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Research questionsiii. the diagnostic accuracy of CTCA and exercise ECG for CAD in patients with suspected ACSiv. the prognostic accuracy of CTCA and exercise ECG for predicting MACEs in patients withsuspected ACS2. to develop an economic model to:i. estimate the cost-effectiveness [measured as the cost per quality-adjusted life-year (QALY) gainedby each strategy] of using various early biomarker strategies to diagnose MIii. estimate the cost-effectiveness of using biomarkers, CTCA and exercise ECG to risk-stratify patientswith troponin-negative suspected ACSiii. identify the optimal strategies for diagnosing MI and investigating troponin-negative patients inthe NHS, defined as the most cost-effective strategy at the NICE threshold for willingness to payper QALY gainediv. identify the critical areas of uncertainty in the management of suspected ACS and where futureprimary research would produce the most benefit.8NIHR Journals Library
DOI: 10.3310/hta17010 Health Technology Assessment 2013 Vol. 17 No. 1Chapter 3 Assessment of diagnostic andprognostic accuracyWe conducted two systematic reviews of the literature, and meta-analysis (where appropriate), toevaluate the diagnostic accuracy of biochemical markers for MI, and of CTCA and exercise ECGfor CAD, as well as two further reviews to evaluate the prognostic performance of both approaches forpredicting MACEs. The population in all reviews was unselected patients with suspected ACS.The systematic reviews and meta-analysis were undertaken in accordance with the guidelines publishedby the Centre for Reviews and Dissemination for undertaking systematic reviews 26 and the CochraneDiagnostic Test Accuracy Working Group on the meta-analysis of diagnostic tests. 27Methods for reviewing diagnostic accuracyIdentification of studiesElectronic databasesAll searches were undertaken by an information specialist (PE) in November 2010. Studies were identifiedby searching the following electronic databases:• z MEDLINE (via Ovid SP) 1950–• z MEDLINE In-Process & Other Non-Indexed Citations (via Ovid SP) 1950–• z Cumulative Index of Nursing and Allied Health Literature (CINAHL) (via EBSCO) 1981–• z EMBASE (via Ovid SP) 1980–• z Web of Science (WoS) (includes Science Citation Index and Conference Proceedings Citation Index) [viaWeb of Knowledge (WoK)] 1899–• z Cochrane Central Register of Controlled Trials (CENTRAL)• z Cochrane Database of Systematic Reviews (CDSR)• z NHS Database of Abstracts of Reviews of Effects (DARE)• z Health Technology Assessment database (HTA).Sensitive keyword strategies using free text and, where available, thesaurus terms using Boolean operatorsand database-specific syntax were developed to search the electronic databases. For the biochemicalmarkers reviews, synonyms relating to the population (e.g. chest pain, ACS or MI) were combined withterms for the biochemical markers of interest, and the reference standard (troponin), and a search filteraimed at restricting results to studies of either diagnostic accuracy or prognosis (used in the searchesof MEDLINE, CINAHL and EMBASE). For the CTCA and exercise ECG review, synonyms relating to thepopulation (e.g. chest pain, ACS or MI) were combined with terms for the diagnostic tests, and thereference standard (coronary angiography) or outcomes (e.g. MACE), and a search filter aimed atrestricting results to studies of either diagnostic accuracy or prognosis (used in the searches of MEDLINE,CINAHL and EMBASE). Date limits or language restrictions were not used on any database for eitherreview. All resources were searched from 1985 (CTCA review) or 1995 (biomarkers review) to November2010. Examples of the MEDLINE search strategy for each review is provided in Appendix 1.Other resourcesTo identify additional published, unpublished and ongoing studies, the reference lists of all relevant studies(including existing systematic reviews) were checked. In addition, key experts in the field were approachedto identify any relevant citations missed by the search methods applied.© 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.9
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Page 10 and 11: ContentsAppendix 5 Expected discoun
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Appendix 923. Westwood ME, Whiting
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