Debating the use of angioplasty and thrombolytics in acute MI

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    Debating the use of angioplasty and thrombolytics in acute MI PTCA. has been verified as the 'oprimoi

    repeifusion strategy', compared with thrombo-lytic therapy. on the basis of better clinical outcome and less subsequent use of hea1thcare resources. says Mr Eric Bales from the University of Michigan Ann Arbor, US. PTCA has a higher initial cost than thrombolytic therapy; however, it is associated with lower follow-up costs as a resuh of shorter duration of hospitalisatio n, reduced recurrence of ischaemia and stroke. fewer expensive complications. and fewer subsequent procedures and hospital adm issions.

    Mr Bates believes that less severe residual stenoses and higher infarct artery patency rates explain these superior outcomes. PTCA is also associated with lower inhospital monality rates than thrombolytic therapy. percutaneous trQn,lIumilUl/ coronary angioplascy Bues ER. Primary ... ,iopWIy is the gptimaI approach to early reperfusioa in pWe:n1$ .... ith ICIItc myocardial infarction. American Journal of~~12: 146-150. FdlI99S ___

    Targeted therapy beneficial It would be more cost effective to limit the use

    of PTCA to patients with large infarcts, cardio-genic shock and contraindications to thrombolytic therapy. argues J Ward Kennedy from the University of Washington. Seattle. US. Using these guidelines. coronary anery reperfusion would be performed on the largest number of patients at the lowest possible cost. he says. Mr Kennedy is concerned about the use of PT'CA, which is a complicated and costl y technique, for the routine management of patients with small-to medium-size infarcts.

    'It is .. ery unlikely thaI that direct PTCA can be shown to be superior to thrombolytic therapy in this large group of low-risk patients', he comments. It has been reported that the direct cost of PTCA is equal to. or less than. that for thrombolytics. However. he believes that a COSt analysis comparing PTCA with streptokinase. rather than alteplase (t-PA1. may show that the cost of initial thrombolytic therapy is a lot less. Wan! Kennedy J. The rd"rive I"Derits or dina angiopWty venu.s inI;nloenaus tIwmboI)'tiI:: th!:npy for the ~ of KUIe myoc;ardW infan:tJon. ~ Journalof~~. 2: ISI - IS3. Feb 1995

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    Alglucerase dispute revisited A mathem alical equation needs to be developed

    that estimates the most efficient and equitable allocation of healthcare resources. according to Stephen Push from Genzyme Corporation, Massachusetts. US. l Such an equation will enable patients with Gaucher's disease to receive alglucerase. a drug that is expensive but very effective. he adds.

    According to Mr Push. Drs Ernest Beutler and Alan Garber from the US have assumed thai a treat-ment can be cost effective only if its cost/quality-adjusted life-year is less than some cut-off point between SUS30 OOO-SUS 100 000. However, cost-effectiveness analysis cannot determ ine where this cut-off point should be, he says. It is his belief that optimal cost-effectiveness ratios can only be calculated for individuals. not patient groups, and that this ideal varies between individuals with different incomes and viewpoints on risk. 'Whose optimum should become the cut-off pointfor a group?', asks Mr Push .

    Define the aim of CEA The goal of cost-effectiveness analysis (CEA) is

    to measure the outcome resulting from a given expenditure on an intervention. In replying. Dr Alan Garber from Stanford University School of Mcdicine, California. suggests that Mr Push has confused thi s goal with the optimal cost-effective cutoff - a measure of individual demand for health improvemenl .2

    Dr Garber points out that cost-effectiveness analysis was never meant 10 provide a mathematical formula for allocating resources equitably and efficiently. Howevcr, he does question how healthcare services can be delivered effic iently without encouraging the use of the most cost-effective inter-ventions. High-dose alglucerase is a poor perfonner, using cost effectiveness as a measure. he notes.

    Cost is 'prohibitive' Just because wealthy or risk-averse individuals

    are willing to pay more per quality-adjusted life-year saved docs not mean that the drug in question is of good val ue and should be covered under health insurance. comments Dr Garber.

    'The cost of pro .. iding all co .. erage that society's wealthiest m emben might desire is prohibiti .. e'. he claims. (See related article. p2. this issue]

    I . P\I~ s. Al&l--: thelkb.1e COIILilIues. P'hannac:oEc:oos 1: 268. Mar I99S 2. Olll'b:r A.\1. AI,lucerue: thedebf,tc conLillues. Reply. f''IwmIIc:06l;onomic:s 1: 268-269. Mil' I99S .... .....

    >- Editorial comment: According to Drs Beuller and Garber. Ihere appears to Iu widespread consensus Ihal an inluvention cosling > $US100 OOOIqualiry-adjusled life-year saved is too expensive and/or ineffeclive {see PMrmacoResources 10: 7. 6 Aug 1994 f. Urtihr this scenario. Ihey claim Ihal only alglucuase 30 Ulkg every 2 weeks and 2.3 Ulkg thrice weekly M~'e tM potential to be cost eifectiW!, compared with no rreatment.