Cost-effectiveness analysis of patient management alternatives after uncomplicated myocardial infarction: a model

Quantitative decision analyses provide a means whereby the effectiveness, in terms of patient outcome, and costs of diverse clinical approaches to the care of patients with cardiovascular disease can be made explicit and understandable. Increasingly, the profession is being required to justify the costs of clinical care to society, government and third party payers. Such justifications can be effectively presented when structured in decision analytic format. To demonstrate the utility of decision analysis and its extension--cost-effectiveness analysis--as a technique for presenting the rationale for clinical practices and technology utilization, the Cardiovascular Norms Committee of the American College of Cardiology sponsored a model cost-effectiveness analysis. Alternative management options, 6 month mortality and costs for the post-myocardial infarction patient were compared. The options included exercise electrocardiography, exercise thallium scintigraphy and coronary angiography, followed by coronary artery bypass surgery for patients with left main coronary disease only or patients with left main disease, three vessel disease or single or double vessel disease and a significant amount of myocardium in jeopardy. Within the constraints of the model, proceeding directly to angiography for risk stratification was the most effective approach, lowering expected mortality from 8% to approximately 3%. The marginal costs for this strategy, however, were high. The most cost-effective approach was to screen patients initially with exercise electrocardiography.