Pitfalls in the economic evaluation of thrombolysis in myocardial infarction. The impact of national differences in the cost of thrombolytics and of differences in the efficacy across patient subgroups.
BACKGROUND
The economic evaluation of the results of the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Artery (GUSTO) trial found that recombinant tissue plasminogen activator is more cost-effective than streptokinase for the treatment of acute myocardial infarction.


OBJECTIVE
We evaluated the impact on a cost effectiveness analysis, of the differences in the cost of thrombolytics among countries and of differences in efficacy across patient subgroups.


METHODS
We considered the crude costs of streptokinase and recombinant tissue plasminogen activator in Germany, Italy, the United Kingdom, and the United States of America, and the 30-day mortality found in the GUSTO trial. We calculated the incremental costs for each life saved when streptokinase is substituted by recombinant tissue plasminogen activator. We also calculated the incremental costs for each life saved for two protocols implying a selective use of streptokinase and recombinant tissue plasminogen activator (age-selective protocol: recombinant tissue plasminogen activator in patients < or = 75 years, streptokinase in older patients; site-selective protocol: recombinant tissue plasminogen activator in anterior acute myocardial infarction, streptokinase in non-anterior acute myocardial infarction).


RESULTS
The incremental costs for each life saved when streptokinase is substituted by recombinant tissue plasminogen activator in all GUSTO patients vary greatly among countries: the incremental costs for each life saved are 31%, 45%, and 97% higher in Germany, Italy, and the United States of America compared to the United Kingdom. The use of a site-selective protocol implies a halved cost-effectiveness ratio compared to the use of recombinant tissue plasminogen activator in all cases of acute myocardial infarction.


CONCLUSIONS
(1) The cost-efficacy of recombinant tissue plasminogen activator vs streptokinase in acute myocardial infarction varies greatly among countries due to differences in the cost of drugs. (2) A selective use of thrombolytics for some sites of infarction is more cost-effective than the exclusive use of recombinant tissue plasminogen activator.
Lorenzoni
R
R
Istituto di Clinica Medica e Cardiologia, University of Florence, Italy. lorenzoni.r@lunet.it
Pagano
D
D
Mazzotta
G
G
Rosen
S D
SD
Fattore
G
G
De Caterina
R
R
Gensini
G
G
D000368:Aged; D003362:Cost-Benefit Analysis; D016527:Drug Costs; D004359:Drug Therapy, Combination; D005343:Fibrinolytic Agents / Q000191:economics* / Q000627:therapeutic use; D006493:Heparin / Q000191:economics / Q000627:therapeutic use; D006801:Humans; D009203:Myocardial Infarction / Q000188:drug therapy* / Q000191:economics*; D011994:Recombinant Proteins; D013300:Streptokinase / Q000191:economics / Q000627:therapeutic use; D015912:Thrombolytic Therapy / Q000191:economics*; D010959:Tissue Plasminogen Activator / Q000191:economics / Q000627:therapeutic use
D005343:Fibrinolytic Agents; D011994:Recombinant Proteins; D006493:Heparin; D013300:Streptokinase; D010959:Tissue Plasminogen Activator