MICE or NICE? An economic evaluation of clinical decision rules in the diagnosis of heart failure in primary care

Monahan, Mark; Barton, Pelham; Taylor, Clare; Roalfe, Andrea; Hobbs, F D Richard; Cowie, Martin R.; Davis, Russell; Deeks, Jonathan J; Mant, Jonathan; McCahon, Deborah; McDonagh, Theresa A.; Sutton, George C.; Tait, Lynda

doi:10.1016/j.ijcard.2017.02.149

Cited by 12 publications

(15 citation statements)

References 20 publications

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“…162 (30) 36 3325 (33) 98 ( Extended audit on identifying HF patients Prevalence rates for HF depend highly on the setting, the mean age of the population, the definition of HF, and the identification method used, which were confirmed by the current study. 3,9,24,25 The prevalence of HF was 1.7% of the patient population on the basis of a search for a registered diagnosis in GPs' EHRs, and the prevalence of HF increased to 3.0% after implementing an extended audit.…”

Section: Discussionsupporting

confidence: 64%

“…The same result was described in the Spanish study, 29 while natriuretic peptides were clearly more widely used in the Netherlands (69% availability) 8 . The remaining uncertainty in HFpEF diagnoses, despite available echocardiography data, pleads for a wider availability of natriuretic peptides in primary care 11,30,33,34 . Another important theme is the communication about the HF diagnosis by specialists that should be improved.…”

Section: Discussionmentioning

confidence: 55%

“…8 The remaining uncertainty in HFpEF diagnoses, despite available echocardiography data, pleads for a wider availability of natriuretic peptides in primary care. 11,30,33,34 Another important theme is the communication about the HF diagnosis by specialists that should be improved. Uniform terminology, unequivocal diagnostic terms (e.g.…”

Section: Characteristics Of Heart Failure Patients In General Practicementioning

confidence: 99%

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Impact of an extended audit on identifying heart failure patients in general practice: baseline results of the OSCAR‐HF pilot study

et al. 2020

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Aims Identifying heart failure (HF) patients in general practice is challenging, and little is known about the current quality of care. We implemented an extended audit from the electronic health records (EHRs) of general practitioners (GPs) to identify HF patients and investigate patient characteristics and quality of care. Methods and results This study describes the baseline results of the OSCAR-HF pilot study in eight general practices (51 GPs) in Flanders, Belgium. This prospective trial ran for 6 months. Interventions included an extended audit, an N-terminal pro-Btype natriuretic peptide point-of-care test, and assistance of a specialist HF nurse. The extended audit searched on risk factors for HF, HF symptoms, signs, and medication in the GPs' EHR to generate a list of possible HF patients. GPs determined which patients had HF. Those HF patients constituted the OSCAR-HF study population. Each patient file was manually revised to extract biomarker measurements, echocardiography data, and quality indicators. An independent panel of experts assessed the validity of GPs' HF diagnoses. Feedback about the validity of the HF diagnosis was given to the GP. Out of 18 011 patients ≥ 40 years, we identified 310 patients with a registered HF diagnosis before the study start (HF prevalence: 1.7%). The extended audit led to a 74% increase in identified HF patients (n = 538, HF prevalence: 3.0%) with a mean age of 79 ± 11 years. The prevalence of HF with reduced ejection fraction (HFrEF) was 20% (n = 110). A high proportion of patients underwent echocardiography in the past 5 years (86%, n = 462). Natriuretic peptides were rarely available in patients' files (19%, n = 100). Medical specialists should improve communication about the HF diagnosis because a specialist diagnosis was present in only 225 patients (42%) while 67% (n = 359) of the HF diagnoses were judged objectified by a panel of experts. Assigning a diagnosis of HF was particularly difficult in HF patients with preserved EF (HFpEF). HFrEF treatment rates with renin-angiotensin-aldosterone system blockers (84%, n = 92) and beta-blockers (86%, n = 94) were very good; however, target doses were hardly reached (34% and 14%, respectively). Conclusions This study highlighted the need to improve case finding for HF in general practice and showed that an extended audit in the GPs' EHR was a successful strategy to do so. To improve the quality of HF care in general practice, specific strategies are needed to diagnose HFpEF and to reach target doses of disease-modifying drugs in HFrEF patients.

