[Cost-benefit study of different thrombolytic strategies in treating 156 patients with symptomatic pulmonary thromboembolism]

OBJECTIVE

To compare the costs and benefits of different thrombolytic strategies with urokinase (UK) and recombinant tissue plasminogen activator (rt-PA) in treating acute pulmonary thromboembolism (PTE), with aim of providing optimal thrombolytic medication.

METHODS

Data from 156 patients with PTE from January 2006 to December 2011 in Tangshan Gongren Hospital was analyzed retrospectively. All patients were treated by thrombolysis, among them 104 patients were treated with 1×10(4) U/kg of UK and 52 patients were treated with 50 mg of rt-PA. The therapeutic effects of two methods were compared and the complication incidence rate and medical cost were also compared.

RESULTS

There were no significant differences in the symptom remission rate, the recanalization rate, and the incidence of complications between UK group and rt-PA group (68.2% vs. 71.2%, 63.5% vs. 73.1%, 14.4% vs. 17.3%, all P > 0.05), but the treatment cost (yuan) of UK group was remarkably lower than that of rt-PA group (408 ± 120 vs. 6500 ± 634, P < 0.01).

CONCLUSION

Different thrombolytic strategies with UK and rt-PA yield similar efficacy, however, the medical cost was significant decreased in UK group.

Cost-effectiveness of cytochrome P450 2C19 genotype screening for selection of antiplatelet therapy with clopidogrel or prasugrel

STUDY OBJECTIVE

To estimate the cost-effectiveness of genotype-guided selection of antiplatelet therapy compared with selecting clopidogrel or prasugrel irrespective of genotype.

DESIGN

Decision model based on event occurrence in the Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition with Prasugrel-Thrombolysis in Myocardial Infarction (TRITON-TIMI) 38.

PATIENTS

Simulated cohort of patients with acute coronary syndrome scheduled to undergo percutaneous coronary intervention (PCI), consisting of three arms: those receiving genotype-guided antiplatelet therapy with clopidogrel or prasugrel, those receiving clopidogrel regardless of genotype, and those receiving prasugrel regardless of genotype.

MEASUREMENTS AND MAIN RESULTS

All three arms of the model incorporated the probability that patients would experience a cardiovascular event (death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke), a bleeding event (major or minor bleeding), or no event while receiving antiplatelet therapy during the 15 months after the scheduled PCI. The cytochrome P450 (CYP) 2C19 genotype determined antiplatelet drug selection in the genotyping group. Cost-effectiveness was expressed as the incremental cost-effectiveness ratio (ICER) for each event avoided in the genotype-guided therapy arm versus the other two arms. Genotype-guided antiplatelet therapy was dominant, or more effective and less costly, when compared with the selection of clopidogrel (ICER -$6760 [95% confidence interval (CI) -$6720 to -$6790]) or prasugrel (ICER -$11,710 [95% CI -$11,480 to -$11,950]) for all patients without regard to genotype. Genotype-guided therapy that included generic clopidogrel was dominant to prasugrel for all patients (ICER -$27,160 [95% CI -$27,890 to -$26,420]). Cost savings were not evident when genotype-guided therapy that included generic clopidogrel was compared with generic clopidogrel for all patients (ICER $2300 [95% CI $2290 to $2320]). [Correction added after online publication 12-Mar-2012: In the previous sentence -$2300 has been corrected as $2300.].

CONCLUSION

Genotype-guided antiplatelet therapy selection may be more cost-effective and may provide more clinical value due to fewer adverse outcomes.

Costing hospital resources for stroke patients using phase-type models

Optimising resources in healthcare facilities is essential for departments to cope with the growing population's requirements. An aspect of such performance modelling involves investigating length of stay, which is a key performance indicator. Stroke disease costs the United Kingdom economy seven billion pounds a year and stroke patients are known to occupy long periods of time in acute and long term beds in hospital as well as requiring support from social services. This may be viewed as an inefficient use of resources. Thrombolysis is a therapy which uses a clot-dispersing drug which is known to decrease the institutionalisation of eligible stroke patients if administered 3 h after incident but it is costly to administer to patients. In this paper we model the cost of treating stroke patients within a healthcare facility using a mixture of Coxian phase type model with multiple absorbing states. We also discuss the potential benefits of increasing the usage of thrombolysis and if these benefits balance the expense of administering the drug.

