Abstract
BackgroundDetection and treatment of heart failure (HF) can improve quality of life and reduce premature mortality. However, symptoms such as breathlessness are common in primary care, have a variety of causes and not all patients require cardiac imaging. In systems where healthcare resources are limited, ensuring those patients who are likely to have HF undergo appropriate and timely investigation is vital. DesignA decision tree was developed to assess the cost-effectiveness of using the MICE (Male, Infarction, Crepitations, Edema) decision rule compared to other diagnostic strategies to identify HF patients presenting to primary care. MethodsData from REFER (REFer for EchocaRdiogram), a HF diagnostic accuracy study, was used to determine which patients received the correct diagnosis decision. The model adopted a UK National Health Service (NHS) perspective. ResultsThe current recommended National Institute for Health and Care Excellence (NICE) guidelines for identifying patients with HF was the most cost-effective option with a cost of £4400 per quality adjusted life year (QALY) gained compared to a “do nothing” strategy. That is, patients presenting with symptoms suggestive of HF should be referred straight for echocardiography if they had a history of myocardial infarction or if their NT-proBNP level was ≥400pg/ml. The MICE rule was more expensive and less effective than the other comparators. Base-case results were robust to sensitivity analyses. ConclusionsThis represents the first cost-utility analysis comparing HF diagnostic strategies for symptomatic patients. Current guidelines in England were the most cost-effective option for identifying patients for confirmatory HF diagnosis. The low number of HF with Reduced Ejection Fraction patients (12%) in the REFER patient population limited the benefits of early detection.
Highlights
Heart failure (HF) is a common clinical condition which is associated with major impact for patients and high costs for health systems, but is not easy to diagnose accurately or early in primary care [1,2,3].M
Otherwise a NT-proBNP test is carried out and the patient is referred straight for echocardiography if the test results are above one of three cut-offs set by gender/symptoms recorded in the clinical rule:
National Institute for Health and Care Excellence (NICE) guidelines for the management of chronic HF6 suggest that a patient presenting with symptoms suggestive of HF should be referred straight for echocardiography if they have a history of myocardial infarction (MI)
Summary
Heart failure (HF) is a common clinical condition which is associated with major impact for patients and high costs for health systems, but is not easy to diagnose accurately or early in primary care [1,2,3].M. There is a paucity of data on diagnostic strategies in patients presenting in primary care with symptoms suggestive of HF where the population are rigorously phenotyped for HF. Detection and treatment of heart failure (HF) can improve quality of life and reduce premature mortality Symptoms such as breathlessness are common in primary care, have a variety of causes and not all patients require cardiac imaging. Design: A decision tree was developed to assess the cost-effectiveness of using the MICE (Male, Infarction, Crepitations, Edema) decision rule compared to other diagnostic strategies to identify HF patients presenting to primary care. Results: The current recommended National Institute for Health and Care Excellence (NICE) guidelines for identifying patients with HF was the most cost-effective option with a cost of £4400 per quality adjusted life year (QALY) gained compared to a “do nothing” strategy. The low number of HF with Reduced Ejection Fraction patients (12%) in the REFER patient population limited the benefits of early detection
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