Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia.
School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
JAMA Intern Med. 2023 Mar 1;183(3):203-211. doi: 10.1001/jamainternmed.2022.6409.
Prehospital point-of-care troponin testing and paramedic risk stratification might improve the efficiency of chest pain care pathways compared with existing processes with equivalent health outcomes, but the association with health care costs is unclear.
To analyze whether prehospital point-of-care troponin testing and paramedic risk stratification could result in cost savings compared with existing chest pain care pathways.
DESIGN, SETTING, AND PARTICIPANTS: In this economic evaluation of adults with acute chest pain without ST-segment elevation, cost-minimization analysis was used to assess linked ambulance, emergency, and hospital attendance in the state of Victoria, Australia, between January 1, 2015, and June 30, 2019.
Paramedic risk stratification and point-of-care troponin testing.
The outcome was estimated mean annualized statewide costs for acute chest pain. Between May 17 and June 25, 2022, decision tree models were developed to estimate costs under 3 pathways: (1) existing care, (2) paramedic risk stratification and point-of-care troponin testing without prehospital discharge, or (3) prehospital discharge and referral to a virtual emergency department (ED) for low-risk patients. Probabilities for the prehospital pathways were derived from a review of the literature. Multivariable probabilistic sensitivity analysis with 50 000 Monte Carlo iterations was used to estimate mean costs and cost differences among pathways.
A total of 188 551 patients attended by ambulance for chest pain (mean [SD] age, 61.9 [18.3] years; 50.5% female; 49.5% male; Indigenous Australian, 2.0%) were included in the model. Estimated annualized infrastructure and staffing costs for the point-of-care troponin pathways, assuming a 5-year device life span, was $2.27 million for the pathway without prehospital discharge and $4.60 million for the pathway with prehospital discharge (incorporating virtual ED costs). In the decision tree model, total annual cost using prehospital point-of-care troponin and paramedic risk stratification was lower compared with existing care both without prehospital discharge (cost savings, $6.45 million; 95% uncertainty interval [UI], $0.59-$16.52 million; lower in 94.1% of iterations) and with prehospital discharge (cost savings, $42.84 million; 95% UI, $19.35-$72.26 million; lower in 100% of iterations).
Prehospital point-of-care troponin and paramedic risk stratification for patients with acute chest pain could result in substantial cost savings. These findings should be considered by policy makers in decisions surrounding the potential utility of prehospital chest pain risk stratification and point-of-care troponin models provided that safety is confirmed in prospective studies.
与具有同等健康结果的现有流程相比，院前即时检测肌钙蛋白和护理人员风险分层可能会提高胸痛护理路径的效率，但与医疗保健成本的关联尚不清楚。
分析院前即时检测肌钙蛋白和护理人员风险分层是否会导致与现有胸痛护理路径相比节省成本。
设计、设置和参与者：在这项对无 ST 段抬高的急性胸痛成年人的经济学评估中，使用成本最小化分析来评估澳大利亚维多利亚州 2015 年 1 月 1 日至 2019 年 6 月 30 日期间救护车、急诊和医院就诊的关联。
护理人员风险分层和即时检测肌钙蛋白。
结果是估计全州急性胸痛的年度平均成本。在 2022 年 5 月 17 日至 6 月 25 日期间，开发了决策树模型来估计 3 种途径下的成本：（1）现有护理，（2）无院前出院的护理人员风险分层和即时检测肌钙蛋白，或（3）院前出院和低风险患者转至虚拟急诊（ED）。院前途径的概率来自文献回顾。使用 50000 次蒙特卡罗迭代的多变量概率敏感性分析用于估计途径之间的平均成本和成本差异。
共有 188551 名因胸痛乘坐救护车就诊的患者（平均[标准差]年龄，61.9[18.3]岁；50.5%女性；49.5%男性；原住民澳大利亚人，2.0%）纳入模型。假设设备寿命为 5 年，即时检测肌钙蛋白的院前途径的基础设施和人员配备年度成本为无院前出院途径 227 万美元，院前出院途径 460 万美元（包含虚拟 ED 成本）。在决策树模型中，与现有护理相比，使用院前即时检测肌钙蛋白和护理人员风险分层的总年度成本均较低，无论是否有院前出院（节省成本，6450 万美元；95%不确定区间[UI]，0.59-16.52 万美元；迭代 94.1%的情况下较低）和有院前出院（节省成本，4284 万美元；95%UI，19.35-72.26 万美元；迭代 100%的情况下较低）。
对急性胸痛患者进行院前即时检测肌钙蛋白和护理人员风险分层可能会带来大量成本节省。在确认前瞻性研究中的安全性后，决策者在考虑院前胸痛风险分层和即时检测肌钙蛋白模型的潜在效用时应考虑这些发现。
