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Assessing the cost-effectiveness of point-of-care testing for primary care patients with symptoms suggestive of acute coronary syndrome : a threshold analysis

Moesker, M.J. (2014) Assessing the cost-effectiveness of point-of-care testing for primary care patients with symptoms suggestive of acute coronary syndrome : a threshold analysis.

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Abstract:Background: Chest complaints such as pain and pressure are challenging to interpret in primary care and have extensive differential diagnoses. Patients as well as their general practitioners (GPs) are often concerned whether these symptoms are indicative of acute coronary syndrome (ACS). Because of the severity of this condition, GPs are advised to refer patients presenting with those symptoms to the emergency department (ED). However, in only 14-16% of the annual 156.000 patients presenting to the GP, cardiac origin is causing the symptoms, resulting in a burden on ED’s resources and the Dutch healthcare budget. Point of care testing (POCT) of cardiac markers might improve the certainty with which ACS can be ruled out in the GPs office and influence referral rates of those patients. To assess if POCT can play a role in ACS diagnostics in primary care, a threshold analysis is performed to estimate the minimum required diagnostic performance for the GP’s assessment combined with POCT, to be cost-effective compared with GP assessments without POCT. Methods: A patient-level health economic model, reflecting a hypothetical cohort of the Dutch population aged >35 years consulting their GP with chest complaints, was developed. The analysis included all direct and indirect medical costs, and productivity losses. Health benefit was expressed as patient’s life expectancy, adjusted for the health-related quality of life; the so-called Quality Adjusted Life Year (QALY). Input data come from an extensive literature search. Quality of life estimates are based on published quality of life weights for patients with ACS and heart failure. Cost estimates come from literature and open access healthcare declaration data. Costs and health benefits are considered over a life-long time horizon. Primary outcome parameters include: a) the incremental cost-utility ratio (ICUR) of the GP’s assessment combined with POCT vs. GP’s assessment alone, and b) the minimum required performance of the GP’s assessment combined with POCT to be considered a cost-effective treatment option compared with GP assessment only. Secondary outcome parameters include differences in mortality and new heart failure cases between the two strategies. Results: The sensitivity and specificity for a GP in diagnosing ACS are 88% and 72% respectively. The minimum required sensitivity of the GP’s assessment combined with POCT should be 91%, the minimum specificity should be 82%. However, a higher sensitivity allows for lower specificity and still be cost-effective. A sensitivity of 91% and specificity of 82% results in a median cost saving for society of € 8.365 (IQR: € 4.788 - € 13.741) for one extra QALY. The number of false-positive referrals will reduce with an estimated median of 1872 (IQR: 1854-1911), while the number of missed diagnoses (false-negatives) will reduce with a median of 20 (IQR: 16-24) per 20.000 patients. Median risk ratios for mortality and heart failure are 0,987 (IQR: 0,971-01,015) and 0,964 (IQR: 0,948-0,982) respectively for the POCT strategy compared with non-POCT strategy. Conclusion/Discussion: An increase in overall sensitivity for excluding ACS at the GP from 88% to 91%, and an increase in specificity from 72% to 82% can be considered a cost-effective strategy in diagnosing ACS at the GP. This is expected to contribute to a reduction of healthcare costs because of less false-positive referrals, as well as an improvement of the quality of care provided because of less missed ACS diagnoses. Further research is necessary to further specify the use of POCT in primary care. Implementation of a clinical decision rule is recommended to be used alongside POCT to ensure safe and (cost)-effective use of POCT in diagnosing ACS.
Item Type:Essay (Master)
Faculty:BMS: Behavioural, Management and Social Sciences
Subject:85 business administration, organizational science
Programme:Health Sciences MSc (66851)
Link to this item:http://purl.utwente.nl/essays/66324
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