Key result
Combining NT-proBNP rule-out with age-specific rule-in thresholds proves more cost-effective than clinical decision or rule-out alone.
Why the study?
NT-proBNP uptake for acute heart failure diagnosis has been poor due to concerns over excessive false positives from the low specificity of a single rule-out threshold, which may be mitigated by adding age-specific rule-in thresholds.
Does NT-proBNP testing using age-specific rule-in/rule-out thresholds improve cost-effectiveness compared to rule-out only or clinical decision alone in patients with suspected acute heart failure in the ED?
Does NT-proBNP testing using age-specific rule-in/rule-out thresholds improve cost-effectiveness compared to rule-out only or clinical decision alone in patients with suspected acute heart failure in the ED?
Effect estimate: Dominant vs CDA; ICER £64,518/QALY for RO vs RI/RO
Combining an NT-proBNP rule-out threshold with age-specific rule-in thresholds is highly cost-effective for diagnosing acute heart failure in the emergency department, reducing unnecessary admissions and echocardiograms.
Clinical assessment misses ~22% of AHF cases; cost-effectiveness analysis leaves optimal NT-proBNP implementation open.
AIMS: When relying on clinical assessment alone, an estimated 22% of acute heart failure (AHF) patients are missed, so clinical guidelines recommend the use of N-terminal pro-B-type natriuretic peptide (NT-proBNP) for AHF diagnosis. Since publication of these guidelines, there has been poor uptake of NT-proBNP testing in part due to concerns over excessive false positive referrals resulting from the low specificity of a single 'rule-out' threshold of <300 pg/mL. Low specificity can be mitigated by the addition of age-specific 'rule-in' NT-proBNP thresholds. METHODS AND RESULTS: A theoretical hybrid decision tree/semi-Markov model was developed, combining global trial and audit data to evaluate the cost-effectiveness of NT-proBNP testing using age-specific rule-in/rule-out (RI/RO) thresholds, compared with NT-proBNP RO only and with clinical decision alone (CDA). Cost-effectiveness was measured as the incremental cost per quality-adjusted life year (QALY) gained and incremental net health benefit. In the base case, using UK-specific inputs, NT-proBNP RI/RO was associated with both greater QALYs and lower costs than CDA. At a willingness-to-pay threshold of £20 000/QALY, NT-proBNP RO was also cost-effective compared with CDA [incremental cost-effectiveness ratio (ICER) of £8322/QALY], but not cost-effective vs. RI/RO (ICER of £64 518/QALY). Overall, NT-proBNP RI/RO was the most cost-effective strategy. Sensitivity and scenario analyses were undertaken; the conclusions were not impacted by plausible variations in parameters, and similar conclusions were obtained for the Netherlands and Spain. CONCLUSIONS: An NT-proBNP strategy that combines an RO threshold with age-specific RI thresholds provides a cost-effective alternative to the currently recommended NT-proBNP RO only strategy, achieving greater diagnostic specificity with minimal reduction in sensitivity and thus reducing unnecessary echocardiograms and hospital admissions.
No takes yet. Share an insight, caveat, or question.
Walkley et al. (2023) studied Suspected acute heart failure (n=1,000). NT-proBNP rule-in/rule-out (RI/RO) strategy vs. NT-proBNP rule-out (RO) only strategy and clinical decision alone (CDA) was evaluated on Incremental cost-effectiveness ratio (ICER) per quality-adjusted life year (QALY) gained (Dominant vs CDA; ICER £64,518/QALY for RO vs RI/RO). An NT-proBNP strategy combining a rule-out threshold with age-specific rule-in thresholds was more effective and less costly than clinical decision alone, and more cost-effective than a rule-out only strategy.
Synapse has enriched 5 closely related papers on similar clinical questions. Consider them for comparative context: