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

DOI: 10.3310/hta17010 Health Technology Assessment 2013 Vol. 17 No. 1Chapter 6 ConclusionsImplications for service provisionThe data cited in the introduction to this report show that chest pain due to suspected ACS isresponsible for a large and growing number of emergency hospital attendances and admissions. Anyrecommendations relating to the management of suspected ACS therefore have substantial potentialimplications for service provision. Hospital Episode Statistics for England (see Chapter 1, The healthcareburden of suspected acute coronary syndrome) show that admissions for chest pain have beenprogressively rising, whereas LoS has been shortening. This probably reflects the increasing use of 10- to12-hour troponin testing, allowing early discharge of patients with suspected MI and application of thistest to increasing numbers of patients.Our economic analysis suggests that hospital admission for 10-hour troponin testing is unlikely to becost-effective compared with high-sensitivity troponin at presentation unless rapid decision-making anddischarge is possible, although this conclusion may not hold in various scenarios if troponin sensitivityat presentation is < 90%. Our sensitivity analysis, admittedly based on data from one study, suggestedthat the 10-hour troponin strategy was very unlikely to be cost-effective compared with a strategy usinga high-sensitivity assay at presentation and 3 hours later. Removing the recommendation for 10-hourtroponin testing from NICE guidance could have substantial benefits for service provision. If patients wererecommended for admission only if troponin level at presentation was positive then we would expect thatfewer patients would need admission to hospital and the rise in chest pain admissions could be attenuatedor even reversed. However, outpatient services for those discharged might need to be developed and/or asmall increase in the risk of adverse outcome after discharge may be observed.Increased use of high-sensitivity troponin assays has other potential implications for service provision.High-sensitivity assays produce more positive results than standard assays and the prognostic significanceof these additional positive cases is not clear. Services have been developed on the assumption thatpatients with a positive troponin have an important risk of adverse outcome and will benefit from furtherinvestigation and intervention. This assumption may not hold for some patients if their troponin elevationindicates only a small increase or no significant increase in risk. Widespread use of high-sensitivity troponintesting has the potential to substantially increase demand for cardiology services. Further research isrequired to determine how and whether this demand should be met.Similarly, any use of alternative biomarkers as an adjunct to troponin testing for ruling out MI atpresentation may have implications for service provision. In our model we assumed that FP alternativebiomarkers would be ignored once a 10-hour troponin test was found to be negative and would not resultin additional testing or prolonged LoS. However, this assumption needs to be tested in practice.Any recommendation that CTCA should be routinely used for troponin-negative patients with suspectedACS (even if selected on the basis of perceived risk) would have substantial service implications andwould require rapid access to CT scanning and reporting in a way that is currently not available in mosthospitals. Our analysis suggests that there is currently insufficient evidence to recommend CTCA but futureresearch will need to take into account the potential impact upon service provision and explore potentialknock-on implications, such as hospital admission being used for patients awaiting CTCA if it is notimmediately available.© 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.117