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Section: Discussionsupporting

confidence: 64%

Section: Discussionmentioning

confidence: 55%

Section: Characteristics Of Heart Failure Patients In General Practicementioning

confidence: 99%

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Impact of an extended audit on identifying heart failure patients in general practice: baseline results of the OSCAR‐HF pilot study

et al. 2020

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“…The CUA of small bite sutures was performed from the perspective of the NHS, since this perspective is recommended by NICE. 17 The alternative is a societal perspective, which would consider costs and benefits to the NHS, as well as accounting for indirect costs, such as the loss of productivity to society from work missed due to recovery from surgical complications. 18 While a societal perspective allows for a more patient-centered analysis of costs, this introduces an element of subjectivity.…”

Section: Methodsmentioning

confidence: 99%

A cost-utility analysis of small bite sutures versus large bite sutures in the closure of midline laparotomies in the United Kingdom National Health Service

Gokani¹,

Elmqvist²,

El-Koubani³

et al. 2018

CEOR

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PurposeThis study aimed to perform an economic evaluation of small bite sutures versus large bite sutures in the closure of midline laparotomies in the United Kingdom National Health Service (NHS).MethodsA cost-utility analysis was conducted using data from a systematic literature review. Large bite sutures placed 10 mm from the wound edge were compared to small bite sutures 3–6 mm from the wound edge. The analysis used a 3-year time horizon in order to take into account complications including incisional hernias and surgical site infections (SSIs). Cost and benefit data were considered from the perspective of the NHS. A two-way sensitivity analysis was conducted to assess the impact of a variation in the clinical effectiveness of small bite sutures.ResultsThe incremental cost-effectiveness ratio was calculated to be −£482.61 per quality-adjusted life year (QALY) using the proposed small bite suture technique, indicating a cost saving to the NHS. Sensitivity analysis demonstrated that small bites are a cost-neutral technique provided that the cost of using small bites is less than £98 per patient. Small bites cost less than £20,000/QALY when they reduce either the rate of SSIs by more than 15% or the rate of hernias by more than 3.4%.ConclusionThis study proposes that small bite sutures should become the mainstay suturing technique in the closure of midline laparotomies, replacing large bite sutures, which dominate current practice. The financial savings accompanied by the decrease in SSI rates and herniation warrant the use of this new technique. The sensitivity analysis demonstrates that findings hold true for a wide range of levels of clinical effectiveness for small bites.

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“…8 A recent systematic review by NICE 6 identified only five studies, [9][10][11][12][13] with low risk of bias, while even fewer studies reported on both HF with reduced (HFrEF) and preserved ejection fraction (HFpEF). The NICE guidelines considered evidence from the REFER study and its associated economic evaluation, 5 acknowledging the limited data available in primary care. By combining the REFER individual patient dataset with a similar prospective study carried out in primary care, we provide additional threshold evaluation in diagnosis of HF in primary care.…”

Section: Introductionmentioning

confidence: 99%

Diagnosing heart failure in primary care: individual patient data meta‐analysis of two European prospective studies

et al. 2021

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Aims Natriuretic peptides are helpful in detecting chronic heart failure (HF) in primary care; however, there are a lack of data evaluating thresholds recommended by clinical guidelines. This study assesses the diagnostic accuracy of N-terminal pro-B-type natriuretic peptide (NT-proBNP) using combined individual patient data from two studies in the UK and the Netherlands. Methods and results Random effects methods were used to estimate the performance characteristics of NT-proBNP thresholds recommended by the European Society of Cardiology (ESC) and the UK National Institute for Health and Care Excellence (NICE) guidelines. New onset HF was diagnosed in 313 of 1073 (29.2%) participants. Age, sex, and atrial fibrillation-adjusted NT-proBNP was a better predictor of HF with reduced ejection fraction (HFrEF) than HF preserved ejection fraction (HFpEF), with area under receiver operating characteristic curve of 0.82 95% CI (0.78 to 0.86) vs. 0.71 (0.66 to 0.75). In persons aged 70 years and over, the ESC threshold at 125 ng/L for detection of all-cause HF had summary negative predictive value (NPV) of 84.9% (81.6 to 88.2), positive predictive value (PPV) 68.1% (63.1 to 73.3), sensitivity 74.9% (69.5 to 80.3), and specificity 80.1% (76.9 to 83.4); the NICE threshold at 400 ng/L had summary NPV of 74.7% (72.1 to 77.2), PPV 81.8% (73.3 to 89.5), sensitivity 43.5% (37.2 to 49.8), and specificity 94.5% (92.3 to 96.7). Conclusions N-terminal pro-B-type natriuretic peptide is better at detecting HFrEF than HFpEF in a primary care setting. In persons aged 70 and over, the ESC threshold of 125 ng/L is more accurate at detecting and excluding HF than the higher level suggested in NICE guidelines. More prospective data are required to establish the optimal NP threshold for detecting chronic HF in general practice.

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MICE or NICE? An economic evaluation of clinical decision rules in the diagnosis of heart failure in primary care

Cited by 12 publications

References 20 publications

Impact of an extended audit on identifying heart failure patients in general practice: baseline results of the OSCAR‐HF pilot study

Impact of an extended audit on identifying heart failure patients in general practice: baseline results of the OSCAR‐HF pilot study

A cost-utility analysis of small bite sutures versus large bite sutures in the closure of midline laparotomies in the United Kingdom National Health Service

Diagnosing heart failure in primary care: individual patient data meta‐analysis of two European prospective studies

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