The cost-effectiveness of thrombolysis administered by paramedics

There is evidence that prehospital thrombolysis improves the outcome in ST-elevation myocardial infarction (STEMI). This study aimed at comparing the cost-effectiveness of prehospital compared to inhospital thrombolysis for STEMI from the National Health System perspective. A decision-analytic model was used to compare these two strategies. The study endpoint was life-years gained. Resource use and costs were estimated from the National Health System perspective. The Decision tree and Markov Model were constructed using the results of published clinical trials. Costs were expressed in Reais (R$), for the year 2005. This model suggests that, from the National Health System perspective, implementing prehospital thrombolysis for ST-elevation myocardial infarction (STEMI) may lead to extra survival and fewer costs when compared to inhospital thrombolysis.

Emergency Medicine Journal, 2002

2004

British Medical Journal, 1997

OBJECTIVES: To assess the cost effectiveness of community thrombolysis relative to hospital thrombolysis by investigating the extra costs and benefits of a policy of community thrombolysis, then establishing the extra cost per life saved by community thrombolysis. DESIGN: Economic evaluation based on the results of the Grampian region early anistreplase trial. SETTING: 29 rural general practices and one secondary care provider in Grampian, Scotland. SUBJECTS: 311 patients recruited to the Grampian region early anistreplase trial. INTERVENTIONS: Intravenous anistreplase given either by general practitioners or secondary care clinicians. MAIN OUTCOME MEASURES: Survival at 4 years and costs of administration of thrombolysis. RESULTS: Relative to hospital thrombolysis, community thrombolysis gives an additional probability of survival at 4 years of 11% (95% confidence interval 1% to 22%) at an additional cost of 425 pounds per patient. This gives a marginal cost of life saved at 4 years of 3,890 pounds (1,990 pounds to 42,820 pounds). CONCLUSIONS: The cost per life saved by community thrombolysis is modest compared with, for example, the cost of changing the thrombolytic drug used in hospital from streptokinase to alteplase.

Family practice, 2015

To investigate whether there is a long-term survival benefit from receipt of thrombolysis in routine care particularly pre-hospital thrombolysis, using 20 year mortality data from the RCGP myocardial infarction (MI) cohort study. During 1991-92 the RCGP MI study assessed GP delivery of thrombolysis. Participants who received pre-hospital thrombolysis (n = 290), thrombolysis in hospital (n = 781) or no thrombolysis (n = 2021) were followed and mortality data collected to June 2012. The relationship between thrombolysis and survival time was analysed using Cox regression at 28 days, 1, 5, 10, 15 years post-AMI, and at end of follow-up (~20 years post-AMI). Compared to those who did not receive it, participants who received thrombolysis had a significant survival benefit at 28 days [adjusted hazard ratio (HR) 0.72, 95% confidence interval (CI): 0.58-0.90]; 1 year (adjusted HR 0.69, 95% CI: 0.57-0.83); 5 years (adjusted HR 0.76, 95% CI: 0.66-0.86); 10 years (adjusted HR 0.85, 95% CI: 0....

Stroke, 2004

Background and Purpose-Thrombolytic therapy is licensed for use in highly selected patients with acute ischemic stroke. We aimed to model the health economic impact of limited use of thrombolytic therapy and to assess whether it was likely to be cost-effective when used more widely in the UK National Health Service (NHS). Methods-The authors formed a discussion panel to develop the decision-analysis model of acute stroke care. It consisted of Markov state-transition processes, with probabilities of different health states determined by certain key variables. The range of estimates of efficacy of recombinant tissue plasminogen activator (rt-PA) was taken from an update to a Cochrane systematic review of randomized trials of thrombolysis. Data on outcome after stroke were taken from our hospital-based stroke register, supplemented by data derived from relevant literature sources. Results-The model suggested that compared with standard care, if eligible patients were treated with rt-PA up to 6 hours, there was a 78% probability of a gain in quality-adjusted survival during the first year, at a cost of £13 581 per quality-adjusted life-year (QALY) gained. Over a lifetime, rt-PA was associated with cost-savings of £96 565 per QALY. However, the estimates were imprecise and highly susceptible to the assumptions used in the economic model; under several plausible assumptions, rt-PA was much less cost-effective than standard care, and under others, a great deal more cost-effective. Conclusions-The estimates of effectiveness and cost-effectiveness were imprecise. Although the benefits appeared promising, the data did not support the widespread use of thrombolytic therapy outside the terms of the current restricted license in routine clinical practice in the NHS. There is a case for new large-scale randomized trials comparing thrombolytic therapy with control up to 6 hours to determine more precisely the effects of rt-PA on short-term and long-term survival and its cost-effectiveness when used in a wider range of patients. (Stroke.