Cost-effectiveness of CT perfusion for selecting patients for intravenous thrombolysis: a US hospital perspective

BACKGROUND AND PURPOSE

Improved selection of patients with stroke for IV tPA treatment may enhance clinical outcomes. Given the limited availability of MR imaging in hospitals, we examined the cost-effectiveness of adding CTP to the usual CT-based methods for selecting patients on the basis of the presence and extent of penumbra.

MATERIALS AND METHODS

A decision-analytic model estimated the costs and outcomes associated with penumbra-based CTP selection in a patient population similar to that enrolled in the IV tPA clinical trials. Model inputs were obtained from published literature, clinical trial data, standard US costing sources, and expert opinion. Cost per life-year saved and cost per QALY gained were estimated from a hospital perspective.

RESULTS

Addition of penumbra-based CTP to standard unenhanced CT improved favorable outcome (mRS, ≤1) by 0.59% and reduced cost by $42 compared with selection based on unenhanced CT alone. Life-years and QALYs improved. Multivariate sensitivity analysis predicted cost-effectiveness (≤$50,000 per QALY) in 89.2% of simulation runs.

CONCLUSIONS

Using penumbra-based CTP after routine CT to select patients with ischemic stroke for IV tPA is cost-effective compared with the usual CT-based methods for hospitals. With the ease of access of CTP, penumbra-based selection methods may be readily available to hospitals. Thus, this economic analysis may lend further support to the consideration of a paradigm shift in acute stroke evaluation.

Cost and health outcome of primary percutaneous coronary intervention versus thrombolysis in acute ST-segment elevation myocardial infarction-Results of the Swedish Early Decision reperfusion Study (SWEDES) trial

BACKGROUND

In ST-elevation myocardial infarction, primary percutaneous coronary intervention (PCI) has a superior clinical outcome, but it may increase costs in comparison to thrombolysis. The aim of the study was to compare costs, clinical outcome, and quality-adjusted survival between primary PCI and thrombolysis.

METHODS

Patients with ST-elevation myocardial infarction were randomized to primary PCI with adjunctive enoxaparin and abciximab (n = 101), or to enoxaparin followed by reteplase (n = 104). Data on the use of health care resources, work loss, and health-related quality of life were collected during a 1-year period. Cost-effectiveness was determined by comparing costs and quality-adjusted survival. The joint distribution of incremental costs and quality-adjusted survival was analyzed using a nonparametric bootstrap approach.

RESULTS

Clinical outcome did not differ significantly between the groups. Compared with the group treated with thrombolysis, the cost of interventions was higher in the PCI-treated group ($4,602 vs $3,807; P = .047), as well as the cost of drugs ($1,309 vs $1,202; P = .001), whereas the cost of hospitalization was lower ($7,344 vs $9,278; P = .025). The cost of investigations, outpatient care, and loss of production did not differ significantly between the 2 treatment arms. Total cost and quality-adjusted survival were $25,315 and 0.759 vs $27,819 and 0.728 (both not significant) for the primary PCI and thrombolysis groups, respectively. Based on the 1-year follow-up, bootstrap analysis revealed that in 80%, 88%, and 89% of the replications, the cost per health outcome gained for PCI will be <$0, $50,000, and $100,000 respectively.

CONCLUSION

In a 1-year perspective, there was a tendency toward lower costs and better health outcome after primary PCI, resulting in costs for PCI in comparison to thrombolysis that will be below the conventional threshold for cost-effectiveness in 88% of bootstrap replications.

