SSL Prize session

COST-EFFECTIVENESS OF MANAGEMENT STRATEGIES FOR PATIENTS WITH ACUTE, UNDIFFERENTIATED CHEST PAIN

S. Goodacre, N. Calvert. Medical Care Research Unit, School of Health and Related Research, Regent Court, 30 Regent Street, Sheffield S1 4DA.

Background: Patients presenting to hospital with acute chest pain, undiagnosed by electrocardiograph and clinical assessment, have a low, but important, risk of significant myocardial ischaemia. Strategies for detecting ischaemia in this situation have received little formal evaluation and vary from low cost, poor effectiveness (discharging all home) to high cost, high effectiveness (admission and intensive investigation). This study aimed to compare the relative cost-effectiveness of potential diagnostic strategies.

Methods: Decision analysis modelling was used to determine the incremental cost per life saved for each of five strategies, compared to the next most effective alternative, or a baseline strategy of discharging all patients home without further testing.

Results: The incremental cost per life saved increased with the complexity of each diagnostic strategy, relative to the next most effective. Cardiac enzyme testing alone cost £92,352 per life saved compared to discharge without testing. Adding 2-6 hours of observation and repeat enzyme testing cost an extra £99,277 per life saved. Adding exercise testing to this strategy cost £163,755 per life saved. A strategy of overnight admission, enzyme and exercise testing was markedly more expensive with a marginal cost of £707,066 per life saved, while a strategy consisting of overnight admission without exercise testing was subject to extended dominance. Sensitivity analysis revealed that the results were sensitive to variation in the cost providing each strategy.

Conclusion: Strategies consisting of 2-6 hours observation and repeat enzyme testing, either with or without exercise testing, incur similar costs per life saved to presently funded interventions for coronary heart disease, while strategies requiring hospital admission may be considered to be prohibitively poor value for money. …