Cost-effectiveness of a rule-out algorithm of acute myocardial infarction in low-risk patients: emergency primary care versus hospital setting

Abstract

Aims Hospital admissions of patients with chest pain considered as low risk for acute coronary syndrome contribute to increased costs and crowding in the emergency departments. This study aims to estimate the cost-effectiveness of assessing these patients in a primary care emergency setting, using the European Society of Cardiology (ESC) 0/1-h algorithm for high-sensitivity cardiac troponin T, compared to routine hospital management. Methods A cost-effectiveness analysis was conducted. For the primary care estimates, costs and health care expenditure from the observational OUT-ACS (One-hoUr Troponin in a low-prevalence population of Acute Coronary Syndrome) study were compared with anonymous extracted administrative data on low-risk patients at a large general hospital in Norway. Patients discharged home after the hs-cTnT assessment were defined as low risk in the primary care cohort. In the hospital setting, the low-risk group comprised patients discharged with a non-specific chest pain diagnosis (ICD-10 codes R07.4 and Z03.5). Loss of health related to a potential increase in acute myocardial infarctions the following 30-days was estimated. The primary outcome measure was the costs per quality-adjusted life year (QALY) of applying the ESC 0/1-h algorithm in primary care. The secondary outcomes were health care costs and length of stay in the two settings. Results Differences in costs comprise personnel and laboratory costs of applying the algorithm at primary care level (€192) and expenses related to ambulance transports and complete hospital costs for low-risk patients admitted to hospital (€1986). Additional diagnostic procedures were performed in 31.9% (181/567) of the low-risk hospital cohort. The estimated reduction in health care cost when using the 0/1-h algorithm outside of hospital was €1794 per low-risk patient, with a mean decrease in length of stay of 18.9 h. These numbers result in an average per-person QALY gain of 0.0005. Increased QALY and decreased costs indicate that the primary care approach is clearly cost-effective. Conclusion Using the ESC 0/1-h algorithm in low-risk patients in emergency primary care appears to be cost-effective compared to standard hospital management, with an extensive reduction in costs and length of stay per patient.

Rule-out of non-ST-segment elevation acute coronary syndrome by a single, pre-hospital troponin measurement: a randomized trial

“…Implementation of this pre-hospital rule-out strategy in low-risk patients could achieve a significant reduction in healthcare costs by more efficient use of ambulance services and less ED visits. 13 , 25 A recent study has shown that rule-out of NSTE-ACS in emergency primary care is cost-effective, which is in line with our results. In that study, the European Society of Cardiology 0/1 h algorithm with a high-sensitivity troponin assay in a hospital laboratory was used to identify low-risk patients, whereas our study offers an algorithm that does not require a laboratory and can be performed on-site.…”

“…In that study, the European Society of Cardiology 0/1 h algorithm with a high-sensitivity troponin assay in a hospital laboratory was used to identify low-risk patients, whereas our study offers an algorithm that does not require a laboratory and can be performed on-site. 13 A total of 91.5% of the patients in the pre-hospital rule-out strategy were not transferred to the ED, while all of these patients would have been transferred to the ED in the absence of a pre-hospital strategy. Hence, the pre-hospital rule-out strategy reduces the number unnecessary ED visits, which contributes to a reduction in ED overcrowding.…”

“… 10 Pre-hospital rule-out of ACS has recently been shown to reduce healthcare costs in a trial in Norway. 13 Implementation of routine pre-hospital POC troponin measurement has been shown to effectively identify high-risk patients in Denmark, whereas pre-hospital HEART score assessment including a POC troponin measurement has been shown to adequately identify low-risk patients in the Netherlands and the United States. 16 , 17 , 27 …”

“… 14 Pre-hospital risk stratification of chest pain patients has been shown to help to reduce ED overcrowding and reduce costs. 13 The HEART [History, Electrocardiogram (ECG), Age, Risk factors and Troponin] score is a simple and well validated tool for risk stratification of chest pain patients in the ED, with a very strong overall inter-operator reliability, regardless of the level of education of healthcare professionals. 10 , 15 When a point-of-care (POC) troponin measurement is incorporated in the HEART score, ambulance paramedics can adequately identify low-risk patients by pre-hospital HEART score assessment.…”

Ruling out acute coronary syndrome in primary care with a clinical decision rule and a capillary, high-sensitive troponin I point of care test: study protocol of a diagnostic RCT in the Netherlands (POB HELP)

“…However, due to the low incidence of ACS in primary care, results from ED settings are not generalisable to primary care settings. Although use of a troponin point of care test (POCT) in primary care reduced the number of referrals in both a model-based and an observational study, the impact has yet to be studied in clinical practice 15–17…”