Kaambwa Billingsley, Ratcliffe Julie, Horsfall Matthew, Astley Carolyn, Karnon Jonathan, Coates Penelope, Arstall Margaret, Zeitz Christopher, Worthley Matthew, Beltrame John, Chew Derek P
Health Economics Unit, Flinders University, Adelaide, Australia.
Health Economics Unit, Flinders University, Adelaide, Australia.
Int J Cardiol. 2017 Jul 1;238:144-150. doi: 10.1016/j.ijcard.2017.02.141. Epub 2017 Mar 2.
Patients with low and intermediate risk chest pain features comprise the greatest proportion presenting to emergency services for evaluation of suspected acute coronary syndromes (ACS). The efficient and timely identification of patients with these features remains a major challenge within clinical practice. Troponin assays are increasingly being used for the determination of risk among patients presenting with chest pain potentially facilitating more appropriate care. To date, no economic evaluation comparing high-sensitivity troponin T (hs-TnT) reporting to standard troponin T (c-TnT) reporting in the routine management of suspected ACS and based on longer-term clinical outcomes has been conducted.
An economic evaluation was conducted with 1937 participants randomized to either hs-TnT (n=973) or c-TnT (n=964) with 12month follow-up. The primary outcome measure was the number of cumulative combined outcomes of all-cause mortality and new or recurrent ACS avoided. Mean per participant Australian Medicare costs were higher in the hs-TnT arm compared to the c-TnT arm (by $1285/patient). Mean total adverse clinical outcomes avoided were higher in the hs-TnT arm (by 0.0120/patient) resulting in an incremental cost-effectiveness ratio (ICER) of $108,552/adverse clinical outcome avoided. An ICER of $49,030/adverse clinical outcome avoided was obtained when the analysis was restricted to patients below the threshold of normal Troponin testing (actual c-TnT levels <30ng/L).
hs-TnT reporting leads to fewer adverse clinical events but at a high ICER. For the routine implementation of hs-TnT to be more cost-effective, substantial changes in clinical practice will be required.
Australian New Zealand Clinical Trials Registry (ACTRN12614000189628). https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=365726.
具有低风险和中风险胸痛特征的患者在因疑似急性冠状动脉综合征（ACS）前往急诊服务机构进行评估的患者中占比最大。在临床实践中，高效且及时地识别具有这些特征的患者仍然是一项重大挑战。肌钙蛋白检测越来越多地用于确定胸痛患者的风险，这可能有助于提供更恰当的治疗。迄今为止，尚未进行基于长期临床结局，比较在疑似ACS的常规管理中高敏肌钙蛋白T（hs-TnT）报告与标准肌钙蛋白T（c-TnT）报告的经济学评估。
进行了一项经济学评估，1937名参与者被随机分为hs-TnT组（n = 973）或c-TnT组（n = 964），并进行了12个月的随访。主要结局指标是避免的全因死亡率以及新发或复发ACS的累积联合结局的数量。与c-TnT组相比，hs-TnT组每位参与者的澳大利亚医疗保险平均费用更高（每位患者高1285美元）。hs-TnT组避免的平均总不良临床结局更高（每位患者高0.0120），导致增量成本效益比（ICER）为每避免一个不良临床结局108,552美元。当分析仅限于肌钙蛋白检测正常阈值以下的患者（实际c-TnT水平<30ng/L）时，获得的ICER为每避免一个不良临床结局49,030美元。
hs-TnT报告导致不良临床事件减少，但ICER较高。要使hs-TnT的常规应用更具成本效益，临床实践将需要进行重大改变。
澳大利亚新西兰临床试验注册中心（ACTRN12614000189628）。https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=365726。
