Effectiveness and cost-effectiveness of thrombolysis in submassive pulmonary embolism.
BACKGROUND
Thrombolytic therapy is controversial in patients with submassive pulmonary embolism.


METHODS
We performed a cost-effectiveness analysis to compare health effects and costs of treatment with alteplase plus heparin sodium vs heparin alone in hemodynamically stable patients with pulmonary embolism and right ventricular dysfunction by developing a Markov model and using data from clinical trials and administrative sources.


RESULTS
Based on data from a recent randomized trial, we assumed that the risk of clinical deterioration requiring treatment escalation was almost 3 times higher in patients who received heparin alone (23.2% vs 7.6%) but that the risk of death was equal in the 2 cohorts (2.7%). Based on registry data, we assumed that the risk of intracranial hemorrhage was approximately 3 times higher in patients who received alteplase plus heparin (1.2% vs 0.4%). Under these and other assumptions, thrombolysis resulted in marginally higher total lifetime health care costs ($43,900 vs $43,300) and was slightly less effective (10.52 vs 10.57 quality-adjusted life-years) than treatment with heparin alone. Thrombolysis was more effective and cost less than $50,000 per quality-adjusted life-year gained when we assumed that the baseline risk of death in the heparin group was 3 times the base-case value (8.1%) and that alteplase reduced the relative risk of death by at least 10%.


CONCLUSIONS
Available data do not support the routine use of thrombolysis to treat patients with submassive pulmonary embolism. However, thrombolysis may prove to be cost-effective in selected subgroups of hemodynamically stable patients in whom the risk of death is higher.
Perlroth
Daniella J
DJ
Department of Medicine, School of Medicine, Stanford University, Stanford, California, USA.
Sanders
Gillian D
GD
Gould
Michael K
MK
D003362:Cost-Benefit Analysis; D004359:Drug Therapy, Combination; D005343:Fibrinolytic Agents / Q000191:economics* / Q000627:therapeutic use; D017048:Health Care Costs; D006493:Heparin / Q000191:economics / Q000627:therapeutic use; D006801:Humans; D011655:Pulmonary Embolism / Q000188:drug therapy / Q000191:economics*; D016032:Randomized Controlled Trials as Topic; D015912:Thrombolytic Therapy / Q000191:economics*; D010959:Tissue Plasminogen Activator / Q000191:economics* / Q000627:therapeutic use; D016896:Treatment Outcome
D005343:Fibrinolytic Agents; D006493:Heparin; D010959:Tissue Plasminogen Activator