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Potential cost effectiveness of initial myocardial perfusion imaging for assessment of emergency department patients with chest pain |
Radensky P W, Hilton T C, Fulmer H, McLaughlin B A, Stowers S A |
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Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. Health technology Initial single-photon emission computed tomography (SPECT) myocardial perfusion imaging using technetium-99m sestamibi in the evaluation of emergency department patients with chest pain.
Economic study type Cost-effectiveness analysis.
Study population Male and female patients who underwent initial SPECT myocardial perfusion imaging and male and female patients with angina-like chest pain and a normal or nondiagnostic ECG.
Setting Hospital. The economic study was carried out in Florida, USA.
Dates to which data relate The main effectiveness data were taken from a previously published study conducted in 1994 and a single trial conducted in 1996. Cost and resource data were derived from 1991-93 sources. The price year was 1994.
Source of effectiveness data The final study and outcome data were derived from a previously published single study.
Link between effectiveness and cost data The costing was undertaken, partially retrospectively, on the same patient sample as that used in the economic study.
Modelling A decision analysis model was used to assess the potential cost-effectiveness of initial SPECT myocardial perfusion imaging compared with a normal or nondiagnostic ECG.
Outcomes assessed in the review The outcomes assessed were the predictive accuracy, sensitivity and specificity of SCAN and NO SCAN.
Study designs and other criteria for inclusion in the review The authors did not specifically report the study design or inclusion criteria.
Sources searched to identify primary studies Criteria used to ensure the validity of primary studies Methods used to judge relevance and validity, and for extracting data Number of primary studies included Methods of combining primary studies Investigation of differences between primary studies Results of the review The predictive accuracy was 85% (SCAN) versus 45% (NO SCAN) (p=0.0001).
The sensitivity was 94% (SCAN) versus 88% (NO SCAN).
The specificity was 83% (SCAN) versus 37% (NO SCAN) (p=0.0001).
Measure of benefits used in the economic analysis The measure of benefits was the predictive accuracy, sensitivity and specificity of SCAN and NO SCAN.
Direct costs Admission and/or acute event, admission and/or no acute event and emergency department discharge costs were included in the analysis. The quantities were analysed separately from the costs. The quantity/cost boundary adopted was the payer perspective. Discounting was applied, but the discount rate was not stated. The price year was 1994.
Statistical analysis of costs Sensitivity analysis A one-way, threshold, probability sensitivity analysis was performed on the cost of the perfusion scan, the incidence of acute cardiac events andpredictive accuracy levels.
Estimated benefits used in the economic analysis The predictive accuracy of SCAN strategy was 85% versus 45% of the NO SCAN strategy (p=0.0001).
Cost results The mean costs were $21,375 (+/- $ 2,733) among admitted patients who experienced an acute event, $715 (+/- $71) among patients discharged from the emergency department and $4,969 (+/- $374) among admitted patients who did not have an acute cardiac event. Discounting was performed, but the discount rate was not stated.
Synthesis of costs and benefits The SCAN strategy (mean) cost per patient was $5,019 versus the NO SCAN strategy (mean) cost of $6,051 (with a difference of $1,032, (17%)). The median costs were $4,139 and $4,592 for the SCAN and NO SCAN strategy, respectively, with a difference of $453 (10%). An incremental analysis was performed.
Authors' conclusions The initial SPECT myocardial perfusion imaging strategy in emergency department on patients has been found to be safe, accurate and potentially cost-effective.
CRD COMMENTARY - Selection of comparators The choice of the comparator is clear. The initial SPECT myocardial perfusion imaging is a widely used strategy in emergency department patients with chest pain. You, as a user of this database, should consider whether these are widely used health technologies in your setting.
Validity of estimate of measure of benefit The internal validity of the estimate of measure of benefit used in the economic analysiswas not assessable as effectiveness data came from a previous trial, the full details of which were not given. It has, therefore, been impossible to evaluate whether data have been used selectively.
Validity of estimate of costs The resource quantities were reported separately from the prices. Adequate details of methods of quantity/cost estimation were given. Important cost items were not omitted.
Other issues The authors' conclusions were justified, given the uncertainties in the data but as this is a modelled solution, further validation is required. The issue of generalisability to other settings or countries was not addressed. Appropriate comparisons were made with other studies and the results were not presented selectively.
Implications of the study Prospective analysis is required to validate these preliminary observations.
Source of funding Cost-effectiveness analysis supported in part by grants from DuPont Merck Radiopharmaceuticals, North Billerica, Massachusetts.
Bibliographic details Radensky P W, Hilton T C, Fulmer H, McLaughlin B A, Stowers S A. Potential cost effectiveness of initial myocardial perfusion imaging for assessment of emergency department patients with chest pain. American Journal of Cardiology 1997; 79(5): 595-599 Indexing Status Subject indexing assigned by NLM MeSH Angina Pectoris /diagnosis /radionuclide imaging; Chest Pain /diagnosis /radionuclide imaging; Coronary Circulation; Cost-Benefit Analysis; Death, Sudden, Cardiac /etiology; Decision Making; Decision Support Techniques; Electrocardiography; Emergency Service, Hospital /economics; Forecasting; Humans; Myocardial Infarction /economics /etiology; Patient Admission; Patient Discharge; Prognosis; Prospective Studies; Radiopharmaceuticals; Reproducibility of Results; Retrospective Studies; Risk Factors; Sensitivity and Specificity; Technetium Tc 99m Sestamibi; Tomography, Emission-Computed, Single-Photon /economics AccessionNumber 21997000405 Date bibliographic record published 31/10/1998 Date abstract record published 31/10/1998 |
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