PROJECTED COST-EFFECTIVENESS OF PRIMARY ANGIOPLASTY FOR ACUTE MYOCARDIAL-INFARCTION

Objectives. This study sought to evaluate the cost-effectiveness of pr imary angioplasty for acute myocardial infarction under varying assump tions about effectiveness, existing facilities and staffing and volume of services. Background. Primary angioplasty for acute myocardial inf arction has reduced mortality in some studies, but its actual effectiv eness may vary, and most U.S. hospitals do not have cardiac catheteriz ation laboratories. Projections of cost effectiveness in various setti ngs are needed for decisions about adoption. Methods. We created a dec ision analytic model to compare three policies: primary angioplasty, i ntravenous thrombolysis and no intervention. Probabilities of health o utcomes were taken from randomized trials (base case efficacy assumpti ons) and community based studies (effectiveness assumptions). The base case analysis assumed that a hospital with an existing laboratory wit h night/weekend staffing coverage admitted 200 patients with a myocard ial infarction annually. In alternative scenarios, a new laboratory wa s 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 com pared with thrombolysis and had a cost of $12,000/quality-adjusted lif e-year (QALY) saved compared with no intervention. In sensitivity anal yses, when there was an existing cardiac catheterization laboratory at a hospital with greater than or equal to 200 patients with a myocardi al infarction annually, primary angioplasty had a cost of <$30,000/QAL Y saved under a aide range of assumptions. However, the cost/QALY save d increased sharply under effectiveness assumptions when the hospital had <150 patients with a myocardial infarction annually or when a redu ndant laboratory was built. Conclusions. At hospitals with an existing cardiac catheterization laboratory, primary angioplasty for acute myo cardial infarction would be cost-effective relative to other medical i nterventions under a wide range of assumptions. The procedure's relati ve cost-ineffectiveness at low volumes or redundant laboratories suppo rts regionalization of cardiac services in urban areas. However, appro aches to overcoming competitive barriers and close monitoring of outco mes and costs will be needed. (C) 1997 by the American College of Card iology.