BACKGROUND: Previous studies have shown the median hospital stay for AMI is 9 days. Shortening stays could reduce health care costs. The Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries-1 (GUSTO-1) study showed that patients without cardiac complications 4 days after thrombolysis had 30-day mortality rates of 1%. The authors took this a step further: If the mortality rate for a 4-day uncomplicated hospitalization was low, would a 3-day stay yield similar results? This clinical decision analysis determined whether reducing hospital stays to 3 days would be economically feasible for patients receiving thrombolytics for AMI.
POPULATION STUDIED: GUSTO-1 was an international randomized control trial in which 4 different thrombolytic regimens were compared for more than 41,000 people. The authors of this study used data from the 22,000 people who had uncomplicated 72-hour hospital courses after thrombolysis; “uncomplicated” was defined as the absence of death or serious cardiovascular events.
STUDY DESIGN AND VALIDITY: The authors of this decision analysis compared the cost per year of life saved by discharging patients without complications at 72 hours instead of 96 hours after thrombolysis. The researchers determined the number of patients who survived a treatable ventricular arrhythmia after 3 days and assumed that these patients would have died in an outpatient setting. The primary costs considered were the additional nursing and bed charges for the fourth day. Ancillary costs, such as laboratory testing and stress testing for risk stratification, were assumed to have occurred at a comparable frequency and cost in the outpatient setting. Costs were obtained from reasonable sources with appropriate discounting (discounting means that a benefit in the future is less highly valued than a benefit in the present).
OUTCOMES MEASURED: The primary outcome was cost per life-year saved. Other outcomes included the rates of death, ventricular arrhythmia, and other cardiovascular events.
RESULTS: The rate of ventricular arrhythmia for all 41,000 GUSTO-1 subjects dropped sharply after 48 hours. Of the 22,000 patients with uncomplicated courses at 72 hours, 16 had a subsequent serious ventricular arrhythmia (1 event per 1400 patients). Three patients with arrhythmias died, while 13 survived at least 24 hours. Patients who suffered a ventricular arrhythmia between days 3 and 4 had a 1-year mortality rate of 9.5%, 4 times that of those without arrhythmia. The authors concluded that hospitalizing a patient without complications for 4 days added an average of 0.006 years of life (slightly more than 2 days). This extra hospital day costs $105,629 per year of life saved. The sensitivity analysis showed that the range of costs is between $66,000 and $184,000 per year of life saved.
This study shows that it is marginally cost-effective to pay for an extra day for a monitored bed to prevent death of lethal arrhythmias. However, the authors of this study did not evaluate other potential benefits of longer hospitalization, such as further education, safer risk stratification, and improved treatment for complications. For instance, 2.3% of the patients without complications at discharge would have suffered other complications (eg, recurrent ischemia, stroke) within 24 hours. An accurate method for identifying patients at increased risk after 72 hours would improve overall cost-effectiveness. Given these concerns, this study does not convincingly show that shortening the length of stay to 3 days is truly cost-effective.