title: MICE or NICE? An economic evaluation of clinical decision rules in the diagnosis of heart failure in primary care.
abstract: BACKGROUND
  Detection 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.
  
  
  METHODS
  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.
  
  
  METHODS
  Data 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.
  
  
  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. 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.
  
  
  CONCLUSIONS
  This 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.
authors.affiliation: Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, United Kingdom.
authors.forename: Mark
authors.initials: M
authors.lastname: Monahan
authors.affiliation: Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, United Kingdom.
authors.forename: Pelham
authors.initials: P
authors.lastname: Barton
authors.affiliation: Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, University of Oxford, OX2 6GG, United Kingdom.
authors.forename: Clare J
authors.initials: CJ
authors.lastname: Taylor
authors.affiliation: Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, United Kingdom.
authors.forename: Andrea K
authors.initials: AK
authors.lastname: Roalfe
authors.affiliation: Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, University of Oxford, OX2 6GG, United Kingdom. Electronic address: richard.hobbs@phc.ox.ac.uk.
authors.forename: F D Richard
authors.initials: FDR
authors.lastname: Hobbs
authors.affiliation: Faculty of Medicine, National Heart and Lung Institute, Imperial College London, South Kensington Campus, London SW7 2AZ, United Kingdom.
authors.forename: Martin
authors.initials: M
authors.lastname: Cowie
authors.affiliation: Department of Cardiology, Sandwell and West Birmingham Hospitals, Lyndon, West Bromwich, West Midlands B71 4HJ, United Kingdom.
authors.forename: Russell
authors.initials: R
authors.lastname: Davis
authors.affiliation: Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, United Kingdom.
authors.forename: Jon
authors.initials: J
authors.lastname: Deeks
authors.affiliation: Department of Public Health & Primary Care, University of Cambridge, Strangeways Research Laboratory, Wort's Causeway, Cambridge CB1 8RN, United Kingdom.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Mant
authors.affiliation: Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, United Kingdom.
authors.forename: Deborah
authors.initials: D
authors.lastname: McCahon
authors.affiliation: Department of Cardiology, King's College Hospital, Denmark Hill, London SE5 9RS, United Kingdom.
authors.forename: Theresa
authors.initials: T
authors.lastname: McDonagh
authors.affiliation: Faculty of Medicine, National Heart and Lung Institute, Imperial College London, South Kensington Campus, London SW7 2AZ, United Kingdom.
authors.forename: George
authors.initials: G
authors.lastname: Sutton
authors.affiliation: School of Health Sciences, University of Nottingham, B Floor, South Block Link, Queen's Medical Centre, Nottingham NG7 2HA, United Kingdom.
authors.forename: Lynda
authors.initials: L
authors.lastname: Tait
mesh_terms: D000368:Aged; D000066491:Clinical Decision-Making / Q000379:methods; D003362:Cost-Benefit Analysis / Q000379:methods; D004487:Edema / Q000191:economics / Q000453:epidemiology / Q000628:therapy; D004739:England / Q000453:epidemiology; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000191:economics* / Q000453:epidemiology / Q000628:therapy*; D006801:Humans; D008297:Male; D009203:Myocardial Infarction / Q000191:economics / Q000453:epidemiology / Q000628:therapy; D017410:Practice Guidelines as Topic / Q000592:standards; D011320:Primary Health Care / Q000191:economics* / Q000379:methods / Q000592:standards; D011446:Prospective Studies; D013222:State Medicine / Q000191:economics*
keywords: Cost benefit analysis; Economic model; General practice; Medical economics; Natriuretic peptide