Chest Pain Management Using Prehospital Point-of-Care Troponin and Paramedic Risk Assessment

Abstract

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.

Direct admission versus interhospital transfer for revascularisation in non‐ST‐segment elevation myocardial infarction

“…The Royal Free Hospital managed to reduce median time to ICA through this pathway to 2.8 h (IQR 1.5–9) compared to 60 h (IQR 33–116) with use of a pathway similar to the pathway evaluated in our study 2 . Additionally, a two recently conducted randomized trials by Camaro et al 18 and Dawson et al 19 demonstrated that prehospital rule‐out of ACS with a point‐of‐care troponin measurement in chest pain patient's notably reduced healthcare expenditure. However, there is not yet consensus on the most ideal form of prehospital triage as several methods are still in the early stages of development and trials are currently being conducted 20 .…”

“…The Royal Free Hospital managed to reduce median time to ICA through this pathway to 2.8 h (IQR 1.5-9) compared to 60 h (IQR 33-116) with use of a pathway similar to the pathway evaluated in our study 2. Additionally, a two recently conducted randomized trials by Camaro et al18 and Dawson et al19 demonstrated that prehospital rule-out of ACS with a point-of-care troponin…”

Are we ready for prehospital troponin testing by paramedics?

“…A cost-minimisation study analysed the possible cost savings of using prehospital paramedic risk assessments and POC troponin testing compared with current care processes in Victoria, Australia 3. Prehospital risk stratification was based on two risk scores: the well-validated HEART risk score,2 which includes History, ECG, Age, Risk factors and Troponin, and the ECAMM score (Early Chest pain Admission Mortality and Myocardial infarction).…”

Are We Ready for Prehospital Troponin Testing?

“…Personnel for EMS perform initial triage and stabilization; some are empowered to interpret electrocardiograms and activate hospital catheterization laboratories. The study by Dawson et al in this issue of JAMA Internal Medicine modeled potential cost savings of troponin testing for prehospital triaging of patients with chest pain. The study concluded that implementing such a strategy could realize cost savings by appropriately triaging patients to lower levels of care.…”

“…Extended chest pain observation protocols permit consideration of other diagnoses, such as pulmonary embolism and aortic dissection, and expedite treatment when needed. In this study, the authors relied on a virtual emergency department as a final safety check before direct discharge from EMS. In practicality, virtual triage tools are scarce, and the default will remain emergency department triage.…”