COST-EFFECTIVENESS OF THROMBOLYTIC THERAPY WITH TISSUE-PLASMINOGEN ACTIVATOR AS COMPARED WITH STREPTOKINASE FOR ACUTE MYOCARDIAL-INFARCTION
COST-EFFECTIVENESS OF THROMBOLYTIC THERAPY WITH TISSUE-PLASMINOGEN ACTIVATOR AS COMPARED WITH STREPTOKINASE FOR ACUTE MYOCARDIAL-INFARCTION
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DOI：
10.1056/nejm199505253322106
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发表时间：
1995-05-25
影响因子：
158.5
通讯作者：
TOPOL, EJ
中科院分区：
文献类型：
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作者：
MARK, DB;HLATKY, MA;TOPOL, EJ
背景。急性心肌梗死患者接受加速组织型纤溶酶原激活剂（t-PA）治疗（在1个半小时内给予，而不是常规的3小时，并且三分之二的剂量在前30分钟给予），在链激酶和组织型纤溶酶原激活剂对冠状动脉闭塞的全球利用（GUSTO）研究中，30天死亡率比接受链激酶治疗的患者低15%。这相当于30天死亡率绝对降低1%。我们试图评估使用t-PA与链激酶相比是否具有成本效益。我们的主要或基本案例的成本效益分析使用了GUSTO研究的数据，并根据杜克心血管疾病数据库中心肌梗死幸存者的记录预测了预期寿命。在初步分析中，我们假设在一年后使用t-PA不会产生额外的治疗费用，并且在入组一年后t-PA的相对生存获益仍然明显。入组一年后，接受t-PA治疗的患者比接受链激酶治疗的患者有更高的费用（2,845美元）和更高的生存率（增加1.1%，或每1000名患者中有11人接受治疗）。在每个治疗组的预期寿命的基础上，未来成本和收益均以每年5%折现的增量成本效益比为每年节省32,678美元的生命，使用t-PA在年轻患者中成本效益最低，而在老年患者中成本效益最高，在所有年龄段，使用t-PA治疗前梗死患者产生更有利的成本效益值，在我们的二次分析中，成本-效果值对t-PA预期长期生存收益的降低和t-PA组患者第一年后预期医疗费用的适度或较大增加最为敏感，相反，我们的结果对GUSTO研究中发现的t-PA治疗患者致残性卒中发生率较高相关的额外费用甚至非常不利的假设并不敏感。与其他疗法相比，加速t-PA治疗的成本效益优于链激酶治疗，社会认为这些疗法所增加的医疗效益是值得的。
Background. Patients with acute myocardial infarction who were treated with accelerated tissue plasminogen activator (t-PA) (given over a period of 1 1/2 hours rather than the conventional 3 hours, and with two thirds of the dose given in the first 30 minutes) had a 30-day mortality that was 15 percent lower than that of patients treated with streptokinase in the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary arteries (GUSTO) study, This was equivalent to an absolute decrease of 1 percent in 30-day mortality, We sought to assess whether the use of t-PA, as compared with streptokinase, is cost effective.Methods. Our primary, or base-case, analysis of cost effectiveness used data from the GUSTO study and life expectancy projected on the basis of the records of survivors of myocardial infarction in the Duke Cardiovascular Disease Database. In the primary analysis, we assumed that there were no additional treatment costs due to the use of t-PA after the first year and that the comparative survival benefit of t-PA was still evident one year after enrollment.Results. One year after enrollment, patients who received t-PA had both higher costs ($2,845) and a higher survival rate (an increase of 1.1 percent, or 11 per 1000 patients treated) than streptokinase-treated patients. On the basis of the projected life expectancy of each treatment group, the incremental cost-effectiveness ratio with both future costs and benefits discounted at 5 percent per year - was $32,678 per year of life saved, The use of t-PA was least cost effective in younger patients and most cost effective in older patients, At all ages, the use of t-PA in patients with anterior infarctions yielded more favorable cost-effectiveness values, In our secondary analyses, the cost-effectiveness values were most sensitive to a lowering of the projected long-term survival benefits of t-PA and to moderate or greater increases in the projected medical costs for patients in the t-PA group after the first year, In contrast, our results were not sensitive to even very unfavorable assumptions about the additional costs associated with the higher rate of disabling stroke that was noted in patients treated with t-PA in the GUSTO study.Conclusions. The cost effectiveness of treatment with accelerated t-PA rather than streptokinase compares favorably with that of other therapies whose added medical benefit for dollars spent is judged by society to be worthwhile.