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

Abstract

Background: 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.

Methods: 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.

Results: 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.

Conclusions: 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.

Figure 1

Markov model (simplified). "True positive," "false positive," "true negative," and "false negative" describe the general practitioner's referral decision, and the values are based both on the reported test characteristics as well as the prevalence of acute coronary syndrome (ACS). ASA = aspirin, NSTE-ACS = non ST-elevation acute coronary syndrome, STEMI = ST-elevation myocardial infarction.

Figure 2

Tornado diagram. This Tornado diagram shows the incremental cost-effectiveness ratio (ICER) of the range of values for each variable tested in the one-way sensitivity analysis. A negative ICER is described in the text as "cost-saving."