Cost-effectiveness of follow-up algorithms for chronic thromboembolic pulmonary hypertension in pulmonary embolism survivors

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  FIGURE 1. The 11 scenarios evaluating different follow-up algorithms to detect chronic thromboembolic pulmonary hypertension (CTEPH) in acute pulmonary emoblism (PE) patients. a) Algorithms identified using a literature search; b) hypothetical algorithms in which diagnostic tests are performed in all acute PE patients; and c) hypothetical algorithms in which diagnostic tests are only performed in patients that remain symptomatic during follow-up. A green line presents a “positive result” and a red line presents a “negative result” of the diagnostic test. All algorithms start ∼3 months after an index PE diagnosis. Assumptions made in the evaluation of the algorithms: if available, we used the echocardiogram performed as a part of the InShape II algorithm to calculate diagnostic accuracy of the echocardiogram. For patients who were not subjected to an echocardiogram as part of the InShape II algorithm, we used the 2-year follow-up echocardiogram as a surrogate outcome. The algorithms by Lewczuk et al. [15] (A3) used repeating measurement of diagnostic tests at different time-points in case of a negative test result in the preceding test. The InShape II study did not perform all diagnostic…

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  FIGURE 2. Flowchart of dedicated follow-up, (additional) diagnostic and treatment costs of each scenario. a) Scenario 0: no structural follow-up for chronic thromboembolic pulmonary hypertension (CTEPH). b) Scenarios in which a dedicated follow-up algorithm is applied. As right heart catheterisation (RHC) is the golden standard for CTEPH diagnosis, there were considered to be no false-positive CTEPH diagnoses. However, a false-negative result from a diagnostic test prior to RHC is possible; therefore a temporarily false-negative CTEPH diagnosis is included in our model (b). PE: pulmonary embolism; VQ: ventilation/perfusion.

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  FIGURE 3. Lifelong healthcare costs per chronic thromboembolic pulmonary hypertension patient (in euros) for the 12 scenarios. RHC: right heart catheterisation; VQ: ventilation/perfusion; TTE: trans-thoracic echocardiogram; ESC: European Society of Cardiology.

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  FIGURE 4. Total lifelong healthcare costs and quality-adjusted life-years (QALYs) per chronic thromboembolic pulmonary hypertension (CTEPH) patient. A scenario is dominated if there is another algorithm that is at least as good on both costs and QALYs, and strictly better on at least one of costs and QALYs. A scenario is weakly dominated if it is dominated by a mixture of two other algorithms. The scenarios that are not (weakly) dominated by others are potentially cost-effective and together form the efficient frontier (black line). 0: no dedicated CTEPH follow-up; A1: European Society of Cardiology; A2: InShape II; A3: Lewczuk et al. [15]; A4: Held et al. [16]; A5: InShape IV; B1: trans-thoracic echocardiogram (TTE)-ventilation/perfusion scan (VQ)-right heart catheterisation (RHC); B2: VQ-TTE-RHC; B3: VQ-RHC; C1: symptom-TTE-VQ-RHC; C2: symptom-VQ-TTE-RHC; C3: symptom-VQ-RHC.