What is the clinical evidence from this study?

Study design: Observational. Population: Possible acute coronary syndromes (n=719). Intervention: High-sensitivity troponin I-supported algorithms vs. Standard care (sensitive troponin protocols). Primary outcome: Direct hospital costs, number of false-negative and false-positive cases in the assessment of acute coronary syndrome (average cost reduction of $490).

What question did this study set out to answer?

To evaluate the hospital-level health economic implications and diagnostic performance of multiple high-sensitivity troponin I testing protocols for emergency department chest pain assessment.

June 1, 2017BMJ OpenOpen Access

The organisational value of diagnostic strategies using high-sensitivity troponin for patients with possible acute coronary syndromes: a trial-based cost-effectiveness analysis

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Key result

High-sensitivity troponin I-supported algorithms increased diagnostic accuracy from 90.0% to 94.0% and reduced average costs by $490 per patient compared with standard care.

Why the study?

Do high-sensitivity troponin I-enabled algorithms reduce hospital costs and improve diagnostic accuracy compared to standard care in ED patients with suspected ACS?

Population

719 adult patients presenting to the emergency department with at least 5 minutes of chest pain suggestive…

Comparison

High-sensitivity troponin I-enabled diagnostic… vs Standard care using a sensitive troponin assay…

Design

Cohort, Laboratory technicians were blinded to patient data. A second…

Follow-up

30 days

Authors

PJPaul JülicherAbbott (United States)JGJaimi GreensladeCardiac Imaging WPWilliam ParsonageQueensland University of Technology

Discussion

Member takes

Implication

May improve ED efficiency and lower costs; leaves open need for prospective validation before practice change.

Key Points

To evaluate the hospital-level health economic implications and diagnostic performance of multiple high-sensitivity troponin I testing protocols for emergency department chest pain assessment.
Developed a cost prediction model and economic microsimulation using 40,000 bootstrapped iterations based on a single-center cohort from the prospective ADAPT trial (recruited 2008–2011).
Analyzed data from 719 patients with complete records (out of 938 presenting with at least 5 minutes of symptoms suggestive of acute coronary syndrome) in an adult emergency department of a tertiary referral hospital.
Compared five high-sensitivity troponin I algorithms incorporating accelerated rule-out criteria against standard care to measure direct hospital costs, length of stay, and diagnostic accuracy.
High-sensitivity troponin I algorithms increased overall diagnostic accuracy from 90.0% to 94.0% while yielding an average direct hospital cost reduction of $490 per patient compared with standard care.
Accelerated diagnostic algorithms incorporating limit of detection and modified 2-hour ADAPT rules shortened hospital length of stay by 13.6 hours (6.2 hours for high-sensitivity troponin I alone) and reduced overnight hospitalizations by up to 43%.
Accelerated rule-out protocols prevented 7.5% of short-stay unit admissions and 25% of cardiac ward admissions, with all clinical and economic benefits observed exclusively in patients without acute coronary syndromes.

Study Design

Type

Observational (n=719)

Multicenter

Structured PICO

Do high-sensitivity troponin I-enabled algorithms reduce hospital costs and improve diagnostic accuracy compared to standard care in ED patients with suspected ACS?

Population

719 adult patients presenting to the emergency department with at least 5 minutes of symptoms suggestive of acute coronary syndrome.

Exposure

High-sensitivity troponin I (hsTnI)-enabled diagnostic algorithms (including hsTnI alone, hsTnI + limit of detection, hsTnI + modified ADAPT accelerated diagnostic protocol, or combinations)

Comparator

Standard care using a sensitive troponin assay (Beckman Coulter second-generation AccuTnI) and standard assessment

Outcome

Direct hospital costs and diagnostic accuracy (number of false-negative and false-positive cases of acute coronary syndrome at 30 days)

Main Result

Effect estimate: average cost reduction of $490

Absolute Event Rate: 94% vs 90%

Implementing high-sensitivity troponin I algorithms with accelerated diagnostic protocols in the emergency department improves diagnostic accuracy and significantly reduces hospital costs and length of stay for patients with suspected acute coronary syndrome.

Limitations

Cost data were based on information from an administrative database
Cost prediction was limited to activities during the assessment period
Economic implications from breaching specific emergency department targets or access blocks were not taken into account
Generalisability might be hindered by the variety of assessment processes

Cite This Study

Jülicher et al. (2017) conducted an observational in Possible acute coronary syndromes (n=719). High-sensitivity troponin I-supported algorithms vs. Standard care (sensitive troponin protocols) was evaluated on Direct hospital costs, number of false-negative and false-positive cases in the assessment of acute coronary syndrome (average cost reduction of $490). High-sensitivity troponin I-supported algorithms increased diagnostic accuracy from 90.0% to 94.0% and reduced average costs by $490 per patient compared with standard care.

synapsesocial.com/papers/6a73071e95da05bdca32f2ba https://doi.org/10.1136/bmjopen-2016-013653

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