Cost comparison of immediate angioplasty versus thrombolysis followed by conservative therapy for acute myocardial infarction: a randomized prospective trial. Mayo Coronary Care Unit and Catheterization Laboratory Groups

Comparative effectiveness of ST-segment-elevation myocardial infarction regionalization strategies

BACKGROUND

Primary percutaneous coronary intervention (PCI) is more effective on average than fibrinolytic therapy in the treatment of ST-segment-elevation myocardial infarction. Yet, most US hospitals are not equipped for PCI, and fibrinolytic therapy is still widely used. This study evaluated the comparative effectiveness of ST-segment-elevation myocardial infarction regionalization strategies to increase the use of PCI against standard emergency transport and care.

METHODS AND RESULTS

We estimated incremental treatment costs and quality-adjusted life expectancies of 2000 patients with ST-segment-elevation myocardial infarction who received PCI or fibrinolytic therapy in simulations of emergency care in a regional hospital system. To increase access to PCI across the system, we compared a base case strategy with 12 hospital-based strategies of building new PCI laboratories or extending the hours of existing laboratories and 1 emergency medical services-based strategy of transporting all patients with ST-segment-elevation myocardial infarction to existing PCI-capable hospitals. The base case resulted in 609 (95% CI, 569-647) patients getting PCI. Hospital-based strategies increased the number of patients receiving PCI, the costs of care, and quality-adjusted life years saved and were cost-effective under a variety of conditions. An emergency medical services-based strategy of transporting every patient to an existing PCI facility was less costly and more effective than all hospital expansion options.

CONCLUSION

Our results suggest that new construction and staffing of PCI laboratories may not be warranted if an emergency medical services strategy is both available and feasible.

Outcomes of primary percutaneous coronary intervention in acute myocardial infarction at Tehran Heart Center

OBJECTIVE

To describe our experience of primary angioplasty in ST-segment elevation myocardial infarction.

SUBJECTS AND METHODS

During a period of 2 years (April 2003 to May 2005), 83 high-risk patients presenting with acute ST-segment elevation myocardial infarction underwent primary angioplasty subject to availability of balloon dilation within 90 min of admission. In total, 73 stents were implanted; 69 were bare metal stents, while the remaining 4 were paclitaxel-eluting stents. Of the 83 patients, 8 presented with cardiogenic shock. Follow-up was for a period of 9 months. All angiographic, in-hospital and clinical outcomes were recorded on a database.

RESULTS

The procedure was successful in 79 of the 83 patients (95%) and unsuccessful in 4 (5%). Of these 4 patients, 3 died and 1 was treated medically. In 65 patients with zero perfusion, angioplasty was successful in 61 (93.8%), while it was completely successful (100%) in the remaining 18 patients with thrombolysis in myocardial infarction grade 3 perfusion. Vessel patency was achieved in 95% with thrombolysis in myocardial infarction grade 3 flow present in 93%. A total of 7 (8.5%) patients died while in the hospital. Of the 8 with initial cardiogenic shock on presentation, 4 (50%) died in the hospital and of the remaining 4, 1 was lost at 9-month follow-up. In-hospital reocclusion and reinfarction did not occur in any patient.

CONCLUSION

The results suggest that primary angioplasty is logistically feasible in our center with good clinical outcomes.

Can the published cost analysis data for delivery of an efficient primary angioplasty service be applied to the modern National Health Service?

Despite the clinical benefits and safety profile of primary percutaneous coronary intervention (PCI), the health care system in the UK has been slow to adopt this strategy as first line management for ST segment elevation myocardial infarction. The cost implications of a 24 hour a day, seven days per week primary PCI service and the absence of an existing efficient working model within the National Health Service (NHS) framework are two of the major deterrents for provision of such a service. The existent cost effectiveness data for primary PCI is critically reviewed, with particular reference to the NHS.

The limited incorporation of economic analyses in clinical practice guidelines

BACKGROUND

Because there is increasing concern that economic data are not used in the clinical guideline development process, our objective was to evaluate the extent to which economic analyses are incorporated in guideline development.

