Cost effectiveness of the B type natriuretic peptide, electrocardiography, and portable echocardiography for the assessment of patients from the community with suspected heart failure

Cost-effectiveness of B-type natriuretic peptide-guided care in patients with heart failure: a systematic review

Measuring the level of B-type natriuretic peptide (BNP), as a guide to pharmacotherapy, can increase the survival of patients with heart failure. This study is aimed at systematically reviewing the studies conducted on the cost-effectiveness of BNP-guided care in patients with heart failure. Using the systematic review method, we reviewed the published studies on the cost-effectiveness of BNP-guided care in patients with heart failure during the years 2004 to 2017. The results showed that all studies clearly stated the time horizon of the study and included direct medical costs in their analysis. In addition, most of the studies used the Markov model. The quality-adjusted life years (QALYs) were the main outcome used for measuring the effectiveness. The studies reported various ranges of the incremental cost-effectiveness ratio (ICER); accordingly, the highest ratio was observed in the USA ($32,748) and the lowest ratio was observed in Canada ($6251). Although the results of the studies were different in terms of a number of aspects, such as the viewpoint of the study, the study horizons, and the costs of expenditure items, they reached similar results. Based on the results of the present study, it seems that the use of BNP or N-terminal pro-BNP (NT-pro-BNP) in patients with heart failure may reduce cost compared to the symptom-based clinical care and increase QALY. In this regard, these studies were designed and conducted in high-income countries; thus, the application of these results in low- and middle-income countries will be limited.

NT-proBNP to exclude heart failure in primary care - a pragmatic, cluster-randomized study

Heart failure (HF) is difficult to recognize in primary care. N-terminal pro B-type natriuretic peptide (NT-proBNP) can be used as a rule-out test in HF due to its high negative predictive value. We aim to determine whether the number per 1000 patients of HF diagnoses increase among patients referred from primary care to an outpatient HF clinic, if general practitioners (GPs) were offered NT-proBNP in a real-life setting. All GP practices covered by Randers Regional Hospital were randomized to an intervention group (34 GP practices) and a control group (35 GP practices) in this pragmatic, cluster-randomized controlled trial. The main outcome was the number of patients referred to echocardiography and diagnosed with HF in each group. The number of patients per 1000 diagnosed with HF in the two groups was the same (0.09 (0.02-0.16) vs. 0.14 (0.07-0.21), p = .3541). A total of 700 NT-proBNP analyses, of which 611 were unique, were requested from 31 GP practices in 17.5 months. A total of 184 patients were referred to echocardiography on suspicion of HF. The number of patients per 1000 referred in the intervention group was significantly higher (p < .010). NT-proBNP was measured in 36.6% of referred patients in the intervention group. Significantly more women were diagnosed with HF in the intervention group (56.3% vs. 0%, p = .019). Hence, increased diagnostic effectiveness could not be shown in this real-life setting.

How peptide technology has improved costs and outcomes in patients with heart failure

INTRODUCTION

Heart failure (HF) is characterized by substantial health and economic burden, mainly attributed to increased hospitalizations and readmissions. Its diagnosis remains challenging due to the non-specific nature of the initial symptoms of the disease. Recently, scientific evidence has highlighted the potential of natriuretic peptides (NP) in improving the diagnosis and prognosis of HF and, by extension, in restraining healthcare costs. The present review aimed at providing evidence of their optimal use in terms of economic and health outcomes.

AREAS COVERED

Systematic literature research limited to studies published from February 2006 to February 2016 was performed with the aim of identifying and analyzing all cost-effectiveness and other economic evaluation studies that investigated the economic and health outcomes of NPs use as screening and management tools for HF. Expert commentary: NP testing either added in the standard of care, or substituting frequently used diagnostic procedures for the diagnosis and management of HF, regardless of the healthcare setting of interest, was proved to be a valid tool for clinical decision-making. Moreover it was associated with improved patient outcomes and important cost-savings mainly attributed to lower admission and readmission rates, shorter hospitalization length and improved health-related quality of life.

Performance of BNP and NT-proBNP for diagnosis of heart failure in primary care patients: a systematic review

National and international guidelines have been published recommending the use of natriuretic peptides as an aid to the diagnosis of heart failure (HF) in acute settings; however, few specific recommendations exist for governing the use of these peptides in primary care populations. To summarize the available data relevant to the diagnosis of HF in primary care patient population, we systematically reviewed the literature to identify original articles that investigated the diagnostic accuracy of B-type natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP) in primary care settings. The search yielded 25,864 articles in total: 12 investigating BNP and 20 investigating NT-proBNP were relevant to our objective and included in the review. QUADAS-2 and GRADE were used to assess the quality of the included articles. Diagnostic data were pooled based on three cutpoints: lowest and optimal, as chosen by study authors, and manufacturers' suggested. The effect of various determinants (e.g., age, gender, BMI, and renal function) on diagnostic performance was also investigated. Pooled sensitivity and specificity of BNP and NT-proBNP using the lowest [0.85 (sensitivity) and 0.54 (specificity)], optimal (0.80 and 0.61), and manufacturers' (0.74 and 0.67) cutpoints showed good performance for diagnosing HF. Similar performance was seen for NT-proBNP: lowest (0.90 and 0.50), optimal (0.86 and 0.58), and manufacturers' (0.82 and 0.58) cutpoints. Overall, we rated the strength of evidence as high because further studies will be unlikely to change the estimates diagnostic performance.

Measurement of natriuretic peptides at the point of care in the emergency and ambulatory setting: current status and future perspectives

The measurement of natriuretic peptides (NPs), B-type NP or N-terminal pro-B-type NP, can be an important tool in the diagnosis of acute heart failure in patients presenting to an Emergency Department (ED) with acute dyspnea, according to international guidelines. Studies and subsequent meta-analyses are mixed on the absolute value of routine NP assessment of ED patients. However, levels of NPs are likely to be used also to guide treatment and to assess risk of adverse outcomes in other patients at risk of developing heart failure, including those with pulmonary embolism or diabetes, or receiving chemotherapy. Natriuretic peptide levels, like other biomarkers, can now be measured at the point of care (POC). We have reviewed the current status of NP measurement together with the potential contribution of POC measurement of NPs to clinical care delivery in the emergency and other settings. Several POC systems for measuring NP levels are now available: these produce test results within 15 minutes and appear sufficiently sensitive and robust to be used routinely in diagnostic evaluations. Point-of-care systems could be used to assess NP levels in the ED and community outpatient settings to monitor the risk of acute heart failure. Furthermore, the use of protocol-driven POC testing of NP within the time frame of a patient consultation in the ED may facilitate and accelerate the throughput and disposition of at-risk patients. Appropriately designed clinical trials will be needed to confirm these potential benefits. It is also important that processes of care delivery are redesigned to take full advantage of the faster turnaround times provided by POC technology.

Diagnostic accuracy and cost-effectiveness of a pocket-sized transthoracic echocardiographic imaging device

BACKGROUND

The recently introduced pocket-sized portable transthoracic echocardiography (pTTE) is accurate for measurement of cardiac chamber size and function as well as for assessment of valvular regurgitation. This study aimed to compare the diagnostic accuracy of the pocket-sized pTTE with the standard TTE (sTTE) and assess its cost-effectiveness.

HYPOTHESIS

The use of pocket-sized pTTE, as an initial screening tool, may be feasible, accurate and cost-effective in the diagnostic strategy of cardiac abnormalities.

METHODS

The study subjects were 200 patients scheduled for sTTE and an electrocardiogram (ECG). Each patient underwent pTTE examination with the Vscan (GE Medical Systems, Milwaukee, WI) immediately after sTTE. The findings of pTTE and the ECG were compared with the results of sTTE. Cost-effectiveness was calculated.

