Cost‐effectiveness of Point‐of‐care Biomarker Assessment for Suspected Myocardial Infarction: The Randomized Assessment of Treatment Using Panel Assay of Cardiac Markers (RATPAC) Trial

Abstract

Objectives: Chest pain due to suspected myocardial infarction (MI) is responsible for many hospital admissions and consumes substantial health care resources. The Randomized Assessment of Treatment using Panel Assay of Cardiac markers (RATPAC) trial showed that diagnostic assessment using a point-of-care (POC) cardiac biomarker panel consisting of CK-MB, myoglobin, and troponin increased the proportion of patients successfully discharged after emergency department (ED) assessment. In this economic analysis, the authors aimed to determine whether POC biomarker panel assessment reduced health care costs and was likely to be cost-effective. Methods:The RATPAC trial was a multicenter individual patient randomized controlled trial comparing diagnostic assessment using a POC biomarker panel (CK-MB, myoglobin, and troponin, measured at baseline and 90 minutes) to standard care without the POC panel in patients attending six EDs with acute chest pain due to suspected MI (n = 2,243). Individual patient resource use data were collected from all participants up to 3 months after hospital attendance using self-completed questionnaires at 1 and 3 months and case note review. ED staff and POC testing costs were estimated through a microcosting study of 246 participants. Resource use was valued using national unit costs. Health utility was measured using the EQ-5D self-completed questionnaire, mailed at 1 and 3 months. Quality-adjusted life-years (QALYs) were calculated by the trapezium rule using the EQ-5D tariff values at all follow-up points. Mean costs per patient were compared between the two treatment groups. Cost-effectiveness was estimated in terms of probability of dominance and incremental cost per QALY.Results: Point-of-care panel assessment was associated with higher ED costs, coronary care costs, and cardiac intervention costs, but lower general inpatient costs. Mean costs per patient were £1217.14 (standard deviation [SD] ± 3164.93), or $1,987.14 (SD ± $4,939.25), with POC versus £1005.91 (SD ± £1907.55), or $1,568.64 (SD ± $2,975.78), with standard care (p = 0.056). Mean QALYs were 0.158 (SD ± 0.052) versus 0.161 (SD ± 0.056; p = 0.250). The probability of standard care being dominant (i.e., cheaper and more effective) was 0.888, while the probability of the POC panel being dominant was 0.004. These probabilities were not markedly altered by sensitivity analysis varying the costs of the POC panel and excluding intensive care costs.

Comprehensive bedside point of care testing in critical ED patients: a before and after study

“…We are unaware of other studies that have performed a formal cost-effective analysis when comprehensive POCT is introduced as we did. A previous multicenter RCT of 2243 ED patients with chest pain only found higher ED costs, coronary care costs, and cardiac intervention costs, but lower general inpatient costs when a POC biomarker panel (creatine kinase-MB, myoglobin, troponin) was used [12,13]. However, the cost of the triple biomarker panel used and cost of the POC devices were considerably higher than those in our study.…”

Comparison of new point-of-care troponin assay with high sensitivity troponin in diagnosing myocardial infarction

“…Although it would be hoped that other clinical benefits would offset these increased costs there have been no randomized studies looking at this as a primary outcome. However, the RATPAC group showed in their study that POC testing was not cost effective with higher overall costs in the POC cohort [26]. Conversely, a study by Apple et al [27] showed overall costs per patient were lower.…”

“…The POC assays are more expensive than laboratory assays [26,27]. Although it would be hoped that other clinical benefits would offset these increased costs there have been no randomized studies looking at this as a primary outcome.…”

Investigating the health-economic profiles of biomarker-driven immunosuppresion (BIO-DrIM) following solid organ transplantation

“…However, an appropriate strategy to determine the costs associated with the biomarkerstratification procedures is provided by Fitzgerald et al [32] . The outlined micro-costing strategy focuses on the fact that variability in results is expected for various patients [32] .…”

“…However, an appropriate strategy to determine the costs associated with the biomarkerstratification procedures is provided by Fitzgerald et al [32] . The outlined micro-costing strategy focuses on the fact that variability in results is expected for various patients [32] . Therefore, a sub-study was initiated with a subset of the trial participants to conduct the micro-costing procedure and detect potential differences between patients as well as between treatment arms.…”