METHODS

We searched medline and HealthSTAR databases to identify English-language clinical practice guidelines (1996-1999) and economic analyses (1990-1998). Additional guidelines were obtained from The National Guidelines Clearinghouse Internet site available at http://www.guideline.gov. Eligible guidelines met the Institute of Medicine definition and addressed a topic included in an economic analysis. Eligible economic analyses assessed interventions addressed in a guideline and predated the guideline by 1 or more years. Economic analyses were defined as incorporated in guideline development if 1) the economic analysis or the results were mentioned in the text or 2) listed as a reference. The quality of economic analyses was assessed using a structured scoring system.

RESULTS

Using guidelines as the unit of analysis, 9 of 35 (26%) incorporated at least 1 economic analysis of above-average quality in the text and 11 of 35 (31%) incorporated at least 1 in the references. Using economic analyses as the unit of analysis, 63 economic analyses of above-average quality had opportunities for incorporation in 198 instances across the 35 guidelines. Economic analyses were incorporated in the text in 13 of 198 instances (7%) and in the references in 18 of 198 instances (9%).

CONCLUSIONS

Rigorous economic analyses may be infrequently incorporated in the development of clinical practice guidelines. A systematic approach to guideline development should be used to ensure the consideration of economic analyses so that recommendations from guidelines may impact both the quality of care and the efficient allocation of resources.

[Analysis of the medico-economic literature comparing primary angioplasty and thrombolysis in the management of acute myocardial infarction]

OBJECTIVE

To assess the generalizability of the medico-economic analysis comparing primary coronary angioplasty and thrombolytic therapy for acute myocardial infarction.

METHOD

A systematic analysis of published studies was performed by two independent reviewers, in accordance with guidelines promulgated by health economic experts.

RESULTS

Eleven articles, which concerned seven studies, were selected. Respectively, four evaluations were carried out in U.S. and three other in European countries (France, Netherland and Austria). There were three randomized trials, two observational studies and two decision trees. The costs were respectively ranged 2042 to 83,708 1999 US dollars for thrombolytic therapy and 3289 to 83,477 1999 US dollars for angioplasty. In two randomized trials and one decisional tree, the primary coronary angioplasty was both more effective and less costly than the thrombolysis therapy. One observational study concluded that thrombolytic therapy was less costly than primary angioplasty despite comparable effectiveness. Two analysis could not conclude of a difference between the alternatives, because of lack of statistical power.

DISCUSSION

Published medico-economic analysis remain of a little interest for the French health care system because of lack of transparency in presentation of results. The dominance of the primary angioplasty was sensitive to time required for patient's transfer (ideally less than an hour), to the presence of redundant laboratories in an area and to the presence of an experienced staff for 24 h a day.

The intermediate CCU admission: a preliminary study

In the current health care era, increasing emphasis is being placed on cost reduction. Admitting only high-risk patients to coronary care units (CCU) may reduce hospital costs and charges without adverse clinical outcomes. Recently, guidelines published by the Agency for Healthcare Policy and Research (AHCPR) on suggest that intermediate-risk patients be admitted to an intermediate CCU (ICCU), but the safety and appropriateness of this approach has not been prospectively evaluated. The authors hypothesized that admitting intermediate-risk patients with to an ICCU would be cheaper than admitting to a CCU with comparable safety supporting AHCPR guidelines. To evaluate this, a retrospective cohort study was conducted. Two hundred forty-three intermediate-risk patients consecutively admitted to the CCU (n = 134) and admitted to the ICCU (n = 109) between June 1, 1992 and April 1, 1994 were compared using AHCPR definitions of intermediate risk and a previously published risk prediction model to exclude both very low- and high-risk patients. Extensive demographic, clinical, and diagnostic testing, and treatment, procedural, and outcome data were collected by a trained nurse data collector at the time of admission. Fifty-nine percent of all study patients had at least two coronary risk factors. Twenty-one percent had diabetes. Ninety-eight percent had at least one AHCPR intermediate risk factor for cardiac complications. The two groups (CCU versus ICCU) were quite similar in baseline characteristics: men (56 versus 55%), age (57 +/- 17 versus 60 +/- 17 years), diabetes (22 versus 20%), previous myocardial infarction (30 versus 36%), previous coronary artery surgery (21 versus 21%), and rest pain (78 versus 66%). The use of coronary angiography (44 versus 52%), angioplasty (24 versus 21%), and coronary artery surgery (13 versus 11%) were also similar. The incidence of myocardial infarction or death was similar (3 versus 5%), and length of stay was also similar between groups (6.7 +/- 4.2 versus 6.5 +/- 4.1 days), but cost was less for patients admitted to the ICCU ($13,481 +/- 9,450 versus $10,619 +/- 8,732, P < 0.015). These preliminary data suggest intermediate-risk patients, as identified by AHCPR guidelines, can be treated in an ICCU at lower cost than in a CCU, with reasonable safety. A small incidence of myocardial infarction in ICCU-admitted patients occurs, requiring availability of cardiac resuscitation and continued monitoring of electrocardiographic and enzymatic abnormalities. Admission to ICCU poses no barrier to recommended patient evaluation and management.

