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Cost-effectiveness microsimulation of catheter-directed thrombolysis in submassive pulmonary embolism using a right ventricular function model

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Abstract

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.

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Funding

SM was supported by Grant T32: 5T32HL007633 from the National Heart Lung and Blood Institute (NHLBI).

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Authors and Affiliations

  1. 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

    Stefanie E. Mason, Farbod N. Rahaghi & George R. Washko

  2. Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA

    Jinyi Zhu & Ankur Pandya

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Contributions

SEM and JZ developed the model, interpreted and analyzed the data, and wrote the manuscript. AP contributed to model design, data interpretation and manuscript editing. FR and GW contributed to data interpretation and the editing of the manuscript.

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Correspondence to Stefanie E. Mason.

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Conflict of interest

SM was funded by the NHLBI (as stated above). GW has received grants from BTG Interventional Medicine to analyze images related to catheter-directed therapy. JZ, FR, and AP have no conflicts of interest to disclose. Neither the NHLBI nor BTG had any involvement in model design, analysis or interpretation of model data, preparation, review, or approval of the manuscript, or the decision to submit the manuscript for publication.

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Mason, S.E., Zhu, J., Rahaghi, F.N. et al. Cost-effectiveness microsimulation of catheter-directed thrombolysis in submassive pulmonary embolism using a right ventricular function model. J Thromb Thrombolysis 49, 673–680 (2020). https://doi.org/10.1007/s11239-020-02058-y

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