Cost-effectiveness of percutaneous closure of a patent foramen ovale compared with medical management in patients with a cryptogenic stroke: from the US payer perspective

Aims: To evaluate the cost-effectiveness of percutaneous patent foramen ovale (PFO) closure, from a US payer perspective. Lower rates of recurrent ischemic stroke have been documented following percutaneous PFO closure in properly selected patients. Stroke in patients aged <60 years is particularly interesting because this population is typically at peak economic productivity and vulnerable to prolonged disability. Materials and methods: A Markov model comprising six health states (Stable after index stroke, Transient ischemic attack, Post-Transient Ischemic Attack, Clinical ischemic stroke, Post-clinical ischemic stroke, and Death) was constructed to evaluate the cost-effectiveness of PFO closure in combination with medical management versus medical management alone. The base-case model employed a 5-year time-horizon, with transition probabilities, clinical inputs, costs, and utility values ascertained from published and national costing sources. Incremental cost-effectiveness ratio (ICER) was evaluated per US guidelines, utilizing a discount rate of 3.0%. Results: At 5 years, overall costs and quality-adjusted life-years (QALYs) obtained from PFO closure compared with medical management were $16,323 vs $7,670 and 4.18 vs 3.77, respectively. At 5 years, PFO closure achieved an ICER of $21,049, beneficially lower than the conventional threshold of $50,000. PFO closure reached cost-effectiveness at 2.3 years (ICER = $47,145). Applying discount rates of 0% and 6% had a negligible impact on base-case model findings. Furthermore, PFO closure was 95.4% likely to be cost-effective, with a willingness-to-pay (WTP) threshold of $50,000 and a 5-year time horizon. Limitations: From a cost perspective, our economic model employed a US patient sub-population, so cost data may not extrapolate to other non-US stroke populations. Conclusion: Percutaneous PFO closure plus medical management represents a cost-effective approach for lowering the risk of recurrent stroke compared with medical management alone.

Healthcare costs of stroke and major bleeding in patients with atrial fibrillation treated with non-vitamin K antagonist oral anticoagulants

Objective: To assess long-term healthcare costs related to ischemic stroke and systemic embolism (stroke/SE) and major bleeding (MB) events in patients with non-valvular atrial fibrillation (NVAF) treated with non-vitamin K antagonist oral anticoagulants (NOACs). Materials and methods: Optum's Clinformatics Data Mart database from 1/2009-12/2016 was analyzed. Adult patients with ≥1 stroke/SE hospitalization (index date) were matched 1:1 to patients without stroke/SE (random index date), based on propensity scores. Patients with an MB event were matched to patients without MB. All patients had an NOAC dispensing overlapping index date, ≥12 months of eligibility pre-index date, and ≥1 NVAF diagnosis. The observation period spanned from the index date until the earliest date of death, switch to warfarin, end of insurance coverage, or end of data availability. Mean costs were evaluated: (1) per-patient-per-year (PPPY) and (2) at 1, 2, 3, and 4 years using Lin's method. Results: The cost differences were, respectively, $48,807 and $28,298 PPPY for NOAC users with stroke/SE (n = 1,340) and those with MB (n = 3,774) events compared to controls. Cost differences of patients with vs without stroke/SE were $49,876, $51,627, $57,822, and $60,691 at 1, 2, 3, and 4 years post-index, respectively (p < 0.001). These cost differences were $31,292, $35,658, $44,069, and $47,022 for patients with vs without MB after 1, 2, 3, and 4 years post-index, respectively (p < 0.001). Limitations: Limitations include unobserved confounders, coding and/or billing inaccuracies, limited sample sizes over longer follow-up, and the under-reporting of mortality for deaths occurring after 2011. Conclusions: The incremental healthcare costs incurred by patients with vs without stroke/SE was nearly twice as high as those of patients with vs without MB. Moreover, each additional year up to 4 years after the first event was associated with an incremental cost for patients with a stroke/SE or MB event compared to those without an event.

Modeling the cost effectiveness and budgetary impact of Polypills for secondary prevention of cardiovascular disease in the United States

BACKGROUND

There is underutilization of appropriate medications for secondary prevention of cardiovascular disease (CVD).

METHODS

Usual care (UC) was compared to polypill-based care with 3 versions using a validated micro-simulation model in the NHANES population with prior CVD. UC included individual prescription of up to 4 drug classes (antiplatelet agents, beta-blockers, renin-angiotensin-aldosterone inhibitors and statins). The polypills modeled were aspirin 81 mg, atenolol 50 mg, ramipril 5 mg, and either simvastatin 40 mg (Polypill I), atorvastatin 80 mg (Polypill II), or rosuvastatin 40 mg (Polypill III). Baseline medication use and adherence came from United Healthcare claims data.

