Abstract 18295: Comparison of Long Term Health and Economic Outcomes of ED Triage Strategies for Patients With Acute Chest Pain
Background: Cardiac CT, functional testing and expedited ED triage with subsequent outpatient testing have been proposed as viable strategies to triage patients presenting with acute chest pain. However, long term health and economic outcomes data are not available.
Methods: We developed a Markov microsimulation model to examine 4 ED triage strategies: early CCTA (CCTA) and standard ED evaluation (SOC) based on ROMICAT II, a consensus guideline based strategy, and a previously published expedited ED triage protocol using two troponin measurements. As model input parameters, we used demographics, risk factors and resource utilization as observed in the ROMICAT II study. The model predicted the number of diagnostic tests and costs for the initial ED presentation, 5-year mortality and lifetime outcomes and determined the incremental cost-effectiveness ratios (ICER).
Result: The model accurately predicted multiple ROMICAT II endpoints: Length of stay (CCTA: 23.2 hr (model) vs. 23.2 hr (ROMICAT II trial); SOC: 30.3 hr vs. 30.8 hr), frequency of PCI (CCTA: 5% vs. 5%; SOC: 3% vs. 3%), cumulative radiation exposure (CCTA: 14.0 mSv vs. 14.3 mSv; SOC: 6.1 mSv vs. 5.3 mSv), and total costs during initial ED presentation (CCTA: $4,356 vs. $4,289; SOC: $4,179 vs. $4,060). The expedited ED protocol resulted in substantial savings of resources during the initial ED presentation (Table). After 5 years, however, mortality was highest in the expedited ED strategy and lowest after early CCTA. Moreover, lifetime ICER was $39,700/QALY for CCTA compared to the expedited ED protocol, while SOC and consensus optimal SOC strategies were dominated (i.e., less effective and more expensive).
Conclusion: A Markov microsimulation analysis based on ROMICAT II outcomes predicts that for long term health and economic outcomes CCTA is a cost-effective ED triage strategy for patients presenting with acute chest pain compared to alternative strategies.
- © 2013 by American Heart Association, Inc.