Prehospital rule-out of NSTEACS cost-effective vs. ED admission at 1 year
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Key takeaways:
- Point-of-care rule-out of NSTEACS conferred a similar, low event rate vs. rule-out in the ED.
- Prehospital rule-out was also cost-effective with no significant difference in quality of life at 1 year.
Prehospital rule-out of non-ST-segment elevation ACS with risk assessment and a single troponin test led to lower health care cost with similarly low 1-year outcomes vs. rule-out in the ED, results of the ARTICA trial show.
The long-term results of the ARTICA trial were published in European Heart Journal - Quality of Care and Clinical Outcomes.
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“[This trial demonstrated] consistent results, and now also a more elaborate economic analysis, including quality of life, all showing to a clear economic benefit for the strategy of prehospital rule-out,” Niels van Royen, MD, PhD, professor of cardiology and head of department at Radboud University Medical Center in Nijmegen, the Netherlands, told Healio. “Acute care facilities are overcrowded and expensive. If you can defer patients and see them in a routine outpatient setting this will surely also lead to cost reductions in the U.S.”
The ARTICA trial
ARTICA was an investigator-initiated randomized trial conducted in five ambulance regions in the Netherlands and enrolled 863 participants with suspected NSTEACS (mean age, 54 years; 57% women). Patients with HEART score of 3 or less were randomly assigned to direct transfer to ED or prehospital rule-out NSTEACS with a single point-of-care troponin measurement conducted by ambulance paramedics.
As Healio previously reported, a single point-of-care troponin measurement to rule out NSTEACS in low-risk patients reduced health care costs with similar 30-day adverse event risk compared with the direct-to-ED strategy.
Long-term outcomes of ARTICA
For the present study, van Royen and colleagues evaluated the 1-year outcomes of the ARTICA trial. Primary outcome was health care costs at 1 year. Secondary outcomes included safety — defined as 1-year MACE including ACS, unplanned revascularization or all-cause death — QOL and cost-effectiveness.
One-year follow-up was successful in all original ARTICA participants.
Average health care cost was significantly lower in the prehospital strategy compared with the direct to ED strategy (1,932 vs 2,649 euros), with a mean difference of 717 euros (95% CI, 347-1,087; P < .001).
van Royen and colleagues determined that prehospital rule-out of NSTEACS in low-risk patients was cost-effective, as cost remained lower at 1 year with no significant difference in QOL as measured by EuroQol-5D-5L questionnaires compared with the direct to ED strategy.
The rate of 1-year MACE was similar between early rule-out and direct to ED strategies (5.1% prehospital rule-out vs. 4.2% ED rule-out; P = .54), according to the study.
Moreover, among low-risk patients with NSTEACS ruled out prehospital, 1-year MACE remained low compared with patients ruled out in the ED (1.7% prehospital rule-out vs 1.4% ED rule-out; risk difference, 0.2%; 95% CI, –1.4 to 1.9; P = .79).
“The study was underpowered for safety, and it would be very valuable to repeat this strategy in a larger cohort, powered for clinical outcome and also including patients in different regions of the world,” van Royen told Healio.
For more information:
- Niels van Royen, MD, PhD, can be reached at niels.vanroyen@radboudumc.nl.
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Aarts GWA, et al. Eur Heart J Qual Care Clin Outcomes. 2024;doi:10.1093/ehjqcco/qcae004/7571550.
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