Troponin T monitoring to detect myocardial injury after noncardiac surgery: a cost-consequence analysis.

Can J Surg 2018 06;61(3):185-194

From the University Hospital of Düsseldorf, Düsseldorf, Germany (Lurati Buse); the University Hospital of Basel, Basel, Switzerland (Lurati Buse); the University of Calgary, Calgary, Alta. (Manns); McMaster University, Hamilton, Ont. (Lamy, Guyatt, Tiboni, Devereaux); the Hospital de Clínicas de Porto Alegre, Universidade Federal de Rio Grande do Sul, Brazil (Polanczyk); the Chinese University of Hong Kong, Sha Tin, NT, Hong Kong (Chan); the University of Malaya, Kuala Lampur, Malaysia (Wang); the Fundación Cardioinfantil - Instituto de Cardiología, Bogotá and Universidad Autónoma de Bucaramanga, Bucaramanga, Colombia (Villar); St. John's Medical College and Research Institute, Bangalore, India (Sigamani); the Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio (Sessler); the HCor Research Institute (Hospital do CoraÇão), São Paulo, Brazil (Berwanger); the Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa (Biccard); Barts and The London School of Medicine and Dentistry, London, UK (Pearse); the Hospital de Sant Pau, Barcelona, Spain (Urrútia); the Jagiellonian University Medical College, Krakow, Poland (Szczeklik); the Hospital General Universitario Gregorio Marañón, Madrid, Spain (Garutti); the University of Manitoba, Winnipeg, Man. (Srinathan); the Universidad Peruana Cayetano Heredia, Lima, Peru (Malaga); the Christian Medical College, Ludhiana, India (Abraham); the George Institute for Global Health, University of Sydney, Sydney, Australia (Chow); the University of Alberta Hospital, Edmonton, Alta. (Jacka); the University College London, London, UK (Ackland); the London Health Sciences Centre, London, Ont. (Macneil); the University of Leeds, Leeds, UK (Sapsford); the Royal Liverpool Broadgreen University Hospital Trust, Liverpool, UK (Leuwer); and the HÔpital Pitié-Salpêtrière, Paris, France (Le Manach).

Background: Myocardial injury after noncardiac surgery (MINS) is a mostly asymptomatic condition that is strongly associated with 30-day mortality; however, it remains mostly undetected without systematic troponin T monitoring. We evaluated the cost and consequences of postoperative troponin T monitoring to detect MINS.

Methods: We conducted a model-based cost-consequence analysis to compare the impact of routine troponin T monitoring versus standard care (troponin T measurement triggered by ischemic symptoms) on the incidence of MINS detection. Model inputs were based on Canadian patients enrolled in the Vascular Events in Noncardiac Surgery Patients Cohort Evaluation (VISION) study, which enrolled patients aged 45 years or older undergoing inpatient noncardiac surgery. We conducted probability analyses with 10 000 iterations and extensive sensitivity analyses.

Results: The data were based on 6021 patients (48% men, mean age 65 [standard deviation 12] yr). The 30-day mortality rate for MINS was 9.6%. We determined the incremental cost to avoid missing a MINS event as $1632 (2015 Canadian dollars). The cost-effectiveness of troponin monitoring was higher in patient subgroups at higher risk for MINS, e.g., those aged 65 years or more, or with a history of atherosclerosis or diabetes ($1309).

Conclusion: The costs associated with a troponin T monitoring program to detect MINS were moderate. Based on the estimated incremental cost per health gain, implementation of postoperative troponin T monitoring seems appealing, particularly in patients at high risk for MINS.

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June 2018
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