Cost-effectiveness analysis of short-term clopidogrel therapy for ST elevation myocardial infarction

Clopidogrel improves outcomes in patients with ST-segment elevation myocardial infarction (STEMI) and is recommended in the guidelines. We sought to determine the incremental cost-effectiveness of clopidogrel therapy in this patient population. We used primary patient-level resource use and clinical outcomes data from 3491 STEMI patients treated with fibrinolysis and either clopidogrel or placebo prior to a diagnostic coronary angiogram in the Clopidogrel as Adjunctive Reperfusion Therapy-Thrombolysis in Myocardial Infarction 28 (CLARITY-TIMI 28) trial. Costs for each patient were calculated based on diagnosis-related groups-specific Medicare reimbursement rates for all hospitalizations and the average wholesale price of clopidogrel. Cost per event prevented and cost per life year gained (LYG) were calculated using standard methods. The estimate of LYG due to clopidogrel therapy was based on recurrent myocardial infarction and death outcomes. The bootstrap method was used to produce bias-corrected confidence intervals for cost and efficacy estimates as well as the cost per LYG ratio. Total costs and resource use were not significantly different for the clopidogrel and placebo groups ($8128 vs. $8134), indicating that short-term clopidogrel therapy is an economically dominant treatment strategy. Even in a sensitivity analysis accounting for higher long-term medical costs due to greater life expectancy, clopidogrel remained under $6000 per LYG. Clopidogrel therapy was dominant in 35% of the bootstrap simulations and cost less than $50,000 per LYG in 67% of simulations. In conclusion, this analysis finds short-term clopidogrel therapy to be a highly economically attractive therapy, improving patient outcomes at no increase in costs.

[An economic evaluation of low dose recombinant human tissue-type plasminogen activator for the treatment of acute pulmonary thromboembolism]

OBJECTIVE

To compare and evaluate the cost and effectiveness between recombinant human tissue-type plasminogen activator (rt-PA) 50 mg and 100 mg regimen for the treatment acute pulmonary thromboembolism (PTE).

METHODS

Based on a randomized clinical trial data, 118 cases were enrolled, 65 cases in group 50 mg and 53 cases in group 100 mg, which showed the similar efficacy and safety of rt-PA 50 mg and 100 mg. Progressive improvement in pulmonary artery obstructions was found to be similarly significant in both treatment groups, but there was no significant differences between the two groups (89.1% vs 89.6%, chi(2) = 0.007, P = 0.936). The rates of adverse events in two groups were same as well (17% vs 32%, chi(2) = 3.704, P = 0.054). We compared the cost directly and the cost-effective rate of the two groups. Based the cost saving of individual patient, prevalence rate of acute PTE, and co-pay rate of reimbursement, we calculated the cost saving of societal and payer's perspective.

RESULTS

The cost of group 50 mg is 6352 RMB/person, and the cost of group 100 mg is 12,704 RMB/person. The cost-effect rates of the two groups were 7129 and 14,179 separately. With the same effect, each patient in 50 mg group can save 7050 RMB. If the PTE patients in China were treated with rt-PA 50 mg instead of 100 mg, the society cost saving would be 443,604,624 RMB.

CONCLUSION

rt-PA 50 mg/2 h regimen, compared with 100 mg/2 h, can not only provide similar efficacy and safety, but also show a good health economic saving.

Budget impact analysis of thrombolysis for stroke in Spain: a discrete event simulation model

OBJECTIVE

Thrombolysis within the first 3 hours after the onset of symptoms of a stroke has been shown to be a cost-effective treatment because treated patients are 30% more likely than nontreated patients to have no residual disability. The objective of this study was to calculate by means of a discrete event simulation model the budget impact of thrombolysis in Spain.

METHODS

The budget impact analysis was based on stroke incidence rates and the estimation of the prevalence of stroke-related disability in Spain and its translation to hospital and social costs. A discrete event simulation model was constructed to represent the flow of patients with stroke in Spain.

RESULTS

If 10% of patients with stroke from 2000 to 2015 would receive thrombolytic treatment, the prevalence of dependent patients in 2015 would decrease from 149,953 to 145,922. For the first 6 years, the cost of intervention would surpass the savings. Nevertheless, the number of cases in which patient dependency was avoided would steadily increase, and after 2006 the cost savings would be greater, with a widening difference between the cost of intervention and the cost of nonintervention, until 2015.

