Early health technology assessment of future clinical decision rule aided triage of patients presenting with acute chest pain in primary care

Abstract

The objective of the paper is to estimate the number of patients presenting with chest pain suspected of acute coronary syndrome (ACS) in primary care and to calculate possible cost effects of a future clinical decision rule (CDR) incorporating a point-of-care test (PoCT) as compared with current practice. The annual incidence of chest pain, referrals and ACS in primary care was estimated based on a literature review and on a Dutch and Belgian registration study. A health economic model was developed to calculate the potential impact of a future CDR on costs and effects (ie, correct referral decisions), in several scenarios with varying correct referral decisions. One-way, two-way, and probabilistic sensitivity analyses were performed to test robustness of the model outcome to changes in input parameters. Annually, over one million patient contacts in primary care in the Netherlands concern chest pain. Currently, referral of eventual ACS negative patients (false positives, FPs) is estimated to cost €1,448 per FP patient, with total annual cost exceeding 165 million Euros in the Netherlands. Based on 'international data', at least a 29% reduction in FPs is required for the addition of a PoCT as part of a CDR to become cost-saving, and an additional €16 per chest pain patient (ie, 16.4 million Euros annually in the Netherlands) is saved for every further 10% relative decrease in FPs. Sensitivity analyses revealed that the model outcome was robust to changes in model inputs, with costs outcomes mainly driven by costs of FPs and costs of PoCT. If PoCT-aided triage of patients with chest pain in primary care could improve exclusion of ACS, this CDR could lead to a considerable reduction in annual healthcare costs as compared with current practice.

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

“…Chest pain and other symptoms suggestive of non-ST-segment elevation acute coronary syndrome (NSTE-ACS) represent a major challenge for primary care physicians due to a lack of sensitive diagnostic decision aids outside of hospital [ 2 , 3 ]. Although the prevalence of acute myocardial infarction (AMI) in a primary care setting is usually below 5%, [ 4 – 6 ] diagnostic uncertainty results in defensive practice with increased hospital referral rates for the exclusion of an acute cardiac event [ 7 – 10 ]. Still, as demonstrated by Vester et al, more than 80% of these referrals end up with a non-cardiac diagnosis at discharge [ 11 ].…”

“…There is a growing international awareness to address issues related to overdiagnosis, [ 12 – 16 ] where extensive hospital admission of low-risk patients with chest pain and screening with high-sensitivity cardiac troponins (hs-cTn) are highlighted examples of overuse of care [ 14 – 16 ]. Studies from the Netherlands have shown that hospital admission of patients considered as false-positive ACS [ 6 ] or as low-risk by the HEART (History, Electrocardiogram (ECG), Age, Risk factors and Troponin) score [ 17 ] yield few additional health benefits despite substantial use of healthcare expenditure. Both studies further elaborated on the potential reduction in overall expenses if these low-risk groups were offered improved risk stratification outside the emergency departments (ED) [ 6 , 17 ].…”

“…Studies from the Netherlands have shown that hospital admission of patients considered as false-positive ACS [ 6 ] or as low-risk by the HEART (History, Electrocardiogram (ECG), Age, Risk factors and Troponin) score [ 17 ] yield few additional health benefits despite substantial use of healthcare expenditure. Both studies further elaborated on the potential reduction in overall expenses if these low-risk groups were offered improved risk stratification outside the emergency departments (ED) [ 6 , 17 ].…”

De huisarts is een prima sneltest bij pijn op de borst

“…18 We hebben voor deze unieke flashmob-opzet gekozen om recruteringsproblemen te omzeilen en om snel antwoord te krijgen op de onderzoeksvraag. 19 Deze aanpak bleek vruchtbaar, met een inclusie van 258 patiënten in twee weken tijd. Bij een incidentie van ACS van 19,3% in de onderzoekspopulatie bleek de negatief voorspellende waarde van de MHS echter slechts 88,0% (bij de veelgebruikte afkapwaarde van 2 punten).…”

Evaluating possible acute coronary syndrome in primary care: the value of signs, symptoms, and plasma heart-type fatty acid-binding protein (H-FABP). A diagnostic study

“…1,[5][6][7] To reduce ACS-negative referrals in primary care and thereby diminish costs and patient discomfort -without a rise in missed cases of ACS -a CDR based on a clinical score of signs, symptoms, and POC biomarker testing detecting myocardial cell damage (such as high-sensitive cardiac troponin [hs-cTn] or H-FABP) is desirable. 3,[8][9][10][11][12][13][14][15][16][17] A potential role for H-FABP POC testing was earlier found using a cut-off value of 4 ng/ml, in an emergency department setting. 18…”