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A cost-effectiveness model for coronary thrombolysis/reperfusion therapy
G L Laffel1, H V Fineberg, E Braunwald
1Department of Medicine, Harvard Medical School, Boston, Massachusetts.
Insights
Coronary thrombolysis/reperfusion therapy costs vary significantly based on infarct size, treatment timing, and reocclusion strategy. Intravenous thrombolytic agents are more cost-effective than intracoronary methods or angioplasty.
Area of Science:
- Cardiovascular Medicine
- Health Economics
- Interventional Cardiology
Background:
- Coronary thrombolysis/reperfusion therapy is a critical treatment for acute myocardial infarction.
- Evaluating the cost-effectiveness of different therapeutic strategies is essential for resource allocation.
Purpose of the Study:
- To model the incremental costs and benefits of various coronary thrombolysis/reperfusion strategies.
- To identify key variables influencing the cost per additional survivor.
Main Methods:
- Development of a cost-effectiveness model for coronary thrombolysis/reperfusion.
- Inclusion of intravenous and intracoronary streptokinase, intravenous tissue plasminogen activator, and primary angioplasty.
- Comparison of three reocclusion management strategies.
Main Results:
- Costs per additional survivor varied 2- to 15-fold based on myocardium at risk, treatment delay, reperfusion time, and reocclusion strategy.
- Intravenous thrombolytic strategies were consistently more cost-effective than intracoronary or primary angioplasty.
- Costs of $7,000-$100,000/additional survivor were achieved with optimal intravenous protocols for large/moderate infarcts.
Conclusions:
- Patient selection and treatment strategy are crucial for cost-effective thrombolysis/reperfusion.
- Routine use in small infarcts or bypass surgery for reocclusion increases costs significantly.
- Societal willingness to pay for incremental benefits should guide treatment decisions.
Abstract:
A model was designed to examine the relations between incremental costs and benefits of coronary thrombolysis/reperfusion therapy. The model allows for the study of intravenous and intracoronary streptokinase, intravenous tissue plasminogen activator and primary angioplasty. Three strategies for the management of reocclusion are also compared. It was found that each of the following four variables can be responsible for a 2- to 15-fold variation in the costs per additional survivor: 1) the quantity of jeopardized myocardium, 2) the duration of coronary occlusion before the onset of therapy, 3) the time required from the onset of therapy until reperfusion is achieved, and 4) the reocclusion management strategy. Therapeutic strategies involving intravenous administration of thrombolytic agents were found to be consistently more cost effective than were strategies involving intracoronary administration of thrombolytic agents and primary angioplasty. In patients with a large or moderate-sized infarct, proper selection of intravenous protocols and reocclusion management strategies leads to costs of $7,000 to $100,000/additional survivor, costs that are similar to those of many generally accepted medical practices. Substantially higher costs per additional survivor are incurred with the routine use of thrombolytic therapy in patients with a small infarct or the routine use of coronary artery bypass surgery to reduce the risk of reocclusion after successful thrombolytic therapy. Decisions regarding which patients should receive thrombolysis/reperfusion therapy depend on society's willingness to pay for its incremental benefits.