CONCLUSION

The impact of thrombolysis on society's health and social budget indicates a net benefit after 6 years, and the improvement in health grows continuously. The validation of the model demonstrates the adequacy of the discrete event simulation approach in representing the epidemiology of stroke to calculate the budget impact.

Thrombolytic therapy with alteplase for ischaemic stroke

Stroke is very common, with, for example, around 110,000 people each year in England alone experiencing a first or recurrent episode. Consequences of stroke can include disability and early death, and the condition costs the UK economy around 7 billion pounds annually. Around 70-80% of first strokes are ischaemic (i.e. due to the thromboembolic or thrombotic occlusion of an intracranial artery), and so some patients with stroke may be suitable for thrombolytic therapy. Here we review the evidence for such therapy in acute ischaemic stroke.

Cost-effectiveness of primary percutaneous coronary interventionversusthrombolytic therapy for acute myocardial infarction

OBJECTIVES

We sought to determine the long-term cost-effectiveness of two reperfusion modalities in patients with acute ST-segment elevation myocardial infarction: primary percutaneous coronary intervention (PCI) versus thrombolytic therapy.

DESIGN

A state-transition model that follows patients from when they develop STEMI until they die was developed. The model encompassed events and health states. Sensitivity analyses were undertaken.

RESULTS

For a 65-year old man, life expectancy was 8.3 years with primary PCI and 7.6 years with thrombolytic therapy. The lifetime costs were 19,250 euros (NOK 154,000) and 29,250 euros (NOK 234,000), respectively, for patients living close to an invasive unit. Cost savings from PCI were mainly due to the reduction in future coronary interventions. For patients needing helicopter transport to arrive in time to an invasive unit for PCI, the costs were 24,000 euros (NOK 192,000) and 29,250 euros (NOK 234,000), respectively (all costs undiscounted). For women, the estimates were somewhat higher due to lower mortality.

CONCLUSION

Compared with thrombolytic therapy, reperfusion by primary PCI results in greater health benefits at reduced lifetime costs. These findings may have important clinical implications in an increasing cost-conscious health care environment.

STEMI interventions--a review of relevant clinical trials

Major advances have been made in primary reperfusion and adjunctive therapies for STEMI. Mechanical reperfusion therapy has become the preferred reperfusion strategy for patients with STEMI. Outcomes have improved with the use of stents, platelet inhibitors, and with increased experience, and there is a promise that outcomes can become even better with new methods to enhance myocardial reperfusion and reduce reperfusion injury and with new anticoagulants and drug-eluting stents. Recent trends from the NRMI have shown that the frequency of use of primary PCI has increased and has surpassed lytic therapy, but primary PCI is used to treat only a minority of patients with STEMI. The major challenge for clinicians in the next decade will be to find new ways to make mechanical reperfusion more available, improve outcomes through the use of optimal adjuvant therapies and improved systems of care to speed primary PCI. The nation-wide effort to reduce door-to-balloon times has been launched by American Heart Association, with goal of making primary PCI more available to patients with STEMI.

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.

What is the place of thrombolysis in acute stroke? A review of the literature and a current perspective

The global burden of stroke, the undisputed success of intravenous thrombolysis in the management of myocardial infarction and subsequent evidence from animal models of cerebral infarction have all fuelled intense interest in the potential role for thrombolytic agents in the acute management of stroke in clinical practice. Before any clinical treatment is introduced universally its safety and efficacy must be demonstrated in the routine clinical environment and not just within the ideal conditions of controlled clinical trials. Similarly, the cost effectiveness of a new treatment modality is an essential consideration before its use is promulgated. This paper reviews the current scientific evidence for thrombolysis in stroke with reference to issues of safety, efficacy and cost effectiveness.

Determinants of Costs and the Length of Stay in Acute Coronary Syndromes: A Real Life Analysis of More Than 10 000 Patients

AIMS

The aim of this study was to investigate inpatient costs of acute coronary syndromes (ACS) in Switzerland and to assess the main cost drivers associated with this disease.

