Cost effectiveness of high-sensitivity troponin compared to conventional troponin among patients presenting with undifferentiated chest pain: A trial based analysis.

BACKGROUND: Patients with low and intermediate risk chest pain features comprise the greatest proportion presenting to emergency services for evaluation of suspected acute coronary syndromes (ACS). The efficient and timely identification of patients with these features remains a major challenge within clinical practice. Troponin assays are increasingly being used for the determination of risk among patients presenting with chest pain potentially facilitating more appropriate care. To date, no economic evaluation comparing high-sensitivity troponin T (hs-TnT) reporting to standard troponin T (c-TnT) reporting in the routine management of suspected ACS and based on longer-term clinical outcomes has been conducted. METHODS AND RESULTS: An economic evaluation was conducted with 1937 participants randomized to either hs-TnT (n=973) or c-TnT (n=964) with 12month follow-up. The primary outcome measure was the number of cumulative combined outcomes of all-cause mortality and new or recurrent ACS avoided. Mean per participant Australian Medicare costs were higher in the hs-TnT arm compared to the c-TnT arm (by $1285/patient). Mean total adverse clinical outcomes avoided were higher in the hs-TnT arm (by 0.0120/patient) resulting in an incremental cost-effectiveness ratio (ICER) of $108,552/adverse clinical outcome avoided. An ICER of $49,030/adverse clinical outcome avoided was obtained when the analysis was restricted to patients below the threshold of normal Troponin testing (actual c-TnT levels <30ng/L). CONCLUSIONS: hs-TnT reporting leads to fewer adverse clinical events but at a high ICER. For the routine implementation of hs-TnT to be more cost-effective, substantial changes in clinical practice will be required. CLINICAL TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ACTRN12614000189628). https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=365726.

Economic Considerations of Early Rule-In/Rule-Out Algorithms for The Diagnosis of Myocardial Infarction in The Emergency Department Using Cardiac Troponin and Glycemic Biomarkers.

BACKGROUND: We have previously demonstrated the utility of a rule-in/rule-out strategy for myocardial infarction (MI) using glycemic biomarkers in combination with cardiac troponin in the emergency department (ED). Given that the cost of assessing patients with possible MI in the ED is increasing, we sought to compare the health services cost of our previously identified early rule-in/rule-out approaches for MI among patients who present to the ED with symptoms suggestive of acute coronary syndrome (ACS). METHODS: We compared the cost differences between different rule-in/rule-out strategies for MI using presentation cardiac troponin I (cTnI), high-sensitivity cTnI (hs-cTnI), high-sensitivity cardiac troponin T (hs-cTnT), glucose, and/or hemoglobin A1c (Hb A1c) in 1137 ED patients (7-day MI n = 133) as per our previously defined algorithms and compared them with the European Society of Cardiology (ESC) 0-h algorithm-cutoffs. Costs associated with each decision model were obtained from site-specific sources (length of stay) and provincial sources (Ontario Case Costing Initiative). RESULTS: Algorithms incorporating cardiac troponin and glucose for early rule-in/rule-out were the most cost effective and clinically safest methods (i.e., ≤1 MI missed) for early decision making, with hs-cTnI and glucose yielding lower costs compared to cTnI and glucose, despite the higher price for the hs-cTnI test. The addition of Hb A1c to the algorithms increased the cost of these algorithms but did not miss any additional patients with MI. Applying the ESC 0-h algorithm-cutoffs for hs-cTnI and hs-cTnT were the most costly. CONCLUSIONS: Rule-in/rule-out algorithms incorporating presentation glucose with high-sensitivity cardiac troponin are the safest and most cost-effective options as compared to the ESC 0-h algorithm-cutoffs.

A third troponin T blood sample is not cost-effective in patients with suspected non-ST segment elevation acute coronary syndrome.

BACKGROUND: The diagnosis of acute myocardial infarction requires troponin assessment in at least two blood samples 6-9 hours apart, with an optional third sample 12-24 hours after admission if suspicion is high. Yet, in many institutions, this third sample is routinely drawn. This study aimed to evaluate cost-effectiveness of this third sample of troponin. METHODS: A total of 534 patients with possible Non ST-Elevation Acute Coronary Syndrome (NSTE-ACS) were included. Blood samples for cardiac TroponinT (cTnT) were obtained on arrival, after 6-9 hours, and 12-24 hours after admission. The costs of cTnT analysis, and hospital stay were calculated. RESULTS: Of the 534 patients, 124 had at least one elevated cTnT value. Among these, four patients (3.2%) had cTnT values increased only in the third sample. Based on their risk profile and/or ECG changes, these four patients were eligible for referral to coronary angiography even before the result of the third sample became available. The number of patients whose length of stay was extended solely because of the third sample was 275. Incremental cost of the third blood sample: [534 patients × Euro (EUR) 12 per cTnT analysis] + [275 patients × 0.5 day × EUR 1,550] = EUR 219,533. Approximately 1400 patients with suspected NSTE-ACS are admitted to our department each year. Thus, the total cost per year is: (1,400/534) × EUR 219,533 = EUR 575,555. CONCLUSION: A third troponin sample adds no vital information regarding patients' treatment or investigations plan. On the contrary, it may lead to an unnecessary extension of the admission period and increased costs.

Troponin T: role in altering patient management and enabling earlier discharge from a district general hospital.

The use of troponin T to facilitate early patient discharge was investigated in a prospective study in a district general hospital. Troponin T was measured in 91 patients admitted over a period of 6 months with chest pain but without evidence of myocardial infarction. The main outcome measure was length of hospital stay. A negative troponin T was found in 70 patients. Fifty of these were discharged within 24 h of the troponin result being available and they had a significantly shorter hospital stay than a case control group and a historical control group from the previous 6 months. Troponin T measurement has a role in altering patient management by enabling early discharge, resulting in significant cost savings and increasing bed availability.