The cost-effectiveness of thrombolysis administered by paramedics.
OBJECTIVE
The objective of this study is to estimate the expected health outcomes, costs and cost-effectiveness of changing from current practice, where thrombolytic therapy is given in hospital, to paramedic practice where thrombolytic therapy is administered by appropriately trained paramedics (pre-hospital) for STEMI patients.


METHODS
A decision-analysis microsimulation model was constructed with a 30-day component and a long-term health state transition component. A brief review of the literature was undertaken to obtain data on time-to-needle to populate the model. The primary health outcome was quality-adjusted life years (QALYs); secondary outcomes included cardiac events, procedures and survival. Costs to the Australian healthcare system for the rest of life were taken as the analytical perspective.


RESULTS
On average, STEMI patients gain 0.13 QALYs at an additional life-time cost of $343. The incremental cost-effectiveness ratios were $3428 per life-year gained and $2601 per QALY gained. These estimates were robust to changes in a range of assumptions and parameter values. The most important factor was the time-to-needle - the greater the difference between current practice times and paramedic practice times, the greater the health benefits and lower the cost per QALY (and life-year) gained. A key factor in the model was the substantially lower incidence of heart failure from earlier time-to-needle. Importantly, there was little change in the cost per QALY gained for a wide range of ages; thus, there is no argument to limit thrombolysis by paramedics to above or below an age threshold.


CONCLUSIONS
Paramedics administering thrombolysis can avert some STEMI deaths and the pre-hospital administration of thrombolysis is good value for money.
School of Medicine, Griffith University, Meadowbrook, Queensland, Australia. p.scuffham@griffith.edu.au
Paul A
PA
Scuffham
Vivienne
V
Tippett
D000368:Aged; D000488:Allied Health Personnel; D015331:Cohort Studies; D003362:Cost-Benefit Analysis; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage / Q000191:economics*; D017048:Health Care Costs; D006761:Hospitals; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000188:drug therapy* / Q000191:economics* / Q000401:mortality; D019057:Quality-Adjusted Life Years; D000077785:Tenecteplase; D015912:Thrombolytic Therapy / Q000191:economics*; D010959:Tissue Plasminogen Activator / Q000191:economics / Q000627:therapeutic use; D016896:Treatment Outcome
D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator; D000077785:Tenecteplase