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A cost-effectiveness model of thrombolytic therapy for acute myocardial infarction
S C Kalish1, J H Gurwitz, H M Krumholz
1Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA.
Objective:
To assess the short- and long-term costs and clinical and quality of life outcomes with the use of streptokinase (SK) vs tissue plasminogen activator (tPA) for acute myocardial infarction (MI).
Design:
A decision analysis model.
Patients:
Patients with acute MI who were candidates for thrombolytic therapy and who presented within six hours of symptom onset.
Measurements:
30-day and one-year mortality, impacts of disabling and nondisabling stroke, reinfarction, hemorrhage, hypotension, anaphylaxis, and long-term medical costs.
Results:
Using 30-day mortality data from the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO) trial, the baseline analysis yielded an incremental cost-effectiveness for tPA of $30,300 per additional quality-adjusted life year (QALY) gained, compared with SK. Using one-year mortality data from the GUSTO trial, the analysis yielded an incremental cost-effectiveness for tPA of $27,400 per additional QALY, compared with SK. The incremental cost-effectiveness of tPA over SK was sensitive to the difference in mortality seen with the two agents, exceeding $100,000 per QALY, for a relative survival advantage of approximately one-third that seen in the GUSTO trial. The incremental cost per QALY of tPA remained under $60,000 if the survival benefit was half that seen in the GUSTO trial. The cost-effectiveness of tPA declined with a shorter projected life expectancy following MI and for inferior (vs anterior) wall infarction. The analysis was modestly sensitive to the costs of the thrombolytic agents.
Conclusions:
In spite of its higher cost relative to SK, tPA is a cost-effective therapy for MI under a wide range of assumptions regarding clinical outcomes and costs.