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Title: Chest Pain Management Using Prehospital Point-of-Care Troponin and Paramedic Risk Assessment.
Austin Authors: Dawson, Luke P;Nehme, Emily;Nehme, Ziad;Zomer, Ella;Bloom, Jason;Cox, Shelley;Anderson, David;Stephenson, Michael;Ball, Jocasta;Zhou, Jennifer;Lefkovits, Jeffrey;Taylor, Andrew J;Horrigan, Mark ;Chew, Derek P;Kaye, David;Cullen, Louise;Mihalopoulos, Cathrine;Smith, Karen;Stub, Dion
Affiliation: Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia.
School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
Ambulance Victoria, Melbourne, Australia.
College of Medicine and Public Health, Flinders University, Adelaide, South Australia.
Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Queensland, Australia.
Issue Date: 1-Mar-2023
Date: 2023
Publication information: JAMA internal medicine 2023; 183(3): 203-211
Abstract: Prehospital point-of-care troponin testing and paramedic risk stratification might improve the efficiency of chest pain care pathways compared with existing processes with equivalent health outcomes, but the association with health care costs is unclear. To analyze whether prehospital point-of-care troponin testing and paramedic risk stratification could result in cost savings compared with existing chest pain care pathways. In this economic evaluation of adults with acute chest pain without ST-segment elevation, cost-minimization analysis was used to assess linked ambulance, emergency, and hospital attendance in the state of Victoria, Australia, between January 1, 2015, and June 30, 2019. Paramedic risk stratification and point-of-care troponin testing. The outcome was estimated mean annualized statewide costs for acute chest pain. Between May 17 and June 25, 2022, decision tree models were developed to estimate costs under 3 pathways: (1) existing care, (2) paramedic risk stratification and point-of-care troponin testing without prehospital discharge, or (3) prehospital discharge and referral to a virtual emergency department (ED) for low-risk patients. Probabilities for the prehospital pathways were derived from a review of the literature. Multivariable probabilistic sensitivity analysis with 50 000 Monte Carlo iterations was used to estimate mean costs and cost differences among pathways. A total of 188 551 patients attended by ambulance for chest pain (mean [SD] age, 61.9 [18.3] years; 50.5% female; 49.5% male; Indigenous Australian, 2.0%) were included in the model. Estimated annualized infrastructure and staffing costs for the point-of-care troponin pathways, assuming a 5-year device life span, was $2.27 million for the pathway without prehospital discharge and $4.60 million for the pathway with prehospital discharge (incorporating virtual ED costs). In the decision tree model, total annual cost using prehospital point-of-care troponin and paramedic risk stratification was lower compared with existing care both without prehospital discharge (cost savings, $6.45 million; 95% uncertainty interval [UI], $0.59-$16.52 million; lower in 94.1% of iterations) and with prehospital discharge (cost savings, $42.84 million; 95% UI, $19.35-$72.26 million; lower in 100% of iterations). Prehospital point-of-care troponin and paramedic risk stratification for patients with acute chest pain could result in substantial cost savings. These findings should be considered by policy makers in decisions surrounding the potential utility of prehospital chest pain risk stratification and point-of-care troponin models provided that safety is confirmed in prospective studies.
DOI: 10.1001/jamainternmed.2022.6409
Journal: JAMA internal medicine
Start page: 203
End page: 211
PubMed URL: 36715993
ISSN: 2168-6114
Type: Journal Article
Subjects: Chest Pain/diagnosis
Emergency Service, Hospital/economics
Appears in Collections:Journal articles

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