, Volume 17, Issue 3, pp 263–272 | Cite as

Evaluating the Potential ‘Economic Attractiveness’ of New Therapies in Patients with Non-ST Elevation Acute Coronary Syndrome

  • Eric L. EisensteinEmail author
  • Eric D. Peterson
  • James G. Jollis
  • Barbara E. Tardiff
  • Robert M. Califf
  • J. David Knight
  • Daniel B. Mark
Original Research Article


Objective: To evaluate the relationship between how much a new cardiovascular therapy improves clinical outcomes over current therapies and how much more it can cost while still remaining ‘economically attractive’.

Design: We developed a decision model to predict the 6-month cumulative cost savings and increased life expectancy that could be associated with new therapies for patients with non-ST elevation acute coronary syndrome.

Setting: This modelling study used outcome and cost data from US sources.

Methods: Event probabilities at 30 days and 6 months were estimated from US patients with non-ST elevation in the Global Use of Strategies To Open Occluded Coronary Arteries in Acute Coronary Syndromes (GUSTO) IIb trial; cost estimates were derived from patients enrolled in the Economics and Quality of Life substudy of this trial. Patient life expectancy estimates were calculated using survival estimates for similar patients treated at Duke University Medical Center.

Results: We found that new therapies costing up to $US2000 per episode that reduce 6-month mortality by 0.5%, death and nonfatal myocardial infarction (MI) by 1%, or death, nonfatal MI and revascularisation by 3%, may be cost effective by current standards. When new therapies costing up to $US1000 per episode reduce the absolute rate of death, nonfatal MI and revascularisation at 6 months by 6.5% or more, they may be cost saving.

Conclusion: Our analysis suggests that economic constraints should not inhibit the development of effective new therapies.


Acute Coronary Syndrome Coronary Artery Bypass Graft Decision Model Nonfatal Stroke Revascularisation Rate 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



This work was supported in part by a grant from Hoechst Marion Roussel, Kansas City, Missouri, USA. The authors would like to acknowledge the excellent editorial and technical support of Tracey Simons, M.A. in the preparation of this manuscript.


