title: Cost and cost-effectiveness of an early invasive vs conservative strategy for the treatment of unstable angina and non-ST-segment elevation myocardial infarction.
abstract: BACKGROUND
  In the Treat Angina with Aggrastat and Determine Cost of Therapy with an Invasive or Conservative Strategy (TACTICS)-Thrombolysis in Myocardial Infarction (TIMI) 18 trial, patients with either unstable angina or non-ST-segment elevation myocardial infarction (UA/NSTEMI) treated with the platelet glycoprotein (Gp IIb/IIIa) inhibitor tirofiban had a significantly reduced rate of major cardiac events at 6 months with an early invasive vs a conservative strategy.
  
  
  OBJECTIVE
  To examine total 6-month costs and long-term cost-effectiveness of an invasive vs a conservative strategy.
  
  
  METHODS
  Randomized controlled trial including a priori economic end points.
  
  
  METHODS
  Hospitalization for UA/NSTEMI with 6-month follow-up period.
  
  
  METHODS
  A total of 2220 patients with UA/NSTEMI; economic data from 1722 patients at US-non-VA hospitals.
  
  
  METHODS
  Early invasive strategy with routine catheterization and revascularization as appropriate vs a conservative strategy with catheterization performed only for recurrent ischemia or a positive stress test.
  
  
  METHODS
  Total 6-month costs and incremental cost-effectiveness ratio.
  
  
  RESULTS
  The average initial hospitalization costs among those in the invasive strategy group were $15714 vs $14047 among those in the conservative strategy group, a difference of $1667 (95% confidence interval [CI], $387-3091). The in-hospital costs were offset significantly at the 6-month follow-up, with an average cost in the invasive group of $6098 vs $7180 in the conservative group, a difference of $1082 (95% CI, -$2051 to $76). The average total costs at 6 months, including productivity costs, for the invasive group was $21 813 vs $21 227 for the conservative group, a $586 difference (95% CI, -$1087 to $2486). The average 6-month costs excluding productivity costs in the invasive group was $19 780 vs $19 111 in the conservative group, a difference of $670, 95% CI; (-$1035 to $2321). Estimated cost per year of life gained for the invasive strategy, based on projected life expectancy, was $12739 for the base case, and ranged from $8371 to $25769, based on model assumptions.
  
  
  CONCLUSIONS
  In patients with UA/NSTEMI treated with the Gp IIb/IIIa inhibitor tirofiban, the clinical benefit of an early invasive strategy was achieved with a small increase in cost, yielding favorable projected estimates of cost per year of life gained. These results support the broader use of an early invasive strategy in these patients.
authors.affiliation: Emory Center for Outcomes Research, Division of Cardiology, Department of Medicine, Emory University School of Medicine, 1256 Briarcliff Rd, Suite 1N, Atlanta, GA 30306, USA. emahone@emory.edu
authors.forename: Elizabeth M
authors.initials: EM
authors.lastname: Mahoney
authors.forename: Claudine T
authors.initials: CT
authors.lastname: Jurkovitz
authors.forename: Haitao
authors.initials: H
authors.lastname: Chu
authors.forename: Edmund R
authors.initials: ER
authors.lastname: Becker
authors.forename: Steven
authors.initials: S
authors.lastname: Culler
authors.forename: Andrzej S
authors.initials: AS
authors.lastname: Kosinski
authors.forename: Debbie H
authors.initials: DH
authors.lastname: Robertson
authors.forename: Charles
authors.initials: C
authors.lastname: Alexander
authors.forename: Soma
authors.initials: S
authors.lastname: Nag
authors.forename: John R
authors.initials: JR
authors.lastname: Cook
authors.forename: Laura A
authors.initials: LA
authors.lastname: Demopoulos
authors.forename: Peter M
authors.initials: PM
authors.lastname: DiBattiste
authors.forename: Christopher P
authors.initials: CP
authors.lastname: Cannon
authors.forename: William S
authors.initials: WS
authors.lastname: Weintraub
mesh_terms: D000368:Aged; D000789:Angina, Unstable / Q000191:economics* / Q000628:therapy*; D003362:Cost-Benefit Analysis; D005260:Female; D005500:Follow-Up Studies; D017048:Health Care Costs / Q000706:statistics & numerical data*; D017721:Hospital Costs / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000191:economics* / Q000628:therapy*; D009204:Myocardial Revascularization / Q000191:economics*; D010043:Outcome and Process Assessment, Health Care; D010975:Platelet Aggregation Inhibitors / Q000191:economics / Q000627:therapeutic use*; D019039:Platelet Glycoprotein GPIIb-IIIa Complex / Q000037:antagonists & inhibitors; D019057:Quality-Adjusted Life Years; D000077466:Tirofiban; D014443:Tyrosine / Q000031:analogs & derivatives* / Q000191:economics / Q000627:therapeutic use*; D014481:United States
chemical_list: D010975:Platelet Aggregation Inhibitors; D019039:Platelet Glycoprotein GPIIb-IIIa Complex; D014443:Tyrosine; D000077466:Tirofiban