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

Assessment of cost-effectiveness evidenceTABLE 52 Cost-effectiveness of adding alternative biomarkers to troponinStudyBiomarkersPresentation troponinalone (£/QALY)Presentation troponinand biomarker (£/QALY)10-hour troponintesting (£/QALY)Body 2011 57 TnI or H-FABP 6596 5120 24,147Haltern TnT or H-FABP 4849 14,615 58,3302010 67McCann TnT or H-FABP 5296 5945 54,8202008 76Mion 2007 77 TnI or H-FABP 5785 6125 18,904Keller 2010 71TnT orcopeptin5545 9606 23,222Reichlin TnT or2009 80 copeptin5295 9244 117,176Keller 2010 71Mion 2007 77TnT ormyoglobinTnI ormyoglobin5545 7769 22,7335785 5877 23,048Collinson TnT or IMA 4874 99,948 Dominated2006 48Keating TnT or IMA 4876 Extendedly dominated 23,6582006 70Probabilistic results of the diagnostic modelProbabilistic analysis incorporated uncertainty in the parameter estimates to provide estimates of theprobability that each strategy would be cost-effective at different thresholds for willingness to pay forhealth gain. Figures 38–40 show the probabilistic analysis for patients without known CAD accordingto the doctor-on-demand, twice-daily ward and once-daily ward scenarios. The tables containing theprobabilities at different willingness-to-pay thresholds are in Appendix 7. The probabilistic results weresimilar to those of the deterministic analysis, with the conclusions identical for both methodologies.These analyses show that the strategy based on measuring high-sensitivity troponin at presentation hadthe highest probability of being cost-effective for thresholds of between around £5000 and £23,000/QALYin the doctor-on-demand strategy and for thresholds exceeding around £10,000/QALY for the other twostrategies. For thresholds exceeding around £23,000/QALY in the doctor-on-demand scenario the 10-hourtroponin strategy had the highest probability of being cost-effective. These results reflect the deterministicanalysis and suggest that high-sensitivity troponin on presentation has the highest probability of beingcost-effective in most scenarios and at typically used thresholds for willingness to pay.The prognostic phase modelThis section details the methods and results of the health economic model constructed to compareprognostic strategies for troponin-negative patients without known CAD. We developed a decision-analyticmodel to estimate the costs and QALYs accrued by each potential management strategy for identifyingpatients with subsequent risk of MACEs. The strategies involved using CTCA, exercise ECG or a biomarker(H-FABP) to select patients for further investigation with ICA. We also included a ‘perfect’ strategy of ICAfor all patients and a no-testing strategy. We assumed that patients who were discharged without testingwould ultimately present with further symptoms and receive appropriate testing if they did not die in themeantime. The key aim was to determine the optimal strategy in terms of cost-effectiveness.96NIHR Journals Library