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Journal of Public Health Advance Access originally published online on January 25, 2006
Journal of Public Health 2006 28(1):31-34; doi:10.1093/pubmed/fdi072
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© The Author 2006, Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved.

Is a target culture in health care always compatible with efficient use of resources? A cost-effectiveness analysis of an intervention to achieve thrombolysis targets



Robin Singaroyan

C. Alison Seed

Robin M. Egdell
Robin Singaroyan, Senior House Officer, C. Alison Seed, Specialist Registrar, Robin M. Egdell, Consultant Cardiologist, Department of Cardiology, Macclesfield District General Hospital, Victoria Road, Macclesfield, Cheshire SK10 3BL, UK

Address correspondence to Robin M. Egdell. Email: robegdell{at}hotmail.com

Background The UK government has attempted to improve the quality of health care in the National Health Service and minimize geographical variations in quality by imposing targets in certain areas of health care. The measures taken by local health economies to achieve these targets have not before been subjected to cost-effectiveness analysis. We have assessed the cost effectiveness of an intervention designed to achieve thrombolysis time targets.

Methods In the setting of a single district general hospital in England, we audited local pain-to-needle (PTN) and door-to-needle (DTN) times, before and after a £208 000 ({euro}310 000, $370 000) annual expenditure to improve performance against government targets. The intervention included the recruitment of additional nursing time in the Accident & Emergency Department and the use of a single bolus thrombolytic agent for all patients with ST elevation myocardial infarction. An economic evaluation was performed, based on the expected number of additional lives saved, extrapolated from a meta-analysis of previous thrombolysis trials.

Results The intervention reduced mean DTN time from 37.6 ± 5.9 minutes (mean ± SEM) to 27.6 ± 3.6 minutes (p = 0.06). The cost per life saved was £3 423 ± 850 ({euro}5 100 000, $6 100 000), the cost per life year gained was £222 184 ({euro}330 000, $390 000) and the cost per quality-adjusted life year (QALY) gained was £246 871 ({euro}370 000, $440 000).

Conclusion Although moderately successful at improving performance against government targets, this intervention to promote rapid thrombolysis proved to be an inefficient use of health-care resources. Strict government targets in health care may not always lead to efficient targeting of resources.

Keywords: cost effectiveness, DTN, QALY, thrombolysis


   Introduction
TOP
 Introduction
Methods
 Results
 Discussion
 Limitations of this study
 Conclusion
 Contributors
 Conflict of interest statement
 Funding
 Ethics approval
 Acknowledgements
 References
 
It is well established that thrombolytic therapy improves survival in acute myocardial infarction.1,2 Meta-analyses of thrombolytic trials have confirmed that the survival benefit of thrombolysis is influenced by the delay from the onset of symptoms to the administration of the drug.3,4 Attention has therefore been focused on hospital and pre-hospital systems to minimize this delay. In the United Kingdom, the government published its National Service Framework for Coronary Heart Disease in 2000, applicable to England and Wales.5 This included service standards designed to improve ‘pain-to-needle’ (PTN) and ‘door-to-needle’ (DTN) times. For DTN times, targets were set that 75 per cent of eligible patients should receive thrombolysis within 30 minutes of arrival in hospital by April 2002 and within 20 minutes by April 2003. During the last few years, acute hospitals in England and Wales have experienced pressure to meet these targets. Although any improvement in the care of patients with acute myocardial infarction is to be welcomed, there has to date been very little information on the cost effectiveness of the sort of interventions being used to achieve government targets. We have conducted a cost-effectiveness analysis of a combination of interventions aimed at improving DTN times in our institution.


   Methods
TOP
 Introduction
 Methods
Results
 Discussion
 Limitations of this study
 Conclusion
 Contributors
 Conflict of interest statement
 Funding
 Ethics approval
 Acknowledgements
 References
 
In our institution, a moderate-sized district general hospital serving a mixed urban and rural population of 200 000 people, several low-cost interventions had already been implemented to improve DTN times. These had improved our performance against the government target, but additional measures were needed to hit this target. It was felt that two elements were necessary. Firstly, additional nurses in the Accident & Emergency Department were required for the timely triage and assessment of people presenting with chest pain and to facilitate rapid thrombolysis where appropriate. Secondly, the use of a single bolus thrombolytic agent was necessary to avoid delay associated with setting up intravenous infusions. £224 000 ({euro}330 000, $400 000) was made available, recurrent annually, to fund both elements of this intervention. This budget was agreed after close consultation between primary care commissioners and secondary care providers, with the involvement of both health service managers and relevant clinicians from primary and secondary care. The intention had been to employ 5.8 additional whole-time-equivalent nurses to increase staff levels by one additional nurse on each shift, 24 h per day, seven days per week. Although not committed exclusively to this role, the focus of this additional nurse was on rapid triage of patients presenting acutely with chest pain and the facilitation of timely thrombolysis by the medical staff. During the period of study, the funding was incompletely utilized because of a failure to recruit all of the intended additional nursing time and an underusage of thrombolytic agents compared with projected estimates. The actual additional expenditure during the post-intervention period of the study was £173 247 ({euro}260 000, $310 000), equivalent to an annual expenditure of £207 896 ({euro}310 000, $370 000). This figure was therefore used as the incremental cost in the cost-effectiveness calculations. Of this total, £173 012 ({euro}260 000, $310 000), annualized, was spent on additional nursing time and £34 884 ({euro}52 000, $62 000), annualized, on the additional cost of the more expensive thrombolytic agent.

The cost effectiveness of the intervention was assessed from the viewpoint of the local health economy, encompassing both the primary care-based commissioners of health care and the secondary care-based providers of this particular facet of health care. For reasons of simplicity, the health-care outcome used in the analysis was restricted to lives saved by thrombolysis. No attempt was made to incorporate the wider impacts of thrombolysis as they relate to morbidity, time spent off work and the effect of increased longevity on pension payments. This form of single-domain cost-effectiveness analysis can be defended as being particularly relevant to this situation since the justification for government targets attached to rapid thrombolysis is usually described in terms of lives saved.5

Data for PTN and DTN times were collected retrospectively from routine data submissions to the Myocardial Infarction National Audit Project (MINAP) database. Data were collected for two 10-month periods, corresponding to the periods immediately before and after the introduction of the intervention designed to improve DTN times. PTN time and DTN time were recorded for all patients receiving thrombolytic therapy for acute myocardial infarction during these periods. These patients included similar numbers eligible and ineligible for measurement against the rapid thrombolysis target.

The improvement in mean DTN time between the pre-intervention group and the post-intervention group was calculated and compared against the prevailing targets. The times before and after the intervention were compared using Student’s t-test. The proportions of patients meeting the government DTN time targets were compared using the {chi}2 test. The improvement in mean PTN time between the groups was calculated and used to estimate the number of additional lives saved per thousand. This was achieved using the non-linear equation published by Boersma et al.,4 derived from a meta-analysis of thrombolytic trials

Formula
where Y = number of lives saved per thousand and x = time from onset of pain to thrombolysis in hours.

From this figure, the number of additional life years gained was calculated by using an anticipated mean life expectancy of 15.41 years following thrombolysis for acute myocardial infarction.6 Life years gained were converted to quality-adjusted life years (QALYs) using a mean utility value of 0.9.6 The cost per QALY was then calculated. Costs were calculated in UK sterling, with results also expressed in Euros and US dollars, derived from currency exchange rates of October 2005.


   Results
TOP
 Introduction
 Methods
 Results
Discussion
 Limitations of this study
 Conclusion
 Contributors
 Conflict of interest statement
 Funding
 Ethics approval
 Acknowledgements
 References
 
One hundred and seventy-seven patients were thrombolysed for acute myocardial infarction during the period of study, 91 before the intervention to improve DTN times, 86 after. Of these, 92 (50 before, 42 after) were eligible for measurement against the DTN target, having an admission ECG diagnostic for acute myocardial infarction with no relative contraindications to thrombolysis (age 63 ± 13, mean ± SD, 79 per cent male).

Before the intervention to reduce delay to thrombolysis, the DTN time for patients eligible to be counted against the government target was 37.6 ± 5.9 minutes (mean SEM), compared with 27.6 ± 3.6 minutes after the intervention (p = 0.06). The proportion of these patients who met the 30-minute and 20-minute DTN time targets improved from 56.0 to 76.2 per cent (p < 0.05) and from 36.0 to 54.8 per cent (p = 0.07), respectively. Pre-hospital delay (time from onset of pain to arrival in hospital) was not altered by the intervention (p = 0.72). For those patients ineligible for counting against the government target, there was no improvement in DTN or PTN times (p = 0.67 and p = 0.80, respectively). These patients were therefore not included in the cost-effectiveness calculation.

The reduction in DTN time for the group eligible for counting against the government target resulted in a reduction in PTN time from 219.8 ± 23.6 to 197.6 ± 22.4 minutes (p = ns). This represents a reduction in PTN time of 22 minutes [95% confidence interval (CI) = –42–86 minutes]. Using the Boersma formula, this equates to an increase in expected lives saved from 25.2 to 26.3 per 1000 [a difference of 1.1 (95% CI = –1.7–6.0) per 1000]. During the period of study, a mean of 55.2 patients, eligible for counting against the government target, were thrombolysed per annum. In our population, the intervention therefore saved 0.06 lives per year (95% CI = –0.09–0.33), equivalent to 0.94 life years (95% CI = –1.45–5.10) or 0.84 QALYs (95% CI = –1.30–4.59) gained per annum. The incremental costs of these gains are listed in the Table 1.


