Cost effectiveness of early discharge after uncomplicated acute myocardialinfarction.

Background: Reducing the length of hospitalizations can reduce short-term c osts, but there are few data on the long-term clinical and economic consequ ences of early discharge after uncomplicated myocardial infarction. Methods: Using data from the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO-1) trial, we i dentified 22,361 patients with acute myocardial infarction who had an uncom plicated course for 72 hours after thrombolysis. Then, using a decision-ana lytic model, we examined the cost effectiveness of an additional day of hos pitalization in this group. We defined incremental survival attributable to another day of monitored hospitalization, on the basis of the rate of resu scitation after cardiac arrest between 72 and 96 hours. Lifetime survival c urves for each group in the decision-analytic model were estimated from one -year survival data from GUSTO-1. Results: Of the patients with an uncomplicated course within 72 hours after thrombolysis, 16 had ventricular arrhythmias during the next 24 hours; 13 of these patients (81 percent) survived for at least 24 hours. On average, another 0.006 year of life per patient could be saved by keeping patients w ith an uncomplicated course in the hospital another day. At a cost of $624 for hospital and physicians' services, extending the hospital stay by anoth er day would cost $105,629 per year of life saved. In sensitivity analyses, it was found that a fourth day of hospitalization would be economically at tractive only if its cost could be reduced by more than 50 percent or if a high-risk subgroup could be identified in which the estimated survival bene fit would be doubled. Conclusions: Hospitalization of patients with uncomplicated myocardial infa rction beyond three days after thrombolysis is economically unattractive by conventional standards. (N Engl J Med 2000;342:749-55.) (C)2000, Massachus etts Medical Society.