Emergency Medicine Journal, 2004

To identify the effect on door to needle (DTN) time of moving the site of thrombolysis delivery from the coronary care unit (CCU) to the emergency department (ED). To ascertain if moving the site of thrombolysis enables appropriate use of thrombolysis. Design: Prospective cohort study. Setting: CCU and ED of a 450 bed Scottish district general hospital without on-site primary angioplasty. Participants: Primary site for thrombolysis of patients presenting to the hospital with ST elevation MI (STEMI) moved from CCU to ED on 1 April 2000. Study patients who had a confirmed STEMI and/or received thrombolytic therapy before this date were defined as the pre-change group; those who were diagnosed as STEMI and/or received thrombolytic therapy after this date were defined as the post-change group. Statistical analysis: Mann-Whitney test was used to compare medians and x 2 test for categorical data. Results: 1349 patients were discharged from CCU with a diagnosis of STEMI or received thrombolysis in the ED or CCU between April 1998 and April 2002. There were 632 patients in the pre-change group and 654 patients in the post-change group. Sixty three patients were excluded. Median DTN time for the prechange group (321 thrombolysed patients) was 64 minutes and median DTN time for the post-change group (324 thrombolysed patients) was 35 minutes, a median difference of 25 minutes (95% CI for difference 20 to 29 minutes, p,0.0001, Mann-Whitney U test). A total of 37 patients were thrombolysed but did not have a final diagnosis of STEMI. Conclusion: A significant reduction in DTN times accompanied this change in practice in this hospital.

JAMA Neurology, 2020

IMPORTANCE Rapid thrombolysis treatment for acute ischemic stroke reduces disability among patients who are carefully selected, but service delivery is challenging. OBJECTIVE To determine whether an enhanced Paramedic Acute Stroke Treatment Assessment (PASTA) intervention increased hospital thrombolysis rates. DESIGN, SETTING, AND PARTICIPANTS This multicenter, cluster randomized clinical trial took place between December 2015 and July 2018 in 3 ambulance services and 15 hospitals. Clusters were paramedics based within ambulance stations prerandomized to PASTA or standard care. Patients attended by study paramedics were enrolled after admission if a hospital specialist confirmed a stroke and paramedic assessment started within 4 hours of onset. Allocation to PASTA or standard care reflected the attending paramedic's randomization status. INTERVENTIONS The PASTA intervention included additional prehospital information collection, a structured hospital handover, practical assistance up to 15 minutes after handover, a predeparture care checklist, and clinician feedback. Standard care reflected national guidelines. MAIN OUTCOMES AND MEASURES Primary outcome was the proportion of patients receiving thrombolysis. Secondary outcomes included time intervals and day 90 health (with poor status defined as a modified Rankin Score >2, to represent dependency or death). RESULTS A total of 11 478 patients were screened following ambulance transportation; 1391 were eligible and approached, but 177 did not consent. Of 1214 patients enrolled (mean [SD] age, 74.7 [13.2] years; 590 women [48.6%]), 500 were assessed by 242 paramedics trained in the PASTA intervention and 714 were assessed by 355 paramedics continuing with standard care. The paramedics trained in the PASTA intervention took a mean of 13.4 (95% CI, 9.4-17.4) minutes longer (P < .001) to complete patient care episodes. There was less thrombolysis among the patients in the PASTA group, but this was not significant (PASTA group, 197 of 500 patients [39.4%] vs the standard care group, 319 of 714 patients [44.7%]; adjusted odds ratio, 0.81 [95% CI, 0.61-1.08]; P = .15). Time from a paramedic on scene to thrombolysis was a mean of 8.5 minutes longer in the PASTA group (98.1 [37.6] minutes) vs the standard care group (89.4 [31.1] minutes; P = .01). Poor health outcomes did not differ significantly but occurred less often among patients in the PASTA group (313 of 489 patients [64.0%]) vs the standard care group (461 of 690 patients [66.8%]; adjusted odds ratio, 0.86 [95% CI, 0.60-1.20]; P = .39). CONCLUSIONS AND RELEVANCE An enhanced paramedic assessment did not facilitate thrombolysis delivery. The unexpected combination of thrombolysis and health outcomes suggests possible alternative influences on treatment decisions by the intervention, requiring further evaluation.