Impact of a clinical pathway on the care and costs of myocardial infarction

A time series of 110 patients with acute myocardial infarction admitted between January 1992 and June 1997 examined the effects of a clinical pathway. The pathway reduced length of hospital stay by 2.2 days and hospital charges by $1,008 without compromising care quality and outcomes.

Cost-effectiveness of reperfusion strategies

Reperfusion of acute myocardial infarction has become the standard of management during the first few hours. Cost per year of life saved is one measure of the effectiveness of reperfusion strategies. Estimates of the cost per year of life saved have been approximately $17,000 for streptokinase and percutaneous transluminal coronary angioplasty and approximately $33,000 for tissue plasminogen activator. Assuming that percutaneous transluminal coronary angioplasty is more effective than thrombolysis, we calculated the cost-effectiveness of this strategy in different hospital settings. The estimated costs in hospitals with existing cardiac catheterization laboratories were $11,000 per year of life saved for primary angioplasty and $14,000 for thrombolysis compared with no intervention. In hospitals without catheterization facilities, it would be cost-ineffective to build such laboratories only to treat acute infarction with angioplasty. Preliminary results suggest that stenting may also be cost-effective in association with angioplasty.

Primary angioplasty for the treatment of acute myocardial infarction: experience at two community hospitals without cardiac surgery

OBJECTIVES

We sought to establish the safety and efficacy of primary percutaneous transluminal coronary angioplasty in patients with acute myocardial infarction (AMI) at two community hospitals without on-site cardiac surgery.

BACKGROUND

Though randomized studies indicate that primary angioplasty in AMI may result in superior outcomes compared with fibrinolytic therapy, the performance of primary angioplasty at hospitals without cardiac surgery is debated.

METHODS

Three experienced operators performed 506 consecutive immediate coronary angiograms with primary angioplasty when appropriate in patients with suspected AMI at two community hospitals without cardiac surgery, following established rigorous program criteria.

RESULTS

Clinical high risk predictors (Killip class 3 or 4, age > or = 75 years, anterior AMI, out-of-hospital ventricular fibrillation) and/or angiographic high risk predictors (left main or three-vessel disease or ejection fraction <45%) were present in 69.6%. Angioplasty was performed in 66.2%, with a median time from emergency department presentation to first angiogram of 94 min and a procedural success rate of 94.3%. The in-hospital mortality for the entire study population was 5.3%. Of those without initial cardiogenic shock, the in-hospital mortality was 3.0%. Of 300 patients who were discharged after primary angioplasty, only four died within the first 6 months, with 97.7% follow-up. No patient died or needed emergent aortocoronary bypass surgery because of new myocardial jeopardy caused by a complication of the cardiac catheterization or angioplasty procedure.

CONCLUSIONS

Immediate coronary angiography with primary angioplasty when appropriate in patients with AMI can be performed safely and effectively in community hospitals without on-site cardiac surgery when rigorous program criteria are established.

Projected cost-effectiveness of primary angioplasty for acute myocardial infarction

OBJECTIVES

This study sought to evaluate the cost-effectiveness of primary angioplasty for acute myocardial infarction under varying assumptions about effectiveness, existing facilities and staffing and volume of services.

