Division of Pulmonary and Critical Care Medicine, Department of Medicine, Center for Chest Diseases, Brigham and Women's Hospital, 15 Francis St, Boston, MA, 02115, USA.
Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
J Thromb Thrombolysis. 2020 May;49(4):673-680. doi: 10.1007/s11239-020-02058-y.
Approximately 30-50% of hemodynamically stable patients presenting with acute pulmonary embolism (PE) have evidence of right ventricular (RV) dysfunction. These patients are classified as submassive PE and the role of reperfusion therapy remains unclear. We sought to identify the circumstances under which catheter-directed thrombolysis (CDT) would represent high-value care for submassive PE. We used a computer-based, individual-level, state-transition model with one million simulated patients to perform a cost-effectiveness analysis comparing the treatment of submassive PE with CDT followed by anticoagulation to treatment with anticoagulation alone. Because RV function impacts prognosis and is commonly used in PE outcomes research, our model used RV dysfunction to differentiate health states. One-way, two-way, and probabilistic sensitivity analyses were used to quantify model uncertainty. Our base case analysis generated an incremental cost-effectiveness ratio (ICER) of $119,326 per quality adjusted life year. Sensitivity analyses resulted in ICERs consistent with high-value care when CDT conferred a reduction in the absolute probability of RV dysfunction of 3.5% or more. CDT yielded low-value ICERs if the absolute reduction was less than 1.56%. Our model suggests that catheter-directed thrombolytics represents high-value care compared to anticoagulation alone when CDT offers an absolute improvement in RV dysfunction of 3.5% or more, but there is substantial uncertainly around these results. We estimated the monetary value of clarifying the costs and consequences surrounding RV dysfunction after submassive PE to be approximately $268 million annually, suggesting further research in this area could be highly valuable.
约 30-50%血流动力学稳定的急性肺栓塞 (PE) 患者存在右心室 (RV) 功能障碍的证据。这些患者被归类为亚大块肺栓塞，再灌注治疗的作用仍不清楚。我们试图确定在何种情况下经导管溶栓 (CDT) 将成为亚大块肺栓塞的高价值治疗方法。我们使用基于计算机的、个体水平的状态转移模型，对 100 万例模拟患者进行了成本效益分析，比较了亚大块肺栓塞患者使用 CDT 联合抗凝治疗与单独抗凝治疗的效果。由于 RV 功能会影响预后，并且在 PE 结局研究中经常使用 RV 功能障碍来区分健康状态，我们的模型使用 RV 功能障碍来区分健康状态。采用单向、双向和概率敏感性分析来量化模型的不确定性。我们的基本情况分析得出的增量成本效益比 (ICER) 为每质量调整生命年 119326 美元。敏感性分析得出的结果与高价值护理一致，即当 CDT 降低 RV 功能障碍的绝对概率 3.5%或更多时。如果绝对降低小于 1.56%，则 CDT 产生低价值的 ICER。我们的模型表明，与单独抗凝治疗相比，当 CDT 提供 RV 功能障碍的绝对改善 3.5%或更多时，经导管溶栓治疗具有高价值，但这些结果存在很大的不确定性。我们估计，每年大约有 2.68 亿美元用于阐明亚大块肺栓塞后 RV 功能障碍的成本和后果，这表明在这一领域进行进一步研究可能具有很高的价值。
