Cost and cost-effectiveness of an early invasive vs conservative strategy for the treatment of unstable angina and non-ST-segment elevation myocardial infarction.
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.
Mahoney
Elizabeth M
EM
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
Jurkovitz
Claudine T
CT
Chu
Haitao
H
Becker
Edmund R
ER
Culler
Steven
S
Kosinski
Andrzej S
AS
Robertson
Debbie H
DH
Alexander
Charles
C
Nag
Soma
S
Cook
John R
JR
Demopoulos
Laura A
LA
DiBattiste
Peter M
PM
Cannon
Christopher P
CP
Weintraub
William S
WS
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
D010975:Platelet Aggregation Inhibitors; D019039:Platelet Glycoprotein GPIIb-IIIa Complex; D014443:Tyrosine; D000077466:Tirofiban