THE COST-EFFECTIVENESS OF POINT-OF-CARE TROPONIN TESTING TO DIAGNOSE ACUTE CORONARY SYNDROME IN PRIMARY CARE

Purpose:

The added value of using a point-of-care (POC) troponin test in primary care to rule out acute coronary syndrome (ACS) is currently debated, as general practitioners (GPs) expect not to use this test in patients considered at high risk, and because test sensitivity is inadequate early after symptom onset. This study investigates the potential cost-effectiveness of a strategy of excluding ACS by a GP when a POC troponin test is available versus current practice (without POC troponin). Both test performance depending on symptom duration, as well as selection of patients in whom the test would be performed are taken into account.

Method(s):

A patient-level simulation model was developed, reflecting a hypothetical cohort of the Dutch population aged >35 years consulting the GP with chest complaints. The analysis included all medical costs and productivity losses. Both symptom duration and POC troponin test performance at different time points were incorporated. A lifelong time horizon was applied. It was assumed that this test would not be not used in a) patients presenting <4 hours after onset of complaints, b) patients diagnosed with ST-elevation myocardial infarction based on an electrocardiogram, and c) patients considered at high risk of ACS by the GP. Health outcomes were expressed as Quality-Adjusted Life Years (QALYs). Resource use, quality of life estimates, and costs were based on published evidence. The sensitivity and specificity for diagnosing ACS without POC in primary care are 72.3% and 84.3%, respectively. The main outcome parameters involve the effect of POC troponin testing on 1) incorrect hospital referral decisions (expressed as false-positives and false-negatives), 2) costs, 3) health loss from POC troponin use. 

Result(s):

The use of a POC troponin test decreases the rate of false-positives from 27.6% to 25.0% (relative decrease: 9.5%). In addition, the rate of false-negatives decreases from 0.6% to 0.5% (relative decrease: 11.3%). Costs per patient will decrease with €36/patient. The incremental costs savings per QALY gained are estimated to be €106,000. 

Conclusion(s):

Using POC troponin tests to rule out ACS in primary care is expected to slightly reduce false-positive and false-negative referral decisions. Thus, both unnecessary referrals and potential health loss can be prevented, at decreased healthcare costs. Further research in the optimal use of this test to improve implementation and cost-effectiveness is recommended.