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A cost-effectiveness model of thrombolytic therapy for acute myocardial infarction

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Abstract

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, anaphylazis, 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.

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Authors and Affiliations

  1. the Program for the Analysis of Clinical Strategies, Gerontology Division, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts

    Susan C. Kalish MD, Jerry H. Gurwitz MD & Jerry Avorn MD

  2. the Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut

    Harlan M. Krumholz MD

  3. the Brockton/West Roxbury Veterans Affairs Medical Center, Brockton, Massachusetts

    Jerry H. Gurwitz MD

Authors
  1. Susan C. Kalish MD
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  2. Jerry H. Gurwitz MD
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  3. Harlan M. Krumholz MD
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  4. Jerry Avorn MD
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Additional information

Supported by a research grant from Kabi Pharmacia. Dr. Kalish is the recipient of a Merck/American Federation for Aging Research Fellowship in Clinical Geriatric Pharmacology. Dr. Gurwitz is the recipient of a Clinical Investigator Award (K08 AG00510) from the National Institute on Aging, Bethesda, Maryland.

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Kalish, S.C., Gurwitz, J.H., Krumholz, H.M. et al. A cost-effectiveness model of thrombolytic therapy for acute myocardial infarction. J Gen Intern Med 10, 321–330 (1995). https://doi.org/10.1007/BF02599951

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