Volume 15, Number 4, July-August 2008

Cost-consequences analysis of natriuretic peptide assays to refute symptomatic heart failure in primary care
Michael A Scott, Christopher P Price, Martin R Cowie, Martin J Buxton

In primary care, the significant burden of heart failure is exacerbated by problematic, inaccurate diagnosis that may produce inefficient triaging of patients to echocardiography. UK guidelines recommend using natriuretic peptides in the diagnostic pathway. The costs and consequences of providing a definitive diagnosis for symptomatic heart failure have not been established for peptide testing in primary care. We provide a cost-consequence analysis to compare alternative diagnostic strategies for symptomatic heart failure patients presenting to their GP. Health economic evaluation using decision-tree modelling taking a cohort of patients presenting in primary care with symptomatic heart failure to a definitive diagnosis was performed. The model compared a diagnostic strategy using electrocardiograms (ECGs) interpreted by consultants with the use of B-type natriuretic peptide (BNP) assays. The base-case used data from the UK Natriuretic Peptide (UKNP) study, which used a ‘point-of-care’ assay. Two alternative scenarios were modelled reflecting data from key studies, as was sensitivity to costs. The model demonstrates that, for the base-case scenario, an initial diagnostic strategy of BNP is superior to ECG in terms of diagnosis of symptomatic heart failure in patients presenting in primary care, despite slightly more initial false negatives and a marginally higher cost. The alternative scenarios and sensitivity analyses show that the results are very sensitive to test accuracies and costs, but that, under plausible assumptions, BNP could be both cheaper and clinically superior. The model suggests that, despite parameter uncertainty, the adoption of BNP in primary care is likely to be clinically preferable, be more satisfactory for most patients, and lead to fewer unnecessary echocardiography referrals, at a very small increase in cost.

Br J Cardiol 2008;15:199–204.

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