Pre-hospital ECG for acute coronary syndrome in urban India: A cost-effectiveness analysis

<p>Abstract</p> <p>Background</p> <p>Patients with acute coronary syndrome (ACS) in India have increased pre-hospital delay and low rates of thrombolytic reperfusion. Use of ECG could reduce pre-hospital delay among patients who first present to a general practitioner (GP). We assessed whether performing ECG on patients with acute chest pain would improve long-term outcomes and be cost-effective.</p> <p>Methods</p> <p>We created a Markov model of urban Indian patients presenting to a GP with acute chest pain to compare a GP's performing an ECG versus not performing one. Variables describing the accuracy of a GP's referral decision in chest pain and ACS, ACS treatment patterns, the effectiveness of thrombolytic reperfusion, and costs were derived from Indian data where available and other developed world studies. The model was used to estimate the incremental cost-effectiveness ratio (ICER) of the intervention in 2007 US dollars per quality adjusted life years (QALY) gained.</p> <p>Results</p> <p>Under baseline assumptions, the ECG strategy cost an additional $12.65 per QALY gained compared to no ECG. Sensitivity analyses around the cost of the ECG, cost of thrombolytic, and referral accuracy of the GP yielded ICERs for the ECG strategy ranging between cost-saving and$1124/QALY. All results indicated the intervention is cost-effective under current World Health Organization recommendations.</p> <p>Conclusions</p> <p>While direct presentation to the hospital with acute chest pain is preferable, in urban Indian patients presenting first to a GP, an ECG performed by the GP is a cost-effective strategy to reduce disability and mortality. This strategy should be clinically studied and considered until improved emergency transport services are available.</p

Nine-year comparison of presentation and management of acute coronary syndromes in Ireland: a national cross-sectional survey

BACKGROUND: Shorter time to treatment is associated with lower mortality in acute coronary syndromes (ACS). A previous (1994) survey showed substantial delays for acute myocardial infarction (AMI) in Ireland. The present study compared current practice with 1994 and surveyed acute coronary syndromes as a more complete contemporary evaluation of critical cardiac care than assessing AMI alone. METHODS: Following ethics committee approval, all centres (N = 39) admitting acute cardiac patients to intensive/coronary care unit provided information on 1365 episodes. A cross-sectional survey design was employed. RESULTS: Since 1994, median hospital arrival to thrombolysis time was reduced by 41% (76 to 45 minutes). Thrombolysis was delivered more often in the emergency department in 2003 (48% vs 2%). Thrombolysis when delivered in the emergency department was achieved faster than thrombolysis delivered in intensive/coronary care (35 mins v 60 mins; z = 5.62, p < .0001). Suspected AMI patients who did not subsequently receive thrombolysis took longer to present to hospital (5 h vs 2 h 34 mins; z = 7.33, p < .0001) and had longer transfer times to the intensive/coronary care unit following arrival (2 h 17 mins vs 1 h 10 mins; z = 8.92, p < .0001). Fewer confirmed AMI cases received thrombolysis in 2003 (43% vs 58%). There was an increase in confirmed cases of AMI from 1994 (70% to 87%). CONCLUSIONS: Substantial improvements in time to thrombolysis have occurred since 1994, probably relating to treatment provision in emergency departments. Patient delay pre-hospital is still the principal impediment to effective treatment of ACS. A recent change of definition of AMI may have precluded an exact comparison between 1994 and 2003 data