Centre for Health Economics, University of York, Heslington, UK.
Centre for Health Economics, University of York, Heslington, UK.
Eur J Radiol. 2021 Sep;142:109872. doi: 10.1016/j.ejrad.2021.109872. Epub 2021 Jul 27.
Patients undergoing contrast-enhanced computed tomography (CECT) imaging in a non-emergency outpatient setting often lack a recent estimated Glomerular Filtration Rate measurement. This may lead to inefficiencies in the CECT pathway. The use of point-of-care (POC) creatinine tests to evaluate kidney function in these patients may provide a safe and cost-effective alternative to current practice, as these can provide results within the same CECT appointment.
A decision tree model was developed to characterise the diagnostic pathway and patient management (e.g., intravenous hydration) and link these to adverse renal events associated with intravenous contrast media. Twelve diagnostic strategies including three POC devices (i-STAT, ABL800 Flex and StatSensor), risk factor screening and laboratory testing were compared with current practice. The diagnostic accuracy of POC devices was derived from a systematic review and meta-analysis; relevant literature sources and databases informed other parameters. The cost-effective strategy from a health care perspective was identified based on highest net health benefit (NHB) which were expressed in quality-adjusted life years (QALYs) at £20,000/QALY.
The cost-effective strategy, with a NHB of 9.98 QALYs and a probability of being cost-effective of 79.3%, was identified in our analysis to be a testing sequence involving screening all individuals for risk factors, POC testing (with i-STAT) on those screening positive, and performing a confirmatory laboratory test for individuals with a positive POC result. The incremental NHB of this strategy compared to current practice, confirmatory laboratory test, is 0.004 QALYs. Results were generally robust to scenario analysis.
A testing sequence combining a risk factor questionnaire, POC test and confirmatory laboratory testing appears to be cost-effective compared to current practice. The cost-effectiveness of POC testing appears to be driven by reduced delays within the CECT pathway. The contribution of intravenous contrast media to acute kidney injury, and the benefits and harms of intravenous hydration remain uncertain.
在非急诊门诊环境下进行对比增强计算机断层扫描（CECT）成像的患者通常缺乏最近的估计肾小球滤过率测量值。这可能导致 CECT 路径效率低下。在这些患者中使用即时护理（POC）肌酐测试来评估肾功能可能提供一种安全且具有成本效益的替代当前实践的方法，因为这些测试可以在同一 CECT 预约中提供结果。
开发了一个决策树模型来描述诊断途径和患者管理（例如，静脉补液），并将这些途径与静脉造影剂相关的不良肾脏事件联系起来。将 12 种诊断策略（包括三种 POC 设备（i-STAT、ABL800 Flex 和 StatSensor）、风险因素筛查和实验室检测）与当前实践进行了比较。POC 设备的诊断准确性源自系统评价和荟萃分析；相关文献来源和数据库为其他参数提供了信息。从医疗保健角度出发，确定了具有最高净健康效益（NHB）的成本效益策略，这些策略以每 QALY 20,000 英镑表示的质量调整生命年（QALYs）表示。
在我们的分析中，确定了一种具有 NHB 为 9.98 QALYs 和具有 79.3%的成本效益概率的成本效益策略，该策略涉及对所有人进行风险因素筛查，对筛查阳性者进行 POC 测试（使用 i-STAT），并对 POC 结果阳性者进行确认性实验室测试。与当前实践相比，该策略的增量 NHB 为 0.004 QALY。结果对情景分析具有较强的稳健性。
与当前实践相比，结合风险因素问卷、POC 测试和确认性实验室测试的测试序列似乎具有成本效益。POC 测试的成本效益似乎是由于 CECT 途径中的延迟减少所致。静脉内造影剂对急性肾损伤的贡献，以及静脉内补液的益处和危害仍然不确定。
