Economic Considerations of Early Rule-In/Rule-Out Algorithms for The Diagnosis of Myocardial Infarction in The Emergency Department Using Cardiac Troponin and Glycemic Biomarkers.
BACKGROUND
We have previously demonstrated the utility of a rule-in/rule-out strategy for myocardial infarction (MI) using glycemic biomarkers in combination with cardiac troponin in the emergency department (ED). Given that the cost of assessing patients with possible MI in the ED is increasing, we sought to compare the health services cost of our previously identified early rule-in/rule-out approaches for MI among patients who present to the ED with symptoms suggestive of acute coronary syndrome (ACS).


METHODS
We compared the cost differences between different rule-in/rule-out strategies for MI using presentation cardiac troponin I (cTnI), high-sensitivity cTnI (hs-cTnI), high-sensitivity cardiac troponin T (hs-cTnT), glucose, and/or hemoglobin A1c(Hb A1c) in 1137 ED patients (7-day MI n = 133) as per our previously defined algorithms and compared them with the European Society of Cardiology (ESC) 0-h algorithm-cutoffs. Costs associated with each decision model were obtained from site-specific sources (length of stay) and provincial sources (Ontario Case Costing Initiative).


RESULTS
Algorithms incorporating cardiac troponin and glucose for early rule-in/rule-out were the most cost effective and clinically safest methods (i.e., ≤1 MI missed) for early decision making, with hs-cTnI and glucose yielding lower costs compared to cTnI and glucose, despite the higher price for the hs-cTnI test. The addition of Hb A1cto the algorithms increased the cost of these algorithms but did not miss any additional patients with MI. Applying the ESC 0-h algorithm-cutoffs for hs-cTnI and hs-cTnT were the most costly.


CONCLUSIONS
Rule-in/rule-out algorithms incorporating presentation glucose with high-sensitivity cardiac troponin are the safest and most cost-effective options as compared to the ESC 0-h algorithm-cutoffs.
Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada.
Colleen
C
Shortt
Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, ON, Canada.
Feng
F
Xie
Division of Cardiology, and Population Health Research Institute, McMaster University, Hamilton, ON, Canada.
Richard
R
Whitlock
School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, and the Children's Hospital of Eastern Ontario Research Institute ON, Canada.
Jinhui
J
Ma
Department of Medicine, McMaster University, Hamilton, ON, Canada.
Natasha
N
Clayton
Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada.
Jonathan
J
Sherbino
Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada.
Stephen A
SA
Hill
Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada.
Guillaume
G
Pare
Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada.
Matthew
M
McQueen
Division of Cardiology, and Population Health Research Institute, McMaster University, Hamilton, ON, Canada.
Shamir R
SR
Mehta
Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, ON, Canada.|Division of Cardiology, and Population Health Research Institute, McMaster University, Hamilton, ON, Canada.
P J
PJ
Devereaux
Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada.
Andrew
A
Worster
Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada; kavsakp@mcmaster.ca.
Peter
P
Kavsak
D000465:Algorithms; D015415:Biomarkers / Q000032:analysis; D001786:Blood Glucose / Q000032:analysis*; D015331:Cohort Studies; D004636:Emergency Service, Hospital / Q000191:economics*; D006801:Humans; D009203:Myocardial Infarction / Q000097:blood / Q000175:diagnosis* / Q000191:economics*; D019210:Troponin I / Q000097:blood* / Q000191:economics; D020107:Troponin T / Q000097:blood* / Q000191:economics
D015415:Biomarkers; D001786:Blood Glucose; D019210:Troponin I; D020107:Troponin T