Correspondence

Cost Effectiveness of Early Discharge after Uncomplicated Acute Myocardial Infarction

N Engl J Med 2000; 343:658-659August 31, 2000

Article

To the Editor:

In the abstract of their report on the cost effectiveness of early discharge after uncomplicated acute myocardial infarction, Newby et al. (March 16 issue)1 conclude, “Hospitalization of patients with uncomplicated myocardial infarction beyond three days after thrombolysis is economically unattractive by conventional standards.” When this sentence is taken in context, I understand what the authors mean, yet even in context, the phrase “economically unattractive” comes across as cold when one is balancing the variables of good medical practice, cost, and caring for the patient in the empathetic sense. I suggest that the following statement would be a better conclusion: Hospitalization of patients with uncomplicated myocardial infarction beyond three days after thrombolysis confers no practical therapeutic benefit and adds unnecessary expense.

Gregory L. Eastwood, M.D.
State University of New York Upstate Medical University, Syracuse, NY 13010

1 References

1. 1

   Newby LK, Eisenstein EL, Califf RM, et al. Cost effectiveness of early discharge after uncomplicated acute myocardial infarction. N Engl J Med 2000;342:749-755
   Full Text | Web of Science | Medline

To the Editor:

Newby and colleagues conclude that hospitalization beyond three days “is economically unattractive.” Although they have expressed the results of their analysis in the usual manner — as the cost per year of life saved by extending hospitalization by one day — I wonder whether they don't have things upside down. It would seem that the principal impetus for truncating the length of stay is to reduce the use of resources, not to improve outcomes. Indeed, with this strategy, one would be willing to “accept” a certain rate of death or other adverse clinical consequences in order to save money. This is the opposite of the usual scenario. Perhaps, then, the analysis should be presented as a “reverse” cost-effectiveness ratio: the ratio of deaths accepted (the bad consequence) to dollars saved (the good consequence). Alternatively, the results could be presented as the ratio of savings to harm, or $105,629 saved per year of life lost because of early discharge. Given the different ways gains and losses are viewed,1 would the results be viewed by clinicians and stakeholders in a favorable light?

David Massel, M.D.
University of Western Ontario, London, ON N6A 4G5, Canada

1 References

1. 1

   Tversky A, Kahneman D. The framing of decisions and the psychology of choice. Science 1981;211:453-458
   CrossRef | Web of Science | Medline

To the Editor:

Newby et al. conclude that hospitalization of patients with uncomplicated myocardial infarction beyond three days after thrombolysis is not cost effective. However, several considerations weaken this conclusion. First, patients discharged after three days and subject to either cardiac arrest followed by death or complications requiring rehospitalization may incur emergency care costs outside the hospital if a caregiver or the patient calls for emergency assistance at home. These costs were not included in the analysis.

Second, a univariate sensitivity analysis underestimates the variation of the cost-effectiveness ratio1 and thus decreases the likelihood that the threshold of $50,000 per year of life saved is reached. A multivariate sensitivity analysis, which varies multiple parameters simultaneously, would have been more appropriate for this analysis.

Third, use of the threshold of $50,000 per year of life saved to evaluate the study's cost-effectiveness ratio was not justified and seems to be too conservative. Some authors have proposed a ratio of $100,000 per quality-adjusted year of life as the upper limit of an acceptable cost-effectiveness ratio.2,3 Assuming that patients have mild angina pectoris after uncomplicated myocardial infarction, with a utility of 0.81,4 this ratio corresponds, in 1999 dollars, to $115,000 per year of life saved.

Afschin Gandjour, M.D., M.B.A.
Universität zu Köln, 50935 Cologne, Germany

4 References

1. 1

   Gold ME, Russell LB, Siegel JE, Weinstein MC, eds. Cost-effectiveness in health and medicine. New York: Oxford University Press, 1996.
   

2. 2

   Tosteson AN, Rosenthal DI, Melton LJ III, Weinstein MC. Cost effectiveness of screening perimenopausal white women for osteoporosis: bone densitometry and hormone replacement therapy. Ann Intern Med 1990;113:594-603
   Web of Science | Medline

3. 3

   Goldman L, Weinstein MC, Goldman PA, Williams LW. Cost-effectiveness of HMG-CoA reductase inhibition for primary and secondary prevention of coronary heart disease. JAMA 1991;265:1145-1151
   CrossRef | Web of Science | Medline

4. 4

   Kuntz KM, Fleischmann KE, Hunink MG, Douglas PS. Cost-effectiveness of diagnostic strategies for patients with chest pain. Ann Intern Med 1999;130:709-718
   Web of Science | Medline