Abstract 15562: Cost-Effectiveness of STEMI Management Strategies for Patients Presenting to Non-Urban Centers: A Model-Based Analysis
Introduction: Despite great efforts and expense to transfer patients to existing cardiac catheterization laboratories (CCL’s) for primary PCI, real-world data have shown that door-to-balloon objectives are frequently not met in non-urban communities. As prior cost-effectiveness analyses assumed a locally available, existing CCL, the most cost-effective revascularization strategy for non-urban populations is not known.
Hypothesis: Population demographic and geographic considerations will influence the cost-effectiveness of alternate revascularization strategies.
Methods: We compared 5 revascularization strategies for a hypothetical Canadian population (thrombolysis, transfer to an existing CCL by either ambulance, helicopter, or fixed-wing aircraft, and constructing a new CCL locally). Patient risk factor profiles and strategy-specific event rates were derived from the medical literature (all-cause mortality, ischemic stroke, hemorrhagic stroke, non-cerebral major bleeding, reinfarction, and ischemia-driven revascularization). The mortality benefit of PCI over thrombolysis was modeled as a decremental function of the PCI-related time delay (PCI-rTD).
Results: Under base-case assumptions, thrombolysis and both air transport strategies were dominated. Building a new CCL locally cost $7,667 per QALY gained over ambulance transport. Sensitivity analyses showed that building a new CCL was robustly cost-effective as long as it operated at ≥30% maximum capacity and maintained a PCI-rTD ≤70min. Otherwise, helicopter transport was a cost-effective strategy. Only when the new CCL operated at very low capacity (≤10%) was TNK thrombolysis no longer dominated.
Conclusion: Provided a population of sufficient size, building and staffing a new CCL is a cost-effective STEMI management strategy under a broad range of conditions. In the future, this model can be adapted to define the optimal revascularization strategy for specific communities.
- © 2013 by American Heart Association, Inc.