Early invasive strategy in senior patients with non-ST-segment elevation myocardial infarction: is it cost-effective? - a decision-analytic model and value of information analysis.
cost-effectiveness
early invasive treatment
non-ST-elevation myocardial infarction
value of information analysis
Journal
BMJ open
ISSN: 2044-6055
Titre abrégé: BMJ Open
Pays: England
ID NLM: 101552874
Informations de publication
Date de publication:
20 09 2019
20 09 2019
Historique:
entrez:
23
9
2019
pubmed:
23
9
2019
medline:
2
10
2020
Statut:
epublish
Résumé
Non-ST-elevation myocardial infarction (NSTEMI) is the most common type of heart attack in the UK and it is becoming increasingly prevalent among older people. An early invasive treatment strategy may be effective and cost-effective for treating NSTEMI but evidence is currently unclear. To assess the cost-effectiveness of the early invasive strategy versus medical management in elderly patients with NSTEMI and to provide guidance for future research in this area. A long-term Markov state transition model was developed. Model inputs were systematically derived from a number of sources most appropriate to a UK relevant analysis, such as published studies and national routine data. Costs were estimated from the perspective of National Health Service and Personal Social Services. The model was developed using TreeAge Pro software. Based on a probabilistic sensitivity analysis, a value of information analysis was carried out to establish the value of decision uncertainty both overall and for specific input parameters. In 2017 UK £, the incremental cost-effectiveness ratio of the early invasive strategy was £46 916 for each additional quality-adjusted life-year (QALY) gained, with a probability of being cost-effective of 23% at a cost-effectiveness threshold of £20 000/QALY. There was a considerable decision uncertainty with these results. The value of removing all this uncertainty was up to £1 920 000 annually. Most uncertainty related to clinical effectiveness parameters and the optimal study design to remove this uncertainty would be a randomised controlled trial. Based on current evidence, the early invasive strategy is not likely to be cost-effective for elderly patients with NSTEMI. This conclusion should be interpreted with caution mainly due to the absence of NSTEMI-specific data and long-term clinical effectiveness estimates.
Sections du résumé
BACKGROUND
Non-ST-elevation myocardial infarction (NSTEMI) is the most common type of heart attack in the UK and it is becoming increasingly prevalent among older people. An early invasive treatment strategy may be effective and cost-effective for treating NSTEMI but evidence is currently unclear.
OBJECTIVES
To assess the cost-effectiveness of the early invasive strategy versus medical management in elderly patients with NSTEMI and to provide guidance for future research in this area.
METHODS
A long-term Markov state transition model was developed. Model inputs were systematically derived from a number of sources most appropriate to a UK relevant analysis, such as published studies and national routine data. Costs were estimated from the perspective of National Health Service and Personal Social Services. The model was developed using TreeAge Pro software. Based on a probabilistic sensitivity analysis, a value of information analysis was carried out to establish the value of decision uncertainty both overall and for specific input parameters.
RESULTS
In 2017 UK £, the incremental cost-effectiveness ratio of the early invasive strategy was £46 916 for each additional quality-adjusted life-year (QALY) gained, with a probability of being cost-effective of 23% at a cost-effectiveness threshold of £20 000/QALY. There was a considerable decision uncertainty with these results. The value of removing all this uncertainty was up to £1 920 000 annually. Most uncertainty related to clinical effectiveness parameters and the optimal study design to remove this uncertainty would be a randomised controlled trial.
CONCLUSION
Based on current evidence, the early invasive strategy is not likely to be cost-effective for elderly patients with NSTEMI. This conclusion should be interpreted with caution mainly due to the absence of NSTEMI-specific data and long-term clinical effectiveness estimates.
Identifiants
pubmed: 31542755
pii: bmjopen-2019-030678
doi: 10.1136/bmjopen-2019-030678
pmc: PMC6756447
doi:
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
e030678Subventions
Organisme : Medical Research Council
ID : MR/K02325X/1
Pays : United Kingdom
Informations de copyright
© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.
Déclaration de conflit d'intérêts
Competing interests: None declared.
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