RESULTS

When compared to UC, there were annual reductions of 130,000 to 178,000 myocardial infarctions and 54,000 to 74,000 strokes using Polypill I and II, respectively. From a health sector perspective, in incremental analysis the ICERs for Polypill I and II were $20,073/QALY and $21,818/QALY respectively; Polypill III was dominated but had a similar cost-effectiveness ratio to Polypill II when compared directly to usual care. From a societal perspective, Polypill II was cost-saving and dominated all strategies. Over a 5-year period, those taking Polypill I and II compared to UC saved approximately $12 and $6 per-patient-per-year alive, respectively. Polypill II was the preferred strategy in 98% of runs at a willingness to pay of $50,000 in the probability sensitivity analysis.

CONCLUSIONS

Use of a polypill has a favorable cost profile for secondary CVD prevention in the United States. Reductions in CVD-related healthcare costs outweighed medication cost increases on a per-patient-per-year basis, suggesting that a polypill would be economically advantageous to both patients and payers.

Cost-Effectiveness of Cryoballoon Ablation Versus Radiofrequency Ablation for Paroxysmal Atrial Fibrillation in China: Results Based on Real-World Data

BACKGROUND

Paroxysmal atrial fibrillation (AF) presents a significant economic burden to the healthcare system. Catheter ablations is a commonly adopted treatment for paroxysmal AF.

OBJECTIVES

To evaluate the cost effectiveness of cryoballoon ablation versus radiofrequency ablation in patients with drug-refractory paroxysmal AF in a tertiary hospital in China.

METHODS

A Markov model was developed to study the effects and costs. Cost and probability input data were obtained mainly from a retrospective real-world study conducted in a tertiary hospital. Propensity score matching was used to overcome retrospective bias. Input data gaps were remedied by means of literature review and advice from experts. A simulation was performed for the post-procedure lifetime years. Univariate and probabilistic sensitivity analyses were conducted.

RESULTS

In the base-case analysis of a lifetime time horizon, a patient treated with cryoballoon ablation was associated with 7.85 quality-adjusted life-years (QALYs) and ¥132 222 ($19 913) total costs, whereas a radiofrequency ablation treated patient was associated with 7.71 QALYs and ¥147 304 ($22 184) total costs. The cryoballoon group had slightly better health outcomes (with a difference of 0.14 QALY) and lower total costs (with a difference of ¥15 082) (USD $2 271), and it may be considered as cost-effective or cost-saving strategy (incremental cost-effectiveness ratio -¥110 158 [$16 590] per QALY) for the management of paroxysmal AF. Different scenarios were tested with sensitivity analyses, but still, the outcomes remained cost-effective or cost-saving for cryoballoon ablation.

CONCLUSIONS

An economic evaluation based on real-world data suggests that, relative to radiofrequency ablation, cryoballoon ablation may be considered as a more cost-effective or cost-saving long-term strategy for drug-refractory paroxysmal AF in this tertiary hospital in China. However, further evidence is needed using data from large-scale studies in order to reflect a national perspective.

Interhospital Transfers for Endovascular Therapy for Acute Ischemic Stroke

Background and Purpose- Multiple randomized clinical trials have demonstrated the superiority of endovascular therapy (ET) for large vessel occlusion acute ischemic stroke (AIS). Few centers can provide ET, and significant debate exists about the most efficient and effective ways to provide ET. We sought to assess real-world utilization of ET, the extent to which patients are transferred from one hospital to another for therapy and the implications of transfer status on outcomes. Methods- We used the 2015 to 2016 Healthcare Cost and Utilization Project Nationwide Readmissions Database, which contains nationwide data on nearly half of US admissions. We identified index AIS admissions, vascular risk factors, and treatment with intravenous thrombolysis and ET using International Classification of Disease, Ninth Revision, and International Classification of Disease, Tenth Revision Clinical Modification codes. Main predictors of outcome were treatment with ET and whether there was an interhospital transfer during the index AIS hospitalization. Among patients with AIS readmitted within 30 days, we examined 3 main outcomes: total charges, length of stay, and in-hospital mortality. Results- A total of 23 121 AIS admissions were treated with ET and 874 229 without. Over 5% of patients who received ET were transferred during the index admission compared with <2% of those not treated with ET. Length of stay and total charges were significantly higher in patients transferred (12.3 versus 9.6 days and $233 626 versus $182 881, respectively). More patients treated with ET who were not transferred to the index hospital were discharged home (25.3% versus 44.4%), and ≈25% of patients transferred for ET died during the hospitalization compared with 15.5% not transferred. Conclusions- The minority of all patients with AIS receive ET. The majority of patients who receive ET present directly to the center that performs the procedure, and those transferred for ET have higher length of stay, cost, and mortality that those not transferred.

