presentation troponin strategy. Table 52 shows the ICERs for each strategy compared with the nextmost effective alternative. Details of costs and QALYs are presented in Appendix 6.Table 52 shows that, compared with troponin alone, the addition of H-FABP, copeptin or myoglobinappears to be cost-effective with ICERs of < £20,000–30,000/QALY. However, at this threshold, the10-hour troponin strategy may also be cost-effective according to some of the studies. If the presentationbiomarker and troponin combination increased sensitivity to over 90% 67,76,80 then 10-hour troponin testingwas unlikely to be cost-effective in comparison. If the presentation biomarker and troponin combinationdid not achieve 90% sensitivity, 57,71,77 then 10-hour troponin testing may be considered cost-effective.Neither of the strategies involving IMA appeared to be cost-effective, presumably because both involvedsubstantial losses in specificity with only modest gains in sensitivity compared with troponin alone.TABLE 50 Incremental cost-effectiveness ratios for sensitivity analysis with presentation TnI instead of TnTScenarioICER for presentationADVIA Centaur Ultratroponin I assay (£/QALY)ICER for 10-hour troponintesting (£/QALY)Doctor on demand, patients without known CAD 5029/QALY 15,255/QALYTwice-daily ward round, patients without known CAD 6774/QALY 29,064/QALYOnce-daily ward round, patients without known CAD 7981/QALY 39,116/QALYDoctor on demand, patients with known CAD 6483/QALY 20,775/QALYTwice-daily ward round, patients with known CAD 7947/QALY 38,387/QALYOnce-daily ward round, patients with known CAD 9175/QALY 49,902/QALYTABLE 51 Incremental cost-effectiveness ratios for sensitivity analysis with 3-hour troponin strategyScenarioICER for high-sensitivitytroponin at presentationand 3 hours (£/QALY)ICER for 10-hour troponintesting (£/QALY)Doctor on demand, patients without known CAD 5596 405,312Twice-daily ward round, patients without known CAD 6247 1,008,159Once-daily ward round, patients without known CAD 6727 1,444,659Doctor on demand, patients with known CAD 7735 128,640Twice-daily ward round, patients with known CAD 8189 296,754Once-daily ward round, patients with known CAD 8710 408,536© 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.95
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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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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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