BACKGROUND

Primary angioplasty for acute myocardial infarction has reduced mortality in some studies, but its actual effectiveness may vary, and most U.S. hospitals do not have cardiac catheterization laboratories. Projections of cost-effectiveness in various settings are needed for decisions about adoption.

METHODS

We created a decision analytic model to compare three policies: primary angioplasty, intravenous thrombolysis and no intervention. Probabilities of health outcomes were taken from randomized trials (base case efficacy assumptions) and community-based studies (effectiveness assumptions). The base case analysis assumed that a hospital with an existing laboratory with night/weekend staffing coverage admitted 200 patients with a myocardial infarction annually. In alternative scenarios, a new laboratory was built, and its capacity for elective procedures was either 1) needed or 2) redundant with existing laboratories.

RESULTS

Under base case efficacy assumptions, primary angioplasty resulted in cost savings compared with thrombolysis and had a cost of $12,000/quality-adjusted life-year (QALY) saved compared with no intervention. In sensitivity analyses, when there was an existing cardiac catheterization laboratory at a hospital with > or = 200 patients with a myocardial infarction annually, primary angioplasty had a cost of < $30,000/QALY saved under a wide range of assumptions. However, the cost/QALY saved increased sharply under effectiveness assumptions when the hospital had < 150 patients with a myocardial infarction annually or when a redundant laboratory was built.

CONCLUSIONS

At hospitals with an existing cardiac catheterization laboratory, primary angioplasty for acute myocardial infarction would be cost-effective relative to other medical interventions under a wide range of assumptions. The procedure's relative cost-ineffectiveness at low volumes or redundant laboratories supports regionalization of cardiac services in urban areas. However, approaches to overcoming competitive barriers and close monitoring of outcomes and costs will be needed.

Primary angioplasty for acute myocardial infarction

The use of thrombolytic therapy has been widely accepted for the treatment of acute myocardial infarction. Despite improving mortality, thrombolytic therapy may be contraindicated in many patients presenting with myocardial infarction and is associated with a small, yet significant risk of hemorrhagic sequelae. This article outlines the rationale behind reperfusion therapy, the use of pharmacological thrombolysis and the role of adjunctive angioplasty. The potential advantages of a therapeutic strategy of primary angioplasty, instead of thrombolysis, are discussed. These include anatomical definition, risk stratification, reduced recurrent ischemia, enhanced coronary perfusion and improved coronary patency. The randomized trials in which primary angioplasty and thrombolytic therapy were compared are reviewed. We conclude that angioplasty results in a reduction of short-term mortality and nonfatal reinfarction and therefore advocate the routine use of coronary angioplasty as a primary reperfusion strategy for acute myocardial infarction. The potential limitations of primary angioplasty in the community hospital setting are discussed. Finally, we examine the roles of adjunctive mechanical (e.g. stents) and pharmacological (e.g. Abciximab) means of further enhancing outcomes after primary angioplasty.

Analysis of the relative costs and effectiveness of primary angioplasty versus tissue-type plasminogen activator: the Primary Angioplasty in Myocardial Infarction (PAMI) trial. The PAMI Trial Investigators

OBJECTIVES

We sought to determine the relative cost and effectiveness of two different reperfusion modalities in patients with acute myocardial infarction (AMI).

BACKGROUND

Recent studies have found superior clinical outcomes after reperfusion by primary percutaneous transluminal coronary angioplasty (PTCA) compared with thrombolytic therapy. The high up-front costs of cardiac catheterization may diminish the relative advantages of this invasive strategy.

METHODS

Detailed in-hospital charge data were available from all 358 patients with AMI randomized to tissue-type plasminogen activator (t-PA) or primary PTCA in the United States from the Primary Angioplasty in Myocardial Infarction trial. Resource consumption during late follow-up was estimated by assessment of major clinical events and functional status.