Post-stroke rehabilitation cost with traditional therapy: Evidence from a public hospital

OBJECTIVE

After surviving from an acute phase of stroke, it is essential for stroke survivors to continue therapies to improve their function and quality of life. The aim of this study was to assess the influence of rehabilitation treatment on the society in economic aspect with evidence from a traditional hospital.

METHODS

A prospective cohort study was carried out with patients who were being treated at Traditional Medicine Hospital in Ho Chi Minh City after experiencing a stroke. Patients' relevant medical information was extracted from the hospital's database and placed on a structured questionnaire.

RESULTS

Among 103 eligible patients aged 60.3 } 11.4 years, 93.2% had experienced a stroke for the first time. Eighty-four patients were diagnosed with ischaemic stroke, while the number of haemorrhagic stroke patients was approximately 4.5 times lower (n = 19). The mean total cost was $3,310.40 USD, which included $1,653.60 USD, $539.90 USD and $1,117.00 USD for direct medical, direct non-medical and indirect cost, respectively. Hospital bed costs accounted for a considerable percentage of direct medical costs (41.0%).

CONCLUSIONS

Stroke was determined to be a significant social burden, although patients in this study had already suffered from the acute phase. This study gives decision makers a comparative view about the economic view on the economic burden of the stroke rehabilitation treatment between using traditional national Western and Eastern therapy.

Productivity growth of skilled nursing facilities in the treatment of post-acute-care-intensive conditions

BACKGROUND

Health care is believed to be suffered from a "cost disease," in which a heavy reliance on labor limits opportunities for efficiencies stemming from technological improvement. Although recent evidence shows that U.S. hospitals have experienced a positive trend of productivity growth, skilled nursing facilities are relatively "low-tech" compared to hospitals, leading some to worry that productivity at skilled nursing facilities will lag behind the rest of the economy.

OBJECTIVE

To assess productivity growth among skilled nursing facilities (SNFs) in the treatment of conditions which frequently involve substantial post-acute care after hospital discharge.

METHODS

We constructed an analytic file with the records of Medicare beneficiaries that were discharged from acute-care hospitals to SNFs with stroke, hip fracture, or lower extremity joint replacement (LEJR) between 2006 and 2014. We populated each record for 90 days starting at the time of SNF admission, detailing for each day the treatment site and all associated costs. We used ordinary least square regression to estimate growth in SNF productivity, measured by the ratio of "high-quality SNF stays" to total treatment costs. The primary definition of a high-quality stay was a stay that ended with the return of the patient to the community within 90 days after SNF admission. We controlled for patient demographics and comorbidities in the regression analyses.

RESULTS

Our sample included 1,076,066 patient stays at 14,394 SNFs with LEJR, 315,546 patient stays at 14,154 SNFs with stroke, and 739,608 patient stays at 14,588 SNFs with hip fracture. SNFs improved their productivity in the treatment of patients with LEJR, stroke, and hip fracture by 1.1%, 2.2%, and 2.0% per year, respectively. That pattern was robust to a number of alternative specifications. Regressions on year dummies showed that the productivity first decreased and then increased, with a lowest point in 2011. Over the study period, quality continued to rise, but dominated by higher costs at first. Costs then started to decrease, driving productivity to grow.

CONCLUSION

There has been substantial productivity growth in recent years among SNFs in the U.S. in the treatment of post-acute-care-intensive conditions.

HeART of Stroke: randomised controlled, parallel-arm, feasibility study of a community-based arts and health intervention plus usual care compared with usual care to increase psychological well-being in people following a stroke

INTRODUCTION

People often experience distress following stroke due to fundamental challenges to their identity.

OBJECTIVES

To evaluate (1) the acceptability of 'HeART of Stroke' (HoS), a community-based arts and health group intervention, to increase psychological well-being; and (2) the feasibility of a definitive randomised controlled trial (RCT).

DESIGN

Two-centre, 24-month, parallel-arm RCT with qualitative and economic components. Randomisation was stratified by centre and stroke severity. Participant blinding was not possible. Outcome assessment blinding was attempted.

SETTING

Community.

PARTICIPANTS

Community-dwelling adults ≤2 years poststroke recruited via hospital clinical teams/databases or community stroke/rehabilitation teams.

INTERVENTIONS

Artist-facilitated arts and health group intervention (HoS) (ten 2-hour sessions over 14 weeks) plus usual care (UC) versus UC.

OUTCOMES

The outcomes were self-reported measures of well-being, mood, capability, health-related quality of life, self-esteem and self-concept (baseline and 5 months postrandomisation). Key feasibility parameters were gathered, data collection methods were piloted, and participant interviews (n=24) explored the acceptability of the intervention and study processes.

