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


METHODS
A decision analysis model.


METHODS
Patients with acute MI who were candidates for thrombolytic therapy and who presented within six hours of symptom onset.


METHODS
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.
Kalish
S C
SC
Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA.
Gurwitz
J H
JH
Krumholz
H M
HM
Avorn
J
J
D000368:Aged; D003362:Cost-Benefit Analysis / Q000379:methods; D003661:Decision Support Techniques; D006801:Humans; D018803:Models, Economic; D009203:Myocardial Infarction / Q000188:drug therapy* / Q000401:mortality; D019057:Quality-Adjusted Life Years; D013300:Streptokinase / Q000191:economics* / Q000627:therapeutic use; D015912:Thrombolytic Therapy / Q000191:economics*; D010959:Tissue Plasminogen Activator / Q000191:economics* / Q000627:therapeutic use
D013300:Streptokinase; D010959:Tissue Plasminogen Activator