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  		Table 1 Costs per life saved, life year gained and QALY of the intervention to improve DTN time

 


   Discussion
TOP
 Introduction
 Methods
 Results
 Discussion
Limitations of this study
 Conclusion
 Contributors
 Conflict of interest statement
 Funding
 Ethics approval
 Acknowledgements
 References
 
Main finding of this study
The intervention to improve DTN time in our institution can be viewed as having been moderately successful. DTN time was reduced (p = 0.06) and the prevailing DTN time target achieved in a greater proportion of cases (p < 0.05 and p = 0.07). However, when looked at in terms of cost effectiveness, this same intervention proved to be an inefficient use of health-care resources. The cost per QALY of £245 000 ({euro}370 000, $440 000) is several orders of magnitude higher than most other health-care interventions7,8 and is higher than quoted thresholds for acceptability.7,9

What is already known on this topic
Early thrombolysis is desirable to optimize survival in suspected cases of acute myocardial infarction. In the United Kingdom, government targets exist to encourage hospitals to achieve rapid thrombolysis. However, the pursuit of achieving thrombolysis targets has not previously been subjected to cost-effectiveness analysis.

What this study adds
The attempts by this local health-care economy to achieve government targets for thrombolysis times led to an inefficient use of resources. Under certain circumstances, this may be an inevitable consequence of strict government targets in health care.


   Limitations of this study
TOP
 Introduction
 Methods
 Results
 Discussion
 Limitations of this study
Conclusion
 Contributors
 Conflict of interest statement
 Funding
 Ethics approval
 Acknowledgements
 References
 
A major limitation of our study is the degree of uncertainty resulting from a small patient sample. The 95% CI for cost per QALY reaches infinity because the reduction in PTN time was not statistically significant and the 95% CI for number of lives saved per thousand crosses zero. A larger regional or national study of this sort would be difficult to achieve because there is, to our knowledge, no routine collection of data on resources allocated to the attainment of certain targets. However, the economic inefficiency of our intervention to reduce DTN times can be illustrated by a simple sensitivity analysis, calculating the cost effectiveness of the ‘best case scenario’. Assuming a pre-intervention PTN time at the lowest end of the 95% CI (where the delay versus mortality curve is steepest), a pre-intervention DTN time at the highest end of the 95% CI, and a post-intervention DTN of zero, the cost per life saved, life year gained and QALY calculate to be £836 941, £54 312 and £60 346, respectively ({euro}1 240 000, {euro}80 000 and {euro}89 000; $1 480 000, $96 000 and $107 000). So, whatever limitation our study has in respect of its size, it can be seen that the intervention could not possibly have been cost effective from the outset, even had it achieved a DTN time of zero. This analysis could and should have been performed before funding the intervention, but the political climate at the time was such that not funding this intervention and continuing to miss DTN targets would not have been entertained as a valid option.

The analysis assumes no interaction between the intervention or the outcome and other external factors that were not measured. In reality, the intervention was introduced at a time of increasing focus on achieving rapid thrombolysis, and it is very likely that some improvement in DTN times would have occurred without the £207 896 expenditure. This factor suggests that the calculated costs per life saved, per life year gained and per QALY are underestimates. On the other hand, the intervention will have benefited aspects of health care in our hospital, over and above the effects on absolute survival in acute myocardial infarction. The benefits of thrombolysis probably extend to a reduction in heart failure morbidity among survivors. The additional nursing time in the Accident & Emergency Department will have had other positive health-care impacts in areas distant from acute cardiology. These benefits are difficult to quantify in a way amenable to cost-effectiveness analysis but cannot be wholly ignored when estimating the cost-benefit balance of the intervention.

It is useful to calculate the cost effectiveness of the intervention in an ‘intention-to-treat’ way, as presented here. This is valid in the situation in which expenditure is budgeted to achieve one outcome alone. This form of analysis answers the question ‘What was the cost effectiveness of the financial outlay in terms of the impact on the clinical outcome that was being targeted?’ However, it is also important to assess the cost effectiveness from the broader health-care perspective, taking into account as much as can be factored into the model. Because the positive impact of additional nursing staff in the Accident & Emergency Department on other areas of health care distant from acute cardiology cannot readily be accounted for, one way of dealing with this issue is to run a sensitivity analysis based on the proportion of working time that the additional nurse on shift would spend dealing directly with the assessment, triage and management of patients presenting acutely with chest pain. We have no accurate data on this, but the nature of our Emergency department and the focus of the extra nursing role suggests that this proportion would sit somewhere between 20 and 50 per cent. The cost per QALY of the intervention, adjusted for this factor, is as follows: 20 per cent, £83 000 ({euro}123 000, $147 000); 30 per cent, £103 000 ({euro}152 000, $182 000); 40 per cent, £124 000 ($183 000, $219 000) and 50 per cent, £144 000 ({euro}213 000, $255 000). Although these figures represent an improvement, the intervention remains at greater expense than would usually be deemed acceptable.


