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

More documents

Recommendations

Info

Assessment of cost-effectiveness evidenceTABLE 58 Cost-effectiveness of strategies for (n = 1000) troponin-negative patients, using data from Mills 155Strategy Total costs (£) Total QALYs ICER (£/QALY)No testing 374,040 11,891.14 –Exercise ECG 678,120 11,917.75 Extendedly dominatedH-FABP 544,340 11,911.26 8464CTCA 937,426 11,946.86 11,041ICA 1,705,790 11,950.36 219,532TABLE 59 Cost-effectiveness of strategies for troponin-negative patients, using data from the RATPAC trial 12Strategy Total costs (£) Total QALYs ICER (£/QALY)No testing 260,901 12,180.71 –Exercise ECG 590,601 12,181.78 DominatedH-FABP 449,520 12,182.57 101,408CTCA 876,680 12,184.20 262,061ICA 1,656,701 12,176.07 DominatedThe cost-effectiveness of CTCA therefore appears to depend on the assumed rate of subsequent deathand non-fatal MI. Given the uncertainty in these risks, we performed ‘goal-seeking’ analysis to identify thelevel of risk at which the ICER for CTCA crosses the NICE threshold of £20,000–30,000/QALY comparedwith either H-FABP, ETT or no testing. We assumed a proportional relationship that risk of non-fatal MIis four times the risk of death. The results are shown in Table 60. Depending on the threshold used,CTCA is likely to be cost-effective if the combined risk of death and non-fatal MI within the time periodassumed to be influenced by initial diagnostic testing exceeds 2% (£30,000/QALY threshold) or 2.9%(£20,000/QALY threshold).Probabilistic results of the prognostic modelThe main probabilistic analysis for the prognostic model, using the 1-year event rates from Mills, 155is shown in Figure 41. CTCA had the highest probability of being cost-effective at thresholds above£10,000/QALY. Around £10,000 H-FABP had the highest probability, and below this level no testing hadthe highest probability of being cost-effective.The main probabilistic analysis for the prognostic model, using the 1-year event rates from RATPAC, 12 isshown in Figure 42. No testing was highly likely to be the most cost-effective strategy for all thresholdsof < £100,000/QALY.Value of information analysesThere is always a chance that the wrong decision will be made as a result of the uncertainty in the existinginformation and the costs in terms of health benefit and resources forgone owing to this uncertainty canbe interpreted as expected value of perfect information (EVPI). Perfect information would eliminate thepossibility of making the wrong decision and therefore EVPI is determined jointly by the probability that adecision based on existing information will be wrong and the consequences of a wrong decision.The EVPI, although calculated for individual patients, can also be expressed for the total population ofpatients who stand to benefit, based on prevalence and the lifetime of the technology. This can also bethought as the maximum that the health-care system should be willing to pay for additional evidence toinform the decision in the future and thus is an upper bound on the value of conducting further research,102NIHR Journals Library
DOI: 10.3310/hta17010 Health Technology Assessment 2013 Vol. 17 No. 1TABLE 60 Threshold analysis to identify the cut-off risksThreshold(£/QALY)Risk of nonfatalMIRisk of death20,000 0.023 0.005730,000 0.016 0.00411.0Probability of cost-effectiveness0.90.80.70.60.50.40.30.20.10.00510 15 20 25 30 35 40Willingness-to-pay threshold (£000)4550No TestingETTHFABPCTCAICAFIGURE 41 Probability of cost-effectiveness of strategies using data from Mills. 1551.21.0Probability of cost-effectiveness0.80.60.40.200 20 40 60 80100120 140 160No testingETTHFABPCTCAICA–0.2MAICER (£000)FIGURE 42 Probability of cost-effectiveness of strategies using RATPAC data. 12 MAICER, maximum acceptableincremental cost-effectiveness ratio.i.e. if the population EVPI exceeds the expected costs of additional research then it is potentially costeffectiveto conduct further research.Partial EVPI provides the value of reducing the uncertainty surrounding particular input parameters in thedecision model and this can be used to identify the parameters for which more precise estimates would bemost valuable to focus further research. However, this is computationally expensive for complex models.© 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.103
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:
Page 64 and 65:
Page 66 and 67:
Page 68 and 69:
Page 70 and 71:
Page 72 and 73: Assessment of diagnostic and progno
Page 91 and 92: DOI: 10.3310/hta17010 Health Techno
Page 121: 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 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?