Cost and Cost-Effectiveness of an Early Invasive vs Conservative Strategy for the Treatment of Unstable Angina and Non ST-Segment Elevation Myocardial Infarction - Cost and Cost-Effectiveness of an Early Invasive vs Conservative Strategy for the Treatment of Unstable Angina and Non ST-Segment Elevation Myocardial Infarction
The authors sought to examine total 6-month costs and long-term cost-effectiveness of an invasive vs a conservative strategy in the management of patients with either unstable angina or non ST-segment elevation myocardial infarction (UA/NSTEMI) treated with the platelet glycoprotein (Gp IIb/IIIa) inhibitor tirofiban.
The study design was a randomized controlled clinical trial of patients with either unstable angina or non-ST-segment elevation myocardial infarction. Economic end points were included in the study design a priori and economic data obtained from 1722 patients at US non-VA hospitals.
The average total costs at 6 months, including productivity costs, for the invasive group was $21,813 vs $21,227 for the conservative group, a $586 difference (95% CI, -$1,087 to $2,486). The average 6-month costs if productivity costs were excluded in the invasive group was $19,780 vs $19,111 in the conservative group, a difference of $670; 95% CI; (-$1,035 to $2,321). Estimated cost per year of life gained for the invasive strategy, based on projected life expectancy, was $12,739 for the base case, and ranged from $8,371 to $25,769, based on model assumptions.
The authors concluded that in patients with UA/NSTEMI treated with a GP IIb/IIIa inhibitor, the clinical benefit of an early invasive strategy was achieved with a small increment in cost. The projected estimates of cost per year of life gained appear favorable with the invasive strategy. The authors suggest that these results support the broader use of an early invasive strategy in patients with acute coronary syndromes. This economic analysis of the TACTICS-TIMI 18 suggest that the benefit of an early invasive strategy in reducing major cardiac events is achieved with a small increase in overall cost, with favorable cost-effectiveness ratios after modeling the impact of the lower nonfatal MI rate over the long term. The results of the main trial had suggested that in patients without ST-segment changes or elevated troponin levels there were no significant reductions in either death or non fatal myocardial infarction. Therefore for obvious reasons, the conservative strategy may be the dominant strategy in low-risk individuals by being less expensive and equally effective. Overall, the results of this economic analysis strongly support the ACC/AHA acute coronary syndrome guidelines, which recommends an early invasive strategy for several high-risk subgroups presenting with acute coronary syndromes.
JAMA 2002; 288:1851-1858
Keywords: Myocardial Infarction, Acute Coronary Syndrome, Life Expectancy, Tyrosine, Platelet Membrane Glycoprotein IIb, Troponin, Platelet Glycoprotein GPIIb-IIIa Complex
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