   Conclusion
TOP
 Introduction
 Methods
 Results
 Discussion
 Limitations of this study
 Conclusion
Contributors
 Conflict of interest statement
 Funding
 Ethics approval
 Acknowledgements
 References
 
In devising the intervention to improve DTN times, there was no disagreement within our local health economy, either between primary care commissioners and secondary care providers or between clinicians and managers. The presence of a strict government target led inevitably to an allocation of resources intended to assist in achieving that target. Where a health-care organization is narrowly missing a government target despite having exploited all possible low-cost efficiency improvements, that organization has a powerful incentive to spend a large amount of money to achieve something small in clinical terms.

Much concern has been raised in the United Kingdom over the potential for targets in health care to distort clinical priorities. Our data suggest that a target culture in health care may also promote an inefficient use of resources.


   Contributors
TOP
 Introduction
 Methods
 Results
 Discussion
 Limitations of this study
 Conclusion
 Contributors
Conflict of interest statement
 Funding
 Ethics approval
 Acknowledgements
 References
 
The paper has been read and approved by all authors. R. M. E. and C. A. S. devised and oversaw the study. R. S. and C. A. S. collected the data. R. S. and R. M. E. analysed the data and wrote the manuscript.


   Conflict of interest statement
TOP
 Introduction
 Methods
 Results
 Discussion
 Limitations of this study
 Conclusion
 Contributors
 Conflict of interest statement
Funding
 Ethics approval
 Acknowledgements
 References
 
There is no conflict of interest to declare. The corresponding author (R. M. E.) had full access to all the data in the study and had final responsibility for the decision to submit for publication.


   Funding
TOP
 Introduction
 Methods
 Results
 Discussion
 Limitations of this study
 Conclusion
 Contributors
 Conflict of interest statement
 Funding
Ethics approval
 Acknowledgements
 References
 
No external funding received.


   Ethics approval
TOP
 Introduction
 Methods
 Results
 Discussion
 Limitations of this study
 Conclusion
 Contributors
 Conflict of interest statement
 Funding
 Ethics approval
Acknowledgements
 References
 
The study was performed by retrospective mathematical manipulation of routine audit submissions to a national audit programme. Ethics approval was therefore not required.


   Acknowledgements
TOP
 Introduction
 Methods
 Results
 Discussion
 Limitations of this study
 Conclusion
 Contributors
 Conflict of interest statement
 Funding
 Ethics approval
 Acknowledgements
References
 
The authors thank Jeanette Sarkar and Alison Strong for retrospectively reconstructing the baseline expenditure.


   References
TOP
 Introduction
 Methods
 Results
 Discussion
 Limitations of this study
 Conclusion
 Contributors
 Conflict of interest statement
 Funding
 Ethics approval
 Acknowledgements
 References
 

  1. Gruppo Italiano per lo Studio della Streptochinasi nell’Infarto Miocardico (GISSI). Effectiveness of intravenous thrombolytic treatment in acute myocardial infarction. Lancet 1986; 1: 397–402.[CrossRef][Medline]
  2. ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. Lancet 1988; 2: 349–360.[Medline]
  3. Fibrinolytic Therapy Trialists’ (FTT) Collaborative Group. Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients. Lancet 1994; 343: 311–322.[CrossRef][Web of Science][Medline]
  4. Boersma E, Maas AC, Deckers JW, Simoons ML. Early thrombolytic treatment in acute myocardial infarction: reappraisal of the golden hour. Lancet 1996; 348: 771–775.[CrossRef][Web of Science][Medline]
  5. Anonymous. National service framework for coronary heart disease. Modern standards and service models. London: Department of Health, 2000.
  6. 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: 1418–1424.[Abstract/Free Full Text]
  7. Raftery J. NICE: faster access to modern treatments? Analysis of guidance on health technologies. Br Med J 2001; 323: 1300–1303.[Free Full Text]
  8. Tengs TO, Adams ME, Pliskin JS et al. Five hundred life-saving interventions and their cost-effectiveness. Risk Anal 1995; 15: 369–390.[CrossRef][Web of Science][Medline]
  9. Walker A, Sirel JM, Marsden AK, Cobbe SM, Pell JP. Cost effectiveness and cost utility model of public place defibrillators in improving survival after prehospital cardiopulmonary arrest. Br Med J 2003; 327: 1316–1319.[Abstract/Free Full Text]

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This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow All Versions of this Article:
28/1/31    most recent
fdi072v1
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