METHODS AND RESULTS

We used the national multicenter registry AMIS (acute myocardial infarction in Switzerland) which includes a representative number of 65 hospitals and a total of 11.623 patient records. The following cost modules were analyzed: hospital stay, percutaneous coronary interventions (PCI) and thrombolysis. Expenses were assessed using data from official Swiss national statistical sources. Mean total costs per patient were 12.101 Euro (median 10.929 Euro; 95% CI: 1.161-27.722 Euro). The length of stay ranged from one to 129 days with a mean of 9.5 days (median 8.0 days; 95% CI: 1-23). Overall costs were independently influenced by age, gender and existent co-morbidities, e.g. cerebrovascular disease and diabetes (p < 0.0001).

CONCLUSION

Our study determined specific causes for the high costs associated with hospital treatment on a large representative sample. The results should highlight unnecessary expenses and help policy makers to evaluate the base case for a DRG (Diagnosis Related Groups) scenario in Switzerland. Cost weighting of the identified secondary diagnosis should be considered in the calculation and coding of a primary diagnosis for ACS.

How Diagnosis-Related Group 559 Will Change the US Medicare Cost Reimbursement Ratio for Stroke Centers

BACKGROUND AND PURPOSE

Thrombolysis for acute ischemic stroke saves societal costs, but hospitals that practice acute stroke care appear to shoulder the burden of the cost, which exceeds reimbursement. With creation of the diagnosis-related group (DRG) 559, the US Centers for Medicare and Medicaid Services pays hospitals approximately US $6000 more per case when thrombolysis is administered. We sought to determine the total cost of, and reimbursement for, acute stroke treatment with thrombolysis at a single stroke center and the economic impact of DRG 559.

METHODS

Between September 2001 and December 2004, we collected data on all patients with acute stroke who received thrombolysis. We identified all hospital costs and reimbursement per patient. Financial results were expressed as a cost-reimbursement ratio: average total cost to average total reimbursement per patient. We then reanalyzed data using the projected Medicare hospital reimbursement with DRG 559.

RESULTS

Sixty-seven patients with stroke (mean age, 72 years) were treated (mean length of stay, 4.4 days; mean stroke severity, National Institutes of Health Stroke Scale score of 15; and symptomatic intracranial hemorrhage rate, 7%). The cost-reimbursement ratio was 1.41 (95% CI=0.98 to 2.28) before DRG 559 and estimated to be 0.82 (95% CI=0.66 to 0.97) after DRG 559.

CONCLUSIONS

Our hospital costs have traditionally exceeded Medicare reimbursement for the acute care of thrombolyzed patients with ischemic stroke, but with DRG 559, a new economically favorable cost-reimbursement ratio for hospitals will be established.

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.

Cost-effectiveness of intravenous thrombolysis with alteplase within a 3-hour window after acute ischemic stroke

BACKGROUND AND PURPOSE

The aim of this study was to assess the costs and cost-effectiveness of intravenous thrombolysis treatment with alteplase (Actilyse) of acute ischemic stroke with 24-hour in-house neurology coverage and use of magnetic resonance imaging.

METHODS

A health economic model was designed to calculate the marginal cost-effectiveness ratios for time spans of 1, 2, 3 and 30 years. Effect data were extracted from a meta-analysis of six large-scale randomized and placebo-controlled studies of thrombolytic therapy with alteplase. Cost data were extracted from thrombolysis treatment at Aarhus Hospital, Denmark, and from previously published literature.

RESULTS

The calculated cost-effectiveness ratio after the first year was $55,591 US per quality-adjusted life-year (base case). After the second year, computation of the cost-effectiveness ratio showed that thrombolysis was cost-effective. The long-term computations (30 years) showed that thrombolysis was a dominant strategy compared with conservative treatment given the model premises.

CONCLUSIONS

A high-quality thrombolysis treatment with 24-hour in-house neurology coverage and magnetic resonance imaging might not be cost-effective in the short term compared with conservative treatment. In the long term, there are potentially large-scale health economic cost savings.