A master thesis from Aalborg University
A COST-UTILITY ANALYSIS OF NT-PROBNP AS AN INITIAL RULE-OUT BIOMARKER FOR CHRONIC HEART FAILURE IN PRIMARY CARE: IN A DANISH HEALTHCARE SETTING
[A COST-UTILITY ANALYSIS OF NT-PROBNP AS AN INITIAL RULE-OUT BIOMARKER FOR CHRONIC HEART FAILURE IN PRIMARY CARE]
Author(s)
Term
4. term
Publication year
2023
Submitted on
2023-05-30
Pages
55 pages
Abstract
Baggrund: Kronisk hjertesvigt udgør, med sin stigende forekomst, en betydelig udfordring for folkesundheden i Danmark, hvilket medfører en økonomisk byrde og et øget pres på samfundet. Den nuværende diagnostiske strategi for hjertesvigt indebærer henvisning af alle patienter til ekkokardiografi baseret på en klinisk vurdering. En lovende og besparende biomarkør, NT-proBNP, er tilgængelig og har vist sig at være effektiv i primærsektoren. Anvendelsen af NT-proBNP anbefales i flere internationale retningslinjer, men der er uenighed vedrørende en passende tærskelværdi for den generelle population, og NT-proBNP er fortsat ikke fuldt implementeret i Danmark. Derfor har denne kandidatafhandling til formål at undersøge omkostningseffektiviteten af NT-proBNP sammenlignet med den nuværende standardprocedure samt forskellige tærskelværdier i en dansk kontekst. Desuden at undersøge budgetkonsekvenserne af implementeringen af NT-proBNP. Metode: En cost-utility-analyse blev udført ved brug af et beslutningstræ, som sammenlignede tre strategier, herunder den nuværende standardprocedure, brugen af NT-proBNP ved en tærskelværdi på henholdsvis 125 pg/ml og 400 pg/ml, ud fra et sundhedsperspektiv over et år. I forlængelse heraf blev der udført deterministiske og probabilistiske følsomhedsanalyser for at vurdere usikkerhederne i analysen. Ydermere blev der udført en budgetkonsekvensanalyse over en femårig periode, inklusive et scenario med en lavere pris for NT-proBNP laboratorieanalyse. Der blev udført to systematiske litteratursøgninger for at identificere eksisterende evidens vedrørende anvendelsen af NT-proBNP i primærsektoren samt omkostningsanalyser for NT-proBNP. Resultater: Strategien med en NT-proBNP-tærskelværdi på 400 pg/ml var omkostningseffektiv sammenlignet med de andre strategier på grund af lavere omkostninger og større sundhedsfordele. Implementeringen af NT-proBNP ville medføre besparelser på 2-60 millioner kroner over en femårig periode sammenlignet med den nuværende standardprocedure og kunne stige til over 80 millioner kroner, hvis omkostningerne for NT-proBNP laboratorieanalyser faldt. Konklusion: Det konkluderes, at implementering af NT-proBNP i primærsektoren i Danmark er omkostningseffektivt. En tærskelværdi på 400 pg/ml blev vurderet som omkostningseffektiv, men det tyder på, at den er forbundet med en større risiko for oversete diagnoser på grund af interpersonelle forskelle, komorbiditeter, fænotyper og risikofaktorer.
Background: Chronic heart failure represents a major public health challenge. In Denmark, there is an increasing incidence, leading to a growing economic burden and societal strain. The current diagnostic strategy involves referring all patients for echocardiography based on a clinical examination. However, a promising and less costly rule-out biomarker, NT-proBNP, exists and has demonstrated effectiveness in primary care while resulting in cost savings. Several international guidelines recommend the use of NT-proBNP, however, there is inconsistency regarding an appropriate threshold for the general population. Despite these recommendations, NT-proBNP has not been fully implemented in Denmark. Therefore, this Master’s thesis aims to investigate the cost- effectiveness of NT-proBNP compared to the standard of care and different thresholds in a Danish setting. Additionally, to clarify the budgetary consequences of the implementation of NT-proBNP. Method: A cost-utility analysis was performed using a decision tree comparing three strategies; the standard of care, initial screening with NT-proBNP at a threshold of 125 pg/ml, and a threshold of 400 pg/ml from a healthcare perspective over a year. Moreover, deterministic and probabilistic sensitivity analyses were conducted to assess the uncertainties of the base case. Also, a budget-impact analysis over five years was performed including a scenario with a lower price for the NT-proBNP laboratory analysis. Two systematic literature searches were conducted to identify existing evidence on the use of NT- proBNP in primary care and cost analyses, respectively. Results: The strategy with an NT-proBNP threshold of 400 pg/ml was found to be cost-effective compared to the other strategies due to lower costs and greater health benefits, with a robust result to uncertainties. The implementation of NT-proBNP would result in savings of DKK 2-60 million over five years compared to the standard of care, potentially increasing to above DKK 80 million if the costs for NT-proBNP laboratory analysis decrease. Conclusion: In conclusion, the implementation of NT-proBNP in primary care in Denmark is cost- effective. A threshold of 400 pg/ml was deemed cost-effective; however, it might be associated with a higher risk of missing diagnoses due to interpersonal differences, comorbidities, phenotypes, and risk factors.
Keywords
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