Division of Population Health, Sheffield Centre for Health and Related Research (SCHARR), The University of Sheffield Faculty of Medicine, Dentistry and Health, Sheffield, UK
Division of Population Health, Sheffield Centre for Health and Related Research (SCHARR), The University of Sheffield Faculty of Medicine, Dentistry and Health, Sheffield, UK.
Emerg Med J. 2024 Nov 21;41(12):728-735. doi: 10.1136/emermed-2024-214222.
Acute aortic syndrome (AAS) requires urgent diagnosis with computed tomographic angiography (CTA). Diagnostic strategies need to weigh the benefits of detecting AAS against the costs of using CTA with a low yield of AAS when the prevalence of AAS is low. We aimed to estimate the cost-effectiveness of diagnostic strategies using clinical probability scoring and D-dimer to select patients with potential symptoms of AAS for CTA.
We developed a decision analytical model to simulate the management of patients attending hospital with possible AAS. We modelled diagnostic strategies that used the Aortic Dissection Detection Risk Score (ADD-RS) and D-dimer to select patients for CTA. We used estimates from our meta-analysis, existing literature and clinical experts to model the consequences of diagnostic strategies on survival, health utility, and health and social care costs. We estimated the incremental cost per quality-adjusted life-years gained by each strategy compared with the next most effective alternative on the efficiency frontier.
A strategy based on the Canadian guideline (CTA if ADD-RS>1 or ADD-RS=1 with D-dimer >500 ng/mL) is cost-effective but would result in high rates of CTA if applied to an unselected population (AAS prevalence 0.26%). The strategy is also cost-effective and would result in lower rates of CTA if applied to a more selected population, such as those with a non-zero clinical suspicion of AAS (prevalence 0.61%). For patients currently receiving CTA, using ADD-RS>1 or D-dimer >500 ng/mL to select patients for CTA is cost-effective.
A strategy using ADD-RS>1 or ADD-RS=1 with D-dimer >500 ng/mL to select patients for CTA appears cost-effective but primary research is required to evaluate this strategy in practice and determine how suspicion of AAS is identified.
急性主动脉综合征（AAS）需要通过计算机断层血管造影（CTA）进行紧急诊断。在 AAS 患病率较低的情况下，诊断策略需要权衡检测 AAS 的益处与 CTA 低检出率带来的成本。我们旨在通过临床概率评分和 D-二聚体来估计使用 CTA 选择有潜在 AAS 症状患者的诊断策略的成本效益。
我们开发了一个决策分析模型来模拟有潜在 AAS 症状的患者的就诊管理。我们建立了使用主动脉夹层检测风险评分（ADD-RS）和 D-二聚体来选择疑似患者进行 CTA 的诊断策略模型。我们使用了来自我们的荟萃分析、现有文献和临床专家的估计来模拟诊断策略对生存率、健康效用以及卫生和社会保健成本的影响。我们根据每个策略与效率前沿上的下一个最有效替代方案相比，估计每获得一个质量调整生命年的增量成本。
基于加拿大指南的策略（如果 ADD-RS>1 或 ADD-RS=1 且 D-二聚体>500ng/mL 则进行 CTA）具有成本效益，但如果将其应用于未选择的人群（AAS 患病率为 0.26%），则会导致 CTA 的高检出率。如果将其应用于更具选择性的人群，例如那些具有非零 AAS 临床怀疑的人群（患病率为 0.61%），该策略也具有成本效益，并且会降低 CTA 的检出率。对于目前接受 CTA 的患者，使用 ADD-RS>1 或 D-二聚体>500ng/mL 来选择疑似患者进行 CTA 是具有成本效益的。
使用 ADD-RS>1 或 ADD-RS=1 且 D-二聚体>500ng/mL 来选择疑似患者进行 CTA 的策略似乎具有成本效益，但需要进行进一步的研究以评估该策略在实践中的效果，并确定如何确定对 AAS 的怀疑。
