The cost-effectiveness of thrombolysis administered by paramedics^*

ABSTRACT

Objective: The objective of this study is to estimate the expected health outcomes, costs and cost-effectiveness of changing from current practice, where thrombolytic therapy is given in hospital, to paramedic practice where thrombolytic therapy is administered by appropriately trained paramedics (pre-hospital) for STEMI patients.

Methods: A decision-analysis microsimulation model was constructed with a 30-day component and a long-term health state transition component. A brief review of the literature was undertaken to obtain data on time-to-needle to populate the model. The primary health outcome was quality-adjusted life years (QALYs); secondary outcomes included cardiac events, procedures and survival. Costs to the Australian healthcare system for the rest of life were taken as the analytical perspective.

Results: On average, STEMI patients gain 0.13 QALYs at an additional life-time cost of $343. The incremental cost-effectiveness ratios were $3428 per life-year gained and $2601 per QALY gained. These estimates were robust to changes in a range of assumptions and parameter values. The most important factor was the time-to-needle – the greater the difference between current practice times and paramedic practice times, the greater the health benefits and lower the cost per QALY (and life-year) gained. A key factor in the model was the substantially lower incidence of heart failure from earlier time-to-needle. Importantly, there was little change in the cost per QALY gained for a wide range of ages; thus, there is no argument to limit thrombolysis by paramedics to above or below an age threshold.

Conclusions: Paramedics administering thrombolysis can avert some STEMI deaths and the pre-hospital administration of thrombolysis is good value for money.

Key words: :

• Cardiac death
• Microsimulation
• Pre-hospital care
• STEMI
• Time-to-needle

Acknowledgements

Declaration of interest: This study was funded by the Queensland Ambulance Service, Australia. There were no conflicts of interest in this cost-effectiveness and budget impact assessment. The study was undertaken on an exploratory basis to assess whether thrombolytics administered by paramedics would be financially viable.

The authors thank Intensive Care Paramedics Brett Rogers and John Murray for their assistance in obtaining data and providing comments on an earlier draft of this paper. In addition, the authors are grateful to the reviewers who provided valuable and constructive comments that have helped to substantially improve this article.