Introduction
Over the past 25 years, hospital admissions for suspected acute coronary syndrome have increased in many countries.1 ,2 The majority of these patients are diagnosed with angina pectoris or as suffering from non-specific chest pain (NSCP), that is, coronary disease is not the cause of their pain. NSCP may account for up to 80% of visits to rapid access chest pain clinics because of new episodes of chest pain.3 ,4
In 2013, the mean annual societal cost per NSCP patient was estimated at ∼€10 000.5 Given that 15 million patients are admitted to a hospital with NSCP annually in the USA and Europe,6 ,7 the total costs exceed €150 billion annually, which is similar to the costs incurred by society for patients diagnosed with acute myocardial infarction and angina pectoris.5 ,6 ,8 ,9 Hospital admission days account for 70–90% of the initial healthcare costs,6 ,10 but patients with NSCP continue to incur costs because they often experience repeated episodes of pain,11 ,12 that result in further admissions,5 ,8 decreased quality of life,11 ,12 sick leave and lost productivity.5 In addition, they seek care from a range of healthcare providers outside the hospital setting3 ,5 ,12 ,13 at a level that exceeds those of patients who are diagnosed with chest pain associated with cardiac disease.12 The potential benefit of primary care sector healthcare and the related costs for this patient group are rarely investigated in randomised trials.14
Patients with NSCP are an established subset of patients who present to chest pain units, and musculoskeletal problems are well recognised as potential causes of chest pain, with an estimated prevalence of 10–30%15–17 among patients with NSCP. In 2012, we reported clinical outcomes of a pragmatic, randomised clinical trial evaluating the relative effectiveness of usual care in combination with a primary sector care approach (chiropractic care) compared with usual care in combination with a minimal intervention (self-management). This was in patients presenting to a Danish university hospital with an episode of acute chest pain that was first diagnosed as NSCP and subsequently diagnosed as musculoskeletal chest pain.18 ,19 The chiropractic care group did significantly better than the self-management group, in terms of global perceived effect after 4 weeks of treatment and pain intensity after 12 weeks; however, there were no significant differences between groups after 52 weeks. The aim of the current analysis was to evaluate the 1-year cost-effectiveness of the two approaches in terms of healthcare utilisation, medication and quality of life using self-report questionnaires and Danish national registry-based resource use data.