title: Cost-effectiveness of point-of-care biomarker assessment for suspected myocardial infarction: the randomized assessment of treatment using panel Assay of cardiac markers (RATPAC) trial.
abstract: OBJECTIVE
  Chest pain due to suspected myocardial infarction (MI) is responsible for many hospital admissions and consumes substantial health care resources. The Randomized Assessment of Treatment using Panel Assay of Cardiac markers (RATPAC) trial showed that diagnostic assessment using a point-of-care (POC) cardiac biomarker panel consisting of CK-MB, myoglobin, and troponin increased the proportion of patients successfully discharged after emergency department (ED) assessment. In this economic analysis, the authors aimed to determine whether POC biomarker panel assessment reduced health care costs and was likely to be cost-effective.
  
  
  METHODS
  The RATPAC trial was a multicenter individual patient randomized controlled trial comparing diagnostic assessment using a POC biomarker panel (CK-MB, myoglobin, and troponin, measured at baseline and 90 minutes) to standard care without the POC panel in patients attending six EDs with acute chest pain due to suspected MI (n = 2,243). Individual patient resource use data were collected from all participants up to 3 months after hospital attendance using self-completed questionnaires at 1 and 3 months and case note review. ED staff and POC testing costs were estimated through a microcosting study of 246 participants. Resource use was valued using national unit costs. Health utility was measured using the EQ-5D self-completed questionnaire, mailed at 1 and 3 months. Quality-adjusted life-years (QALYs) were calculated by the trapezium rule using the EQ-5D tariff values at all follow-up points. Mean costs per patient were compared between the two treatment groups. Cost-effectiveness was estimated in terms of probability of dominance and incremental cost per QALY.
  
  
  RESULTS
  Point-of-care panel assessment was associated with higher ED costs, coronary care costs, and cardiac intervention costs, but lower general inpatient costs. Mean costs per patient were £1217.14 (standard deviation [SD] ± 3164.93), or $1,987.14 (SD ±$4,939.25), with POC versus £1005.91 (SD ±£1907.55), or $1,568.64 (SD ±$2,975.78), with standard care (p = 0.056). Mean QALYs were 0.158 (SD ± 0.052) versus 0.161 (SD ± 0.056; p = 0.250). The probability of standard care being dominant (i.e., cheaper and more effective) was 0.888, while the probability of the POC panel being dominant was 0.004. These probabilities were not markedly altered by sensitivity analysis varying the costs of the POC panel and excluding intensive care costs.
  
  
  CONCLUSIONS
  Point-of-care panel assessment does not reduce costs despite reducing admissions and may even increase costs. It is unlikely to be considered a cost-effective use of health care resources.
authors.affiliation: School of Health and Related Research (ScHARR), University of Sheffield, United Kingdom.
authors.forename: Patrick
authors.initials: P
authors.lastname: Fitzgerald
authors.forename: Steve W
authors.initials: SW
authors.lastname: Goodacre
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Cross
authors.forename: Simon
authors.initials: S
authors.lastname: Dixon
mesh_terms: D000328:Adult; D000368:Aged; D015415:Biomarkers / Q000097:blood*; D002637:Chest Pain / Q000097:blood* / Q000191:economics* / Q000209:etiology; D003362:Cost-Benefit Analysis; D052279:Creatine Kinase, MB Form / Q000097:blood; D004636:Emergency Service, Hospital / Q000191:economics; D004739:England; D005260:Female; D005102:Health Expenditures; D006801:Humans; D007902:Length of Stay / Q000191:economics / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000097:blood / Q000150:complications / Q000191:economics; D009211:Myoglobin / Q000097:blood; D019095:Point-of-Care Systems / Q000191:economics*; D019057:Quality-Adjusted Life Years; D011795:Surveys and Questionnaires; D014336:Troponin / Q000097:blood
chemical_list: D015415:Biomarkers; D009211:Myoglobin; D014336:Troponin; D052279:Creatine Kinase, MB Form