Tissue plasminogen activator was cost-effective compared to streptokinase in only selected patients with acute myocardial infarction.
OBJECTIVE
We sought to explore the patient-specific cost-effectiveness in a community-based sample for a therapy for which the average cost-effectiveness in a clinical trial has been well-described.


METHODS
Based on a validated multivariate model, we generated predictions of the effectiveness and cost-effectiveness of t-PA compared to streptokinase on 921 consecutive patients who received thrombolytic therapy for acute myocardial infarction.


RESULTS
The average cost-effectiveness of t-PA was US dollar 40,140 per life-year saved. For the quartile of patients most likely to benefit, the incremental cost-effectiveness of t-PA was US dollar 15,396. However, only 44% of patients who received thrombolytic therapy had an estimated cost-effectiveness ratio below US dollar 50,000 per year of life saved; the ratio was greater than US dollar 100,000 in 37% of treated patients. Patients in the lowest quartile of expected benefit are, overall, more likely to be harmed than to benefit from t-PA.


CONCLUSIONS
Compared to the pattern of thrombolytic agent choice observed, targeting t-PA to the half of patients most likely to benefit could save 247 lives and US dollar 174 million nationally per year.
Clinical Research and Health Policy Studies, Tufts-New England Medical Center/Tufts University School of Medicine, 750 Washington Street, Box 63, Boston, MA 02111, USA. dkent1@tufts-nemc.org
David M
DM
Kent
Sandeep
S
Vijan
Rodney A
RA
Hayward
John L
JL
Griffith
Joni R
JR
Beshansky
Harry P
HP
Selker
D000368:Aged; D003362:Cost-Benefit Analysis; D016527:Drug Costs / Q000706:statistics & numerical data; D005260:Female; D005343:Fibrinolytic Agents / Q000191:economics / Q000627:therapeutic use; D017048:Health Care Costs / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D017059:Models, Econometric; D009203:Myocardial Infarction / Q000188:drug therapy* / Q000191:economics / Q000401:mortality; D018579:Patient Selection; D012680:Sensitivity and Specificity; D013300:Streptokinase / Q000191:economics / Q000627:therapeutic use*; D015912:Thrombolytic Therapy / Q000191:economics* / Q000379:methods; D010959:Tissue Plasminogen Activator / Q000191:economics / Q000627:therapeutic use*; D014481:United States / Q000453:epidemiology
D005343:Fibrinolytic Agents; D013300:Streptokinase; D010959:Tissue Plasminogen Activator