Stroke, 2013

A cute ischemic stroke imposes significant health and economic burden. 1 It accounts for ≥49 million disabilityadjusted life-years annually worldwide. 2 In Australia, the burden is estimated to be 272 500 disability-adjusted life-years, making it the second leading cause of death and disability (after ischemic heart disease). 3 The total annual cost of strokes in Australia in 2011 is estimated to be the equivalent of USD $2.25 billion. 4 Intravenous thrombolysis with recombinant tissue-type plasminogen activator (tPA) has been shown to reduce death and disability in ischemic stroke ≤4.5 hours from onset. 5-9 Randomized controlled studies demonstrated reduction in poor clinical outcomes by 2% to 30% for tPA treatment relative to no tPA treatment. 10-12 Economic studies conducted in North America and Europe showed tPA to be a cost-effective intervention for stroke. 13-16 Cost incurred at 1 year for patients treated with tPA within 3 hours of ictal onset was USD $29 207, and USD $29 810 for patients not treated with tPA, resulting in estimated cost savings of USD $600 per patient treated with tPA in the first year after stroke. 16,17 Although effectiveness and cost-effectiveness of tPA administered within 3 hours of symptom onset are well established, recent studies have also demonstrated benefits ≤4.5 hours after onset. 13,18 In addition, there are inadequate data on the tPA cost-benefits in Australia. Because of differences in healthcare systems, costing methods and demographics, non-Australian data may not be relevant in Australia. One previous study 19 investigated cost-effectiveness of tPA in Australian setting within 3 hours of ictal onset. However, to date, there are no Australian data to validate the cost-effectiveness of tPA when given ≤4.5 hours after onset. We aimed to assess the cost-effectiveness of tPA treatment ≤4.5 hours after stroke onset in a contemporary Australian Background and Purpose-Previous economic studies outside Australia have demonstrated that patients treated with tissuetype plasminogen activator (tPA) within 4.5 hours of stroke onset have lower healthcare costs than those not. We aim to perform cost-effectiveness analysis of intravenous tPA in an Australian setting. Methods-Data on clinical outcomes and costs were derived for 378 patients who received intravenous tPA within 4.5 hours of stroke onset at Royal Melbourne Hospital (Australia) between January 2003 and December 2011. To simulate clinical outcomes and costs for a hypothetical control group assumed not to have received tPA, we applied efficacy data from a meta-analysis of randomized trials to outcomes observed in the tPA group. During a 1-year time-horizon, net costs, years of life lived, and quality-adjusted life-years were compared and incremental cost-effectiveness ratios derived for tPA versus no tPA. Results-In the study population, mean (SD) age was 68.2 (13.5) years and 206 (54.5%) were men. Median National Institutes of Health Stroke Scale score (interquartile range) at presentation was 12.5 (8-18). Compared with no tPA, we estimated that tPA would result in 0.02 life-years and 0.04 quality-adjusted life-years saved per person >1 year. The net cost of tPA was AUD $55.61 per patient. The incremental cost-effectiveness ratios were AUD $2377 per life-year saved and AUD $1478 per quality-adjusted life-years saved. Because the costs of tPA are incurred only once, the incremental costeffectiveness ratios would decrease with increasing time-horizon. Uncertainty analyses indicated the results to be robust. Conclusions-Intravenous tPA within 4.5 hours represents a cost-effective intervention for acute ischemic stroke. (Stroke.