IMPACT OF INTERVENTIONS TO REDUCE BLEEDING ON THE COST-EFFECTIVENESS OF STEMI MANAGEMENT STRATEGIES IN NON-URBAN COMMUNITIES

Purpose: Bleeding complications are both costly and associated with increased mortality for patients undergoing percutaneous coronary intervention (PCI), but have rarely been considered in cost-effectiveness models of heart attack management. We therefore sought to determine whether interventions to reduce bleeding among PCI patients would affect the choice of regional revascularization strategy for patients suffering a heart attack.

Methods: We compared 5 revascularization strategies for a hypothetical population (thrombolysis, transfer to an existing cath lab (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 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). We then evaluated the impact of two bleeding reductions strategies (radial arterial access and bivalirudin thromboprophylaxis) on the cost-effectiveness of the PCI strategies.

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% 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.  Bleedings rates differed between the thrombolytic and PCI strategies. Reducing PCI bleeding complications by either method resulted in a modest decrease in mortality in the PCI arms. Under base case distance and case volume assumptions, this difference did not alter the choice of optimal strategy. However, further exploratory analyses revealed that differential bleeding rates had the potential to influence the threshold combinations of distance and case volume for a new CCL to be a cost-effective option.

Conclusions:  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. While strategies designed to reduce PCI-related bleeding may be important at a patient level, they do not seem to greatly affect the choice of optimal revascularization strategy on a regional level.