ORIGINAL ARTICLE

Cost effectiveness of diagnostic strategies for patients with acute, undifferentiated chest pain

S Goodacre, N Calvert

School of Health and Related Research, Sheffield University, UK

Correspondence to:
Correspondence to:
Dr S Goodacre, 87A Sydney Road, Sheffield S6 3GG, UK;
s.goodacre{at}sheffield.ac.uk

Objectives: Patients presenting to hospital with acute, undifferentiated chest pain have a low, but important, risk of significant myocardial ischaemia. Potential diagnostic strategies for patients with acute, undifferentiated chest pain vary from low cost, poor effectiveness (discharging all home) to high cost, high effectiveness (admission and intensive investigation). This paper aimed to estimate the relative cost effectiveness of these strategies.

Methods: Decision analysis modelling was used to measure the incremental cost per quality adjusted year of life (QALY) gained for five potential strategies to diagnose acute undifferentiated chest pain, compared with the next most effective strategy, or a baseline strategy of discharging all patients home without further testing.

Results: Cardiac enzyme testing alone costs £17 432/QALY compared with discharge without testing. Adding two to six hours of observation and repeat enzyme testing costs an additional £18 567/QALY. Adding exercise testing to this strategy costs £28 553/QALY. A strategy of overnight admission, enzyme, and exercise testing has an incremental cost of £120 369/QALY, while a strategy consisting of overnight admission without exercise testing is subject to extended dominance. Sensitivity analysis revealed that the results are sensitive to variations in the direct costs of running each strategy and to variation in assumptions regarding the effect of diagnostic testing upon quality of life of those with non-cardiac disease.

Conclusion: Observation based strategies incur similar costs per QALY to presently funded interventions for coronary heart disease, while strategies requiring hospital admission may be prohibitively poor value for money. Validation of the true costs and effects of observation based strategies is essential before widespread implementation.

Keywords: chest pain; myocardial ischaemia; cost effectiveness; diagnosis

Abbreviations: QALY, quality adjusted year of life; AMI, acute myocardial infarction; UA, unstable angina; CHD, coronary heart disease; CPOU, chest pain observation unit; EST, exercise stress test; NCP, non-cardiac pain

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This article has been cited by other articles:

• May, J. M., Shuman, W. P., Strote, J. N., Branch, K. R., Mitsumori, L. M., Lockhart, D. W., Caldwell, J. H. (2009). Low-Risk Patients With Chest Pain in the Emergency Department: Negative 64-MDCT Coronary Angiography May Reduce Length of Stay and Hospital Charges. Am. J. Roentgenol. 193: 150-154 [Abstract] [Full Text]  
• Hagberg, S. M., Woitalla, F., Crawford, P. (2008). 2002 ACC/AHA Guideline Versus Clinician Judgment as Diagnostic Tests for Chest Pain. J Am Board Fam Med 21: 101-107 [Abstract] [Full Text]  
• Goodacre, S, Dixon, S (2005). Is a chest pain observation unit likely to be cost effective at my hospital? Extrapolation of data from a randomised controlled trial. Emerg. Med. J. 22: 418-422 [Abstract] [Full Text]  

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Chest pain obervation unit (CPOU) - A road to a cost effective management of Acute Coronary Syndrome

Ranjit Sinharay

EMJ Online, 28 Nov 2003 [Full text]