RESULTS

Compared with t-PA, primary PTCA resulted in reduced rates of in-hospital mortality (2.3% vs. 7.2%, p = 0.03), reinfarction (2.8% vs. 7.2%, p = 0.06), recurrent ischemia (11.3% vs. 28.7%, p < 0.0001) and stroke (0% vs. 3.9%, p = 0.02) and a shorter hospital stay (7.6 +/- 3.3 days vs. 8.4 +/- 4.7 days, p = 0.04). Despite the initial costs of cardiac catheterization in all patients with the invasive strategy, total mean (+/- SD) hospital charges were $3,436 lower per patient with PTCA than with t-PA ($23,468 +/- $13,410 vs. $26,904 +/- $18,246, p = 0.04), primarily due to the reduction in adverse in-hospital outcomes. However, professional fees were higher after primary PTCA ($4,185 +/- $3,183 vs. $3,322 +/- $2,728, p = 0.001), and thus total charges, although favoring PTCA, were not significantly different ($27,653 +/- $13,709 vs. $30,227 +/- 18,903, p = 0.21). At a mean follow-up time of 2.1 +/- 0.7 years, no major differences in postdischarge events or New York Heart Association functional class were present between PTCA- and t-PA-treated patients, suggesting similar late resource consumption. Including in-hospital events, 83% of PTCA-treated patients were alive and free of reinfarction at late follow-up, compared with 74% of t-PA-treated patients (p = 0.06).

CONCLUSIONS

Compared with t-PA, reperfusion by primary PTCA improves clinical outcomes with similar or reduced costs. These findings have important clinical implications in an increasingly cost-conscious health care environment.

Initial cost of primary angioplasty for acute myocardial infarction

OBJECTIVES

We sought to evaluate the initial economic cost of primary angioplasty for acute myocardial infarction under varying assumptions about whether a cardiac catheterization laboratory exists, whether services are provided during night and weekend hours and how cardiovascular surgical backup is arranged.

BACKGROUND

Primary angioplasty for acute myocardial infarction has resulted in clinical outcomes superior or equal to those obtained with thrombolysis in recent studies, but its future implementation depends greatly on its cost and cost-effectiveness. There is a gap in knowledge about the true economic costs of this procedure, and understanding costs under a variety of hypothetic scenarios is important in planning whether and how the procedure should be offered to broad groups of patients.

METHODS

A generalizable spreadsheet model was constructed to calculate the cost of primary angioplasty at a single hospital with assumptions based on data from a large nonprofit health maintenance organization (Kaiser Permanente). The following baseline assumptions were made: 1) A total of 200 patients with myocardial infarction presented to the hospital each year; 2) primary angioplasty was offered for 10 years; 3) the hospital had a cardiac catheterization laboratory; 4) costs of night call for technical personnel and cardiovascular surgical backup were already covered. Other scenarios were modeled to represent different assumptions about existing resources.

RESULTS

Under the baseline assumptions, primary angioplasty cost $1,597/procedure. If night call for technical personnel were a new expense, the average cost would be > or = $3,206. If a new cardiac catheterization laboratory needed to be built, costs would range from $3,866 to $14,339/procedure, depending on how cardiovascular surgical backup was provided. Results were sensitive to assumptions about the annual volume of myocardial infarctions, the number of years the procedure was offered and the costs of labor, construction and equipment.

CONCLUSIONS

The initial cost of providing primary angioplasty for acute myocardial infarction varies greatly, depending on the setting in which it is provided. To provide information for clinical policy decisions, a cost-effectiveness model is needed that combines these initial costs with data on survival, quality of life and rates and costs of subsequent cardiac procedures.

The role of angioplasty in acute myocardial infarction

The role of percutaneous transluminal coronary angioplasty (PTCA) in the management of acute myocardial infarction (AMI) has not yet been precisely defined. The longest experience with PTCA in this setting has been in patients who are not candidates for thrombolytic therapy and in patients in whom thrombolysis has failed. Clinical interest has recently focused on direct use of PTCA (instead of thrombolysis) as the initial approach to reperfusion in AMI. We review the conceptual bases for both thrombolytic therapy and PTCA in AMI, and we then detail the clinical experience with PTCA in a variety of patient populations with AMI to guide use of both therapies in this setting.