RESULTS

There was a strong agreement in the detection of abnormal findings between pTTE and sTTE (agreement = 90%), whereas the agreement between the ECG and sTTE was 65%. When pTTE or the ECG was used as an initial screening tool prior to sTTE, similar cost reduction was obtained (approximately 30%) by reducing the number of referrals for sTTE. However, the negative predictive value of a diagnostic strategy with pTTE (92%) was superior to that with an ECG (67%).

CONCLUSIONS

This study demonstrates that the pocket-sized pTTE provides accurate detection of cardiac structural and functional abnormalities beyond the ECG. In addition, the use of pTTE as an initial screening tool prior to sTTE is cost-effective, suggesting that the pocket-sized pTTE is poised to alter the current diagnostic strategy in clinical practice.

Acute heart failure due to transient left ventricular dyssynchrony: case study

This case study describes an unusual cause of acute heart failure that resolved with early beta-blockade therapy. A 52-year-old woman who had acute heart failure with severe left ventricular systolic dysfunction and left bundle branch block was admitted to a university medical center. Contrast-enhanced magnetic resonance images of the heart did not show any evidence of myocardial infarction or myocarditis. Rate-related left bundle branch block and subsequent left ventricular dyssynchrony resulted in acute systolic dysfunction that resolved with beta-blockade therapy that allowed heart rate control and narrowing of the QRS complex. Of note, the use of inotropic agents would have dramatically worsened the cardiac condition.

B-type natriuretic peptides and echocardiographic measures of cardiac structure and function

Echocardiography and the B-type natriuretic peptides (BNPs) provide powerful incremental assessment of cardiac function, clinical status, and outcome across the spectrum of cardiac disease. There is strong evidence to support their integrated use in the diagnosis and management of cardiovascular disease. Amino-terminal pro-B-type natriuretic peptide (NT-proBNP) or BNP may guide more effective use of echocardiography in screening for asymptomatic left ventricular dysfunction; Doppler echocardiography improves the accuracy of heart failure diagnosis in the setting of intermediate BNP or NT-proBNP levels. Combined assessment of peptides and echocardiography provides more powerful stratification of risk across all stages of heart failure, and integrated use of both tests may identify subjects with valvular disease at greatest risk for progression and guide decision-making for timely intervention.

Accuracy and Cost Comparison of Ultrasound Versus Alternative Imaging Modalities, Including CT, MR, PET, and Angiography

Ultrasound (US) has become widely used in clinical medicine for the diagnosis of a variety of disease processes. The unique ability of US to provide accurate information through an efficacious, painless, portable, and nonionizing method has expanded its role and application in diverse medical settings. Given the current economic environment and the related interest in creating the greatest value for health care expenditures, US has been evaluated to compare its clinical accuracy/efficacy and cost-effectiveness versus other imaging modalities. The following literature review reports the results of research studies aimed at comparing the accuracy/efficacy and cost of US versus alternative imaging modalities, including magnetic resonance imaging, computed tomography, contrast angiography, and single-photon emission computed tomography.

Telomere dynamics unique to meiotic prophase: formation and significance of the bouquet

Telomeres carry out conserved and possibly ancient functions in meiosis. During the specialized prophase of meiosis I, meiotic prophase, telomeres cluster on the nuclear envelope and move the diploid genetic material around within the nucleus so that homologous chromosomes can align two by two and efficiently recombine with precision. This recombination is in turn required for proper segregation of the homologs into viable haploid daughter cells. The meiosis-specific telomere clustering on the nuclear envelope defines the bouquet stage, so named for its resemblance to the stems from a bouquet of cut flowers. Here, a comparative analysis of the literature on meiotic telomeres from a variety of different species illustrates that the bouquet is nearly universal among life cycles with sexual reproduction. The bouquet has been well documented for over 100 years, but our understanding of how it forms and how it functions has only recently begun to increase. Early and recent observations document the timing and provide clues about the functional significance of these striking telomere movements.