Ambavane Apoorva, Lindahl Bertil, Giannitsis Evangelos, Roiz Julie, Mendivil Joan, Frankenstein Lutz, Body Richard, Christ Michael, Bingisser Roland, Alquezar Aitor, Mueller Christian
Modeling and Simulation, Evidera, London, United Kingdom.
Department of Medical Sciences, Uppsala University and Uppsala Clinical Research Center, Uppsala, Sweden.
PLoS One. 2017 Nov 9;12(11):e0187662. doi: 10.1371/journal.pone.0187662. eCollection 2017.
The 1-hour (h) algorithm triages patients presenting with suspected acute myocardial infarction (AMI) to the emergency department (ED) towards "rule-out," "rule-in," or "observation," depending on baseline and 1-h levels of high-sensitivity cardiac troponin (hs-cTn). The economic consequences of applying the accelerated 1-h algorithm are unknown.
We performed a post-hoc economic analysis in a large, diagnostic, multicenter study of hs-cTnT using central adjudication of the final diagnosis by two independent cardiologists. Length of stay (LoS), resource utilization (RU), and predicted diagnostic accuracy of the 1-h algorithm compared to standard of care (SoC) in the ED were estimated. The ED LoS, RU, and accuracy of the 1-h algorithm was compared to that achieved by the SoC at ED discharge. Expert opinion was sought to characterize clinical implementation of the 1-h algorithm, which required blood draws at ED presentation and 1h, after which "rule-in" patients were transferred for coronary angiography, "rule-out" patients underwent outpatient stress testing, and "observation" patients received SoC. Unit costs were for the United Kingdom, Switzerland, and Germany. The sensitivity and specificity for the 1-h algorithm were 87% and 96%, respectively, compared to 69% and 98% for SoC. The mean ED LoS for the 1-h algorithm was 4.3h-it was 6.5h for SoC, which is a reduction of 33%. The 1-h algorithm was associated with reductions in RU, driven largely by the shorter LoS in the ED for patients with a diagnosis other than AMI. The estimated total costs per patient were £2,480 for the 1-h algorithm compared to £4,561 for SoC, a reduction of up to 46%.
The analysis shows that the use of 1-h algorithm is associated with reduction in overall AMI diagnostic costs, provided it is carefully implemented in clinical practice. These results need to be prospectively validated in the future.
1小时算法根据高敏心肌肌钙蛋白（hs-cTn）的基线水平和1小时水平，将疑似急性心肌梗死（AMI）的患者分诊至急诊科（ED）进行“排除”“确诊”或“观察”。应用加速1小时算法的经济后果尚不清楚。
我们在一项大型诊断性多中心hs-cTnT研究中进行了事后经济分析，由两名独立心脏病专家对最终诊断进行集中判定。估计了急诊科（ED）的住院时间（LoS）、资源利用（RU）以及1小时算法与标准治疗（SoC）相比的预测诊断准确性。将1小时算法的ED LoS、RU和准确性与ED出院时SoC所达到的结果进行比较。征求专家意见以描述1小时算法的临床实施情况，该算法要求在ED就诊时和1小时后进行血液检查，之后“确诊”患者转至冠状动脉造影，“排除”患者接受门诊负荷试验，“观察”患者接受SoC。单位成本以英国、瑞士和德国的数据为准。1小时算法的敏感性和特异性分别为87%和96%，而SoC的敏感性和特异性分别为69%和98%。1小时算法的平均ED LoS为4.3小时，SoC为6.5小时，减少了33%。1小时算法与RU的降低相关，这主要是由于非AMI诊断患者在ED的LoS较短。1小时算法估计每位患者的总成本为2480英镑，而SoC为4561英镑，最多降低了46%。
分析表明，使用1小时算法可降低AMI的总体诊断成本，前提是在临床实践中谨慎实施。这些结果未来需要进行前瞻性验证。
