ImportancePrehospital point-of-care troponin testing and paramedic risk stratification might improve the efficiency of chest pain care pathways compared with existing processes with equivalent health outcomes, but the association with health care costs is unclear.ObjectiveTo analyze whether prehospital point-of-care troponin testing and paramedic risk stratification could result in cost savings compared with existing chest pain care pathways.Design, Setting, and ParticipantsIn this economic evaluation of adults with acute chest pain without ST-segment elevation, cost-minimization analysis was used to assess linked ambulance, emergency, and hospital attendance in the state of Victoria, Australia, between January 1, 2015, and June 30, 2019.InterventionsParamedic risk stratification and point-of-care troponin testing.Main Outcomes and MeasuresThe outcome was estimated mean annualized statewide costs for acute chest pain. Between May 17 and June 25, 2022, decision tree models were developed to estimate costs under 3 pathways: (1) existing care, (2) paramedic risk stratification and point-of-care troponin testing without prehospital discharge, or (3) prehospital discharge and referral to a virtual emergency department (ED) for low-risk patients. Probabilities for the prehospital pathways were derived from a review of the literature. Multivariable probabilistic sensitivity analysis with 50 000 Monte Carlo iterations was used to estimate mean costs and cost differences among pathways.ResultsA total of 188 551 patients attended by ambulance for chest pain (mean [SD] age, 61.9 [18.3] years; 50.5% female; 49.5% male; Indigenous Australian, 2.0%) were included in the model. Estimated annualized infrastructure and staffing costs for the point-of-care troponin pathways, assuming a 5-year device life span, was $2.27 million for the pathway without prehospital discharge and $4.60 million for the pathway with prehospital discharge (incorporating virtual ED costs). In the decision tree model, total annual cost using prehospital point-of-care troponin and paramedic risk stratification was lower compared with existing care both without prehospital discharge (cost savings, $6.45 million; 95% uncertainty interval [UI], $0.59-$16.52 million; lower in 94.1% of iterations) and with prehospital discharge (cost savings, $42.84 million; 95% UI, $19.35-$72.26 million; lower in 100% of iterations).Conclusions and RelevancePrehospital point-of-care troponin and paramedic risk stratification for patients with acute chest pain could result in substantial cost savings. These findings should be considered by policy makers in decisions surrounding the potential utility of prehospital chest pain risk stratification and point-of-care troponin models provided that safety is confirmed in prospective studies.

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Aims The relationship between lower socioeconomic status(SES) and poor cardiovascular outcomes is well-described, however there exists a paucity of data exploring this association in cardiogenic shock(CS). This study aimed to investigate whether any disparities exist between SES and the incidence, quality-of-care or outcomes of CS patients attended by emergency medical services(EMS). Methods and results This population-based cohort study included consecutive patients transported by EMS with CS between January 1st 2015 and June 30th 2019 in Victoria, Australia. Data were collected from individually linked ambulance, hospital and mortality datasets. Patients were stratified into SES quintiles using national census data produced by the Australia Bureau of Statistics. A total of 2 628 patients were attended by EMS for CS. The age-standardized incidence of CS amongst all patients was 11.8(95% confidence interval [CI], 11.4–12.3) per 100 000 person-years, with a stepwise increase from the highest to lowest SES quintile(lowest quintile 17.0 vs. highest quintile 9.7 per 100 000 person-years, p-trend < 0.001). Patients in lower SES quintiles were less likely to attend metropolitan hospitals and more likely to be received by inner regional and remote centers without revascularization capabilities. A greater proportion of the lower SES groups presented with CS due to non-ST elevation myocardial infarction(NSTEMI) or unstable angina pectoris(UAP), and overall were less likely to undergo coronary angiography. Multivariable analysis demonstrated an increased 30-day all-cause mortality rate in the lowest 3 SES quintiles when compared to the highest quintile. Conclusion This population-based study demonstrated discrepancies between SES status in the incidence, care-metrics and mortality rates of patients presenting to EMS with CS. These findings outline the challenges in equitable healthcare delivery within this cohort.