pre-hospital thrombolysis
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but it is a shift that has to be accommodated and a challenge that has to be met.
Paul C. Langley College of Pharmacy,
The University of Arizona, Tucson, Arizona, USA
Pre-Hospital Thrombolysis
We read with interest your recent article on the cost implications of pre-hospital thrombolysis. I I I Since one of our products (alteplase; tPA; ActiIyse®) is discussed, we would welcome the opportunity to comment.
There are some deficiencies in the presentation of the economic data. In particular, Mark et al. 121 is misquoted as calculating the cost of using tPA instead of streptokinase (using US costs and medical practice) as $US32678 per additional life saved when in fact this was a cost-effectiveness ratio of $US32 678 per additional life-year saved (for tPA over and above streptokinase). This is the usual way to express this type of calculation and allows comparison in a league table.
The 'detailed calculations' referred to in the paperlll were not explicit and there is no attempt to define the model used or the way in which the calculations were performed. The case for full disclosure of the model and presentation of the results in a more traditional manner is highlighted by the fact that a recent paper on the cost effectiveness of tPA in the Irish context found that the costeffectiveness ratio of alteplase over streptokinase was £16290.29 (Irish pounds) per life-year saved and £16176.72 per quality-adjusted life year (QALY), even in the hospital environment. 131 The extension of the model using UK results, calculated that this would improve the ratio (mainly due to the lower price of alteplase in this country) to £5091.42 per life-year saved and £4999.50 per QALY gained. The results were sensitive to the time of administration of the thrombolytic, al-
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Correspondence
though the steepness of effect noted by Barton and Walley,111 which would have improved the ratio significantly, was not modelled.
The authors state that it is 'clear that the use of pre-hospital thrombolysis with streptokinase appears to offer more benefit than alteplase in hospital' yet the benefits (i.e. life-years saved) are not presented and the acceptability of a cost-effectiveness ratio within the medical interventions normally funded by the National Health Service (NHS) is not discussed. In addition, Barton and Walleylll claim that the healthcare purchasers are faced with a choice between whether to invest in the benefits of the better thrombolytic in hospital or in the use of pre-hospital thrombolysis with a cheaper drug. We strongly disagree with this suggestion. If the best outcome for the patient is to be achieved, the infarct-related artery needs to be opened as early as possible. Therefore, the best treatment strategy would be the most effective thrombolytic administered as soon as possible, not a choice between these two.
We appreciate your review of these comments which we hope can be brought to the attention of both the authors and other readers of PharmacoEconomics.
Anita Burrell and Anthony Hall Medical Department
Boehringer Ingelheim Limited, Bracknell Berkshire, England
References I. Barton S, Walley T. Cost implications of pre-hospital emergency
drug administration: the case of pre·hospital thrombolysis. Pharmacoeconomics 1996; 10 (5): 441-52
2. Mark DB, Hlatky MA, Califf RM, et al. Cost effectiveness of thrombolytic therapy with tissue plasminogen activator as compared with streptokinase for acute myocardial infarction. N Engl J Med 1995; 332: 1418-24
3. Kellet J. Cost effectiveness of accelerated tissue plasminogen activator for acute myocardial infarction. Br J Med Econ 1996; 10: 341-59
The authors reply: The main point made by Anita Burrell and Dr
A.K. Hall is that the best way to perform health economic comparisons is to calculate the cost of
Pharmacoeconomics 1997 Jun: 11 (6)