RESULTS

Despite a low recruitment rate (14%; 95% CI 11% to 18%), 88% of the recruitment target was met, with 29 participants randomised to HoS and 27 to UC (57% male; mean (SD) age=70 (12.1) years; time since stroke=9 (6.1) months). Follow-up data were available for 47 of 56 (84%; 95% CI 72% to 91%). Completion rates for a study-specific resource use questionnaire were 79% and 68% (National Health Service and societal perspectives). Five people declined HoS postrandomisation; of the remaining 24 who attended, 83% attended ≥6 sessions. Preliminary effect sizes for candidate primary outcomes were in the direction of benefit for the HoS arm. Participants found study processes acceptable. The intervention cost an estimated £456 per person and was well-received (no intervention-related serious adverse events were reported).

CONCLUSIONS

Findings from this first community-based study of an arts and health intervention for people poststroke suggest a definitive RCT is feasible. Recruitment methods will be revised.

TRIAL REGISTRATION NUMBER

ISRCTN99728983.

Adverse stroke outcomes among patients with bipolar disorder

Failure to deliver the standard stroke care is suspected to be a potential reason for disproportionately high mortality among patients with co-morbid bipolar disorder (BD). Few studies have explored adverse outcomes and medical care costs concurrently (as a proxy for care intensity) among patients with BD admitted for stroke. Data for this nationwide population-based study were extracted from the Taiwan National Health Insurance Research Database, on 580 patients with BD hospitalized for stroke (the study group) and a comparison group consisting of randomly selected 1740 stroke patients without BD matched by propensity scores. Conditional logistic regression was used to estimate odds ratios (OR) for adverse in-hospital outcomes between study group and comparison group. We found that stroke patients with BD had significantly lower in-hospital mortality (3.28% vs. 5.63%), acute respiratory failure (2.59% vs. 5.57%), and use of mechanical ventilation (6.55% vs. 10.23%) than the comparison group. After adjusting for geographical location, urbanization level, monthly income, hypertension, diabetes, hyperlipidemia, and coronary heart disease, the odds of in-hospital mortality, acute respiratory failure, and use of mechanical ventilation in the BD group were 0.56 (95% CI: 0.34–0.92), 0.46 (95% CI: 0.26–0.80), and 0.63 (95% CI: 0.44–0.91), respectively. No differences were found in hospitalization costs and the length of hospital stay. With comparable hospitalization costs and length of hospital stay, we concluded that stroke patients with BD had lower in-hospital mortality and serious adverse events compared to stroke patients without BD.

Socioeconomic gap between neighborhoods of Budapest: Striking impact on stroke and possible explanations

Introduction

Hungary has a single payer health insurance system offering free healthcare for acute cerebrovascular disorders. Within the capital, Budapest, however there are considerable microregional socioeconomic differences. We hypothesized that socioeconomic deprivation reflects in less favorable stroke characteristics despite universal access to care.

Methods

From the database of the National Health Insurance Fund, we identified 4779 patients hospitalized between 2002 and 2007 for acute cerebrovascular disease (hereafter ACV, i.e. ischemic stroke, intracerebral hemorrhage, or transient ischemia), among residents of the poorest (District 8, n = 2618) and the wealthiest (District 12, n = 2161) neighborhoods of Budapest. Follow-up was until March 2013.

Results

Mean age at onset of ACV was 70±12 and 74±12 years for District 8 and 12 (p<0.01). Age-standardized incidence was higher in District 8 than in District 12 (680/100,000/year versus 518/100,000/year for ACV and 486/100,000/year versus 259/100,000/year for ischemic stroke). Age-standardized mortality of ACV overall and of ischemic stroke specifically was 157/100,000/year versus 100/100,000/year and 122/100,000/year versus 75/100,000/year for District 8 and 12. Long-term case fatality (at 1,5, and 10 years) for ACV and for ischemic stroke was higher in younger District 8 residents (41–70 years of age at the index event) compared to D12 residents of the same age. This gap between the districts increased with the length of follow-up. Of the risk diseases the prevalence of hypertension and diabetes was higher in District 8 than in District 12 (75% versus 66%, p<0.001; and 26% versus 16%, p<0.001).

Discussion

Despite universal healthcare coverage, the disadvantaged district has higher ACV incidence and mortality than the wealthier neighborhood. This difference affects primarily the younger age groups. Long-term follow-up data suggest that inequity in institutional rehabilitation and home-care should be investigated and improved in disadvantaged neighborhoods.

Evaluating the cost-effectiveness of percutaneous closure of a patent foramen ovale versus medical management in patients