  1. 1.
    Califf RM, Eisenstein EL. Cost-effectiveness of therapy for acute ischemic heart disease. In: Talley JD, editor. Cost-effective diagnosis and treatment of coronary artery disease. New York (NY): Igaku-Shoin, 1997: 139–67Google Scholar
  2. 2.
    Califf RM. Spectrum of acute ischemic heart disease: unstable angina to acute myocardial infarction. In: Califf RM, editor. Acute myocardial infarction and other acute ischemic syndromes. St Louis (MO): Mosby, 1996: 1.1–1.19Google Scholar
  3. 3.
    The PARAGON Investigators. International, randomized, controlled trial of lamifiban (a platelet glycoprotein IIb/IIIa inhibitor), heparin, or both in unstable angina. Circulation 1998; 97: 2386–95CrossRefGoogle Scholar
  4. 4.
    The PRISM Study Investigators. A comparison of aspirin plus tirofiban with aspirin plus heparin for unstable angina. N Engl J Med 1998; 338: 1498–505CrossRefGoogle Scholar
  5. 5.
    The PRISM Plus Study Investigators. Inhibition of the platelet glycoprotein IIb/IIIa receptor with tirofiban in unstable angina and non–Q-wave myocardial infarction. N Engl J Med 1998; 338: 1488–97CrossRefGoogle Scholar
  6. 6.
    The PURSUIT Investigators. Inhibition of platelet glycoprotein IIb/IIIa with eptifibatide in patients with acute coronary syndromes without persistent ST-segment elevation. N Engl J Med 1998; 339: 436–43CrossRefGoogle Scholar
  7. 7.
    Eisenstein EL, Mark DB. Economic issues related to diagnosis and therapy for coronary heart disease. In: Pepine CJ, editor. Diagnostic and therapeutic cardiac catheterization. Baltimore (MD): Williams & Wilkins, 1998: 892–913Google Scholar
  8. 8.
    Doubilet P, Weinstein MC, McNeil BJ. Use and misuse of the term ‘cost effective’ in medicine. N Engl J Med 1986; 314: 253–6PubMedCrossRefGoogle Scholar
  9. 9.
    Kuttner R. Columbia/HCA and the resurgence of the for-profit hospital business. N Engl J Med 1996; 335: 362–7PubMedCrossRefGoogle Scholar
  10. 10.
    Antiplatelet Trialist’s Collaboration. Collaborative overview of randomized trials of antiplatelet therapy (I): prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients. BMJ 1994; 308: 81–106CrossRefGoogle Scholar
  11. 11.
    Cairns JA, Markham BA. Economics and efficacy in choosing oral anticoagulants or aspirin after myocardial infarction. JAMA 1995; 273: 955–67CrossRefGoogle Scholar
  12. 12.
    Anonymous. DATA 3.0 user’s manual. Williamstown (MA): TreeAge Software, Inc., 1996Google Scholar
  13. 13.
    Califf RM, Harrelson-Woodlief L, Topol EJ. Left ventricular ejection fraction may not be useful as an end point of thrombolytic therapy comparative trials. Circulation 1990; 82: 1847–53PubMedCrossRefGoogle Scholar
  14. 14.
    The GUSTO IIb Investigators. A comparison of recombinant hirudin with heparin for the treatment of acute coronary syndromes. N Engl J Med 1996; 335: 775–82CrossRefGoogle Scholar
  15. 15.
    Mark DB, Granger CB, Ellis SG, et al. Costs of direct angioplasty versus thrombolysis for acute myocardial infarction: results from the GUSTO II randomized trial [abstract]. Circulation 1996; 94: 168AGoogle Scholar
  16. 16.
    Braunwald E, Mark DB, Jones RH, et al. Unstable angina: diagnosis and management. Rockville (MD): Agency for Health Care Policy and Research 1994: 94–0682Google Scholar
  17. 17.
    Beck JR, Pauker SG. The Markov process inmedical prognosis. Med Decis Making 1983; 3: 419–58PubMedCrossRefGoogle Scholar
  18. 18.
    Sonnenberg FA, Beck JR. Markov models in medical decision making: a practical guide. Med Decis Making 1993; 13: 332–8CrossRefGoogle Scholar
  19. 19.
    Sonnenberg FA, Wong JB. Commentary: fine-tuning life expectancy calculations using Markov processes. Med Decis Making 1993; 13: 171–2CrossRefGoogle Scholar
  20. 20.
    Mark DB, Hlatky MA, Califf RM, et al. Cost effectiveness of thrombolytic therapy with tissue plasminogen activator as compared with streptokinase for acute myocardial infarction. N Engl J Med 1995; 332: 1418–24PubMedCrossRefGoogle Scholar
  21. 21.
    Gold MR, Siegel JE, Russell LB, et al. Cost-effectiveness in health and medicine. New York (NY): Oxford University Press, 1996Google Scholar
  22. 22.
    Kaplan RM, Bush JW. Health-related quality of life measurement for evaluation research and policy analysis. Health Psychol 1981; 1: 61–80CrossRefGoogle Scholar
  23. 23.
    Goldman L, Gordon DJ, Rifkind BM, et al. Cost and health implications of cholesterol lowering. Circulation 1992; 85: 1960–8PubMedCrossRefGoogle Scholar
  24. 24.
    Laupacis A, Feeny D, Detsky AS, et al. How attractive does a new technology have to be to warrant adoption and utilization? Tentative guidelines for using clinical and economic evaluations. Can Med Assoc J 1992; 146: 473–81Google Scholar
  25. 25.
    Kuntz KM, Tsevat J, Goldman L, et al. Cost-effectiveness of routine coronary angiography after acute myocardial infarction. Circulation 1996; 94: 957–65PubMedCrossRefGoogle Scholar
  26. 26.
    Eisenstein EL, Newby LK, Pilote L, et al. Do regional differences in invasive cardiac procedure rates drive costs of care for the acute myocardial infarction patient [abstract]? Circulation 1996; 94: 506CrossRefGoogle Scholar
  27. 27.
    Hemenway D, Sherman H, Mudge GH, et al. Comparative costs versus symptomatic and employment benefits of medical and surgical treatment of stable angina pectoris. Med Care 1985; 23: 133–41PubMedCrossRefGoogle Scholar
  28. 28.
    Mark DB. Medical economics in cardiovascular medicine. In: Topol EJ, editor. Textbook of cardiovascular medicine. New York (NY): Lippincott-Raven, 1997: 1033–62Google Scholar
  29. 29.
    Kong DF, Califf RM, Miller DP, et al. Clinical outcomes of therapeutic agents that block the platelet glycoprotein IIb/IIIa integrin in ischemic heart disease. Circulation 1998; 98: 2829–35PubMedCrossRefGoogle Scholar

Copyright information

© Adis International Limited 2000

Authors and Affiliations

  • Eric L. Eisenstein
    • 1
    Email author
  • Eric D. Peterson
    • 1
  • James G. Jollis
    • 1
  • Barbara E. Tardiff
    • 1
  • Robert M. Califf
    • 1
  • J. David Knight
    • 1
  • Daniel B. Mark
    • 1
  1. 1.The Outcomes Research and Assessment Group, Duke Clinical Research InstituteDuke University Medical CenterDurhamUSA

Personalised recommendations