From the IIB SANT PAU, Institut d'Investigació Biomèdica Sant Pau, Barcelona, Spain (EP, PA-C, IG-S), Centro Cochrane Iberoamericano, Barcelona, Spain (EP, PA-C), CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain (PA-C, IG-S), Hospital de la Santa Creu i Sant Pau, Department of Cardiology, Barcelona, Spain (JÁ-G, MV-B), Hospital Universitario Ramon y Cajal, Department of Cardiology, Madrid, Spain (JÁ-G), Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), Madrid, Spain (JÁ-G), Hospital de la Santa Creu i Sant Pau, Department of Anaesthesia and Pain Management, Barcelona, Spain (PP-I, AF-G), Institut de Recerca Biomèdica de Lleida (IRBLleida), Department of Basic Medical Sciences, Lleida, Spain (MR-M), Research Group in Statistical and Economic Analysis in Health (GRAEES), Lleida, Spain (MR-M), Fundació Institut d'Investigació Sanitària Illes Balears (IdISBa), Department of Cardiology, Palma, Balearic Islands, Spain (MV-B), Hospital de la Santa Creu i Sant Pau, Department of Clinical Epidemiology and Public Health, Barcelona, Spain (IG-S), Hospital de la Santa Creu i Sant Pau, Department of Biochemistry, Barcelona, Spain (CM-B, JO-L), Fundación para la Bioquímica Clínica y Patología Molecular. Barcelona, Spain (JO-L), Universitat Rovira i Virgili, Economy Faculty, Reus, Spain (MC-L), Centro de Investigación en Economía y Sostenibilidad (ECO-SOS), Reus, Spain (MC-L).
Eur J Anaesthesiol. 2023 Mar 1;40(3):179-189. doi: 10.1097/EJA.0000000000001793. Epub 2023 Jan 11.
About 300 million surgeries are performed worldwide annually and this figure is increasing constantly. Peri-operative myocardial injury (PMI), detected by cardiac troponin (cTn) elevation, is a common cardiac complication of noncardiac surgery, strongly associated with short- and long-term mortality. Without systematic peri-operative cTn screening, most cases of PMI may go undetected. However, little is known about cost effectiveness of a systematic PMI screening strategy with high-sensitivity cardiac troponin T (hs-cTnT) after noncardiac surgery.
To assess, in patients with high cardiovascular risk, the cost-effectiveness of a systematic screening strategy using a hs-cTnT assay, to identify patients with PMI after major noncardiac surgery, compared with usual care.
Cost-effectiveness analysis; single centre prospective cohort study.
Spanish University Hospital.
From July 2016 to March 2019, we included 1477 consecutive surgical patients aged ≥65 or if <65, with documented history of cardiovascular disease or impaired renal function, who underwent major noncardiac surgery and required at least an overnight hospital stay. We excluded patients aged <65 years without cardiovascular disease, undergoing minor surgery, or with an expected <24 h hospital stays.
We conducted a decision-tree analysis, comparing a systematic screening strategy measuring hs-cTnT before surgery, and at the 2nd and 3rd days after surgery vs. a usual care strategy. We considered a third-party payer perspective and the outcomes of both strategies in the short-term (30 days follow-up). Information about costs was expressed in Euros-2021. We calculated the incremental cost-effectiveness ratio (ICER) of the systematic hs-cTnT strategy, defined as the expected cost per any additional PMI detected, and explored the robustness of the model using deterministic and probabilistic sensitivity analysis.
ICER of the systematic hs-cTnT screening strategy.
The ICER was €425 per any additionally detected PMI. The deterministic sensitivity analysis showed that a 15% variation in costs, and a 1% variation in the predictive values, had a minor impact over the ICER, except in case of the negative predictive value of the systematic hs-cTnT screening strategy. Monte Carlo simulations (probabilistic sensitivity analysis) showed that systematic hs-cTnT screening would be cost-effective in 100% of cases with a 'willingness to pay' of €780.
Our results suggest that systematic peri-operative PMI screening with hs-cTnT may be cost-effective in the short-term in patients undergoing major noncardiac surgery. Economic evaluations, with a long-term horizon, are still needed.
Clinicaltrials.gov identifier: NCT03438448.
全球每年约有 3 亿例手术，且这一数字还在不断增加。围手术期心肌损伤（PMI）是一种常见的非心脏手术心脏并发症，通过心肌肌钙蛋白（cTn）升高来检测，与短期和长期死亡率密切相关。如果没有系统的围手术期 cTn 筛查，大多数 PMI 可能会被漏诊。然而，对于非心脏手术后使用高敏心肌肌钙蛋白 T（hs-cTnT）进行系统 PMI 筛查策略的成本效益，我们知之甚少。
在心血管风险较高的患者中，评估使用 hs-cTnT 检测对主要非心脏手术后 PMI 进行系统筛查的成本效益，与常规护理相比。
成本效益分析；单中心前瞻性队列研究。
西班牙大学医院。
2016 年 7 月至 2019 年 3 月，我们纳入了 1477 例连续接受手术的患者，年龄≥65 岁，或<65 岁，有心血管疾病病史或肾功能受损，接受了主要非心脏手术，需要至少住院过夜。我们排除了年龄<65 岁且无心血管疾病、接受小手术或预计住院时间<24 小时的患者。
我们进行了决策树分析，比较了术前、术后第 2 天和第 3 天测量 hs-cTnT 的系统筛查策略与常规护理策略。我们从第三方支付者的角度考虑了两种策略的短期（30 天随访）结果。有关成本的信息以欧元-2021 表示。我们计算了系统 hs-cTnT 策略的增量成本效益比（ICER），定义为每检测到一次额外 PMI 的预期成本，并使用确定性和概率敏感性分析来探索模型的稳健性。
系统 hs-cTnT 筛查策略的 ICER。
每检测到一次额外 PMI 的 ICER 为 425 欧元。确定性敏感性分析表明，成本变化 15%，预测值变化 1%，对 ICER 的影响较小，除非系统 hs-cTnT 筛查策略的阴性预测值发生变化。蒙特卡罗模拟（概率敏感性分析）表明，在“支付意愿”为 780 欧元的情况下，系统 hs-cTnT 筛查将在 100%的情况下具有成本效益。
我们的研究结果表明，在接受主要非心脏手术的患者中，使用 hs-cTnT 进行围手术期 PMI 系统筛查可能具有短期成本效益。仍需要进行具有长期时间范围的经济评估。
Clinicaltrials.gov 标识符：NCT03438448。
