Cost-effectiveness analysis of ED decision making in patients with non–high-risk heart failure
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Fig. 1
Simplified schema for the structure of the decision model for an ED patient with ADHF. @ indicates subtree for inpatient admission; &, subtree for early readmission; !, subtree for 30-day events; #, subtree for inpatient complication.
Fig. 2
Marginal cost-effectiveness ratio as a function of the risk of early readmission to the hospital after ED discharge. The base case is an absolute risk of readmission of 6%.
Fig. 3
Marginal cost-effectiveness ratio as a function of the risk of late readmission to the hospital after ED discharge. The base case is an absolute risk of readmission of 40%.
Fig. 4
Deterministic sensitivity analysis for base case. Each parameter is varied across its clinically relevant ranges. 
Beyond an RR of 2.5 for late death after OU discharge, ED discharge becomes the dominant strategy.
Abstract
Background
The ED disposition of patients with non–high-risk acute decompensated heart failure (ADHF) is challenging. To help address this problem, we investigated the cost-effectiveness of different ED disposition strategies.
Methods
We constructed a decision analytic model evaluating the cost-effectiveness of 3 possible ED ADHF disposition strategies in a 60-year-old man: (1) discharge home from the ED; (2) observation unit (OU) admission; (3) inpatient admission. Base case patients had no high-risk features. We used Medicare costs and the national physician fee schedule to capture ED, OU, and hospital costs, including costs of complications and death. All analyses were conducted using Decision Maker software (University of Medicine and Dentistry of New Jersey, Newark, NJ).
Results
Compared to ED discharge, OU admission had a reasonable marginal cost-effectiveness ratio ($44 249/quality adjusted life year), whereas hospital admission had an unacceptably high marginal cost-effectiveness ratio ($684 101/quality adjusted life year). Sensitivity analyses demonstrated that as the risk of early (within 5 days) and late (within 30 days) readmission exceeded 36% and 74%, respectively, in those discharged from the ED, OU admission became less costly and more effective than ED discharge. Similarly, an increase in relative risk of both early and late death in those discharged from the ED improves the marginal cost-effectiveness ratio of OU admission. Finally, as postdischarge event rates increase in those discharged from the OU, hospital admission became more cost-effective.
Conclusion
Observation unit admission for patients with non–high-risk ADHF has a societally acceptable marginal cost-effectiveness ratio compared to ED discharge. However, as ED and OU discharge event rates increase, hospital admission becomes the more cost-effective strategy.
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