The cost-effectiveness of prehospital versus in-hospital thrombolysis for ST-segment elevation myocardial infarction in South Africa

Background. In high-income countries, preventative, long-term, and definitive care has seen mortality from cardiovascular disease (CVD) partially decline, while trends in low- to middle-income countries (LMICs) continue to exceed those of global averages. The burden of severe CVD-related events, especially crucially ST-segment myocardial infarction (STEMI), has risen disproportionally with socioeconomic pressures limiting preventative or definitive supports, particularly in rural or remote areas. Access to percutaneous coronary intervention (PCI) for STEMI in South Africa remains limited, inevitably expanding the therapeutic window to include pharmaco-invasive approaches with in-hospital thrombolysis (IHT) emerging as a widespread default STEMI intervention. Prehospital thrombolysis (PHT) may further bridge resource gaps and improve clinical outcomes due to time-sensitive benefits. Although not widely perceived as cost-prohibitive, cost concerns may however still act as a significant barrier to adoption of PHT. We analysed the cost-effectiveness of IHT in contrast to PHT.

Methods. A cost-effectiveness analysis was conducted using a decision tree to compare PHT and IHT for the treatment of STEMI from a provider perspective. Cost estimates for analysis were obtained from publicly accessible data, including government, labour-earning reports, and industrial equipment pricing tiers. Deterministic and probabilistic sensitivity analyses were conducted to assess parameter uncertainty. The model estimated the incremental cost-effectiveness ratio (ICER), of implementing PHT relative to IHT by measuring outcomes using disability-adjusted life-years (DALYs).

Results. Over a one-year period, PHT dominated IHT as a treatment strategy, demonstrating cost savings per DALY averted and life-years saved. Using PHT as an intervention resulted in cost savings of R190 500 per DALY averted, and R327 438 per life-year saved (LYS) in contrast to IHT. Savings in terms of cost and health outcomes were estimated at R23.78 million with incremental reduced deaths (n = 20), and fewer life-years lost (n = 149).

Conclusion. Given the substantial burden of STEMI-related morbidity and mortality in South Africa, and the resource limitations faced by the public health sector, it is imperative to identify and implement cost-effective strategies to improve patient outcomes. In resource-constrained settings where timely access to PCI is limited, PHT represents a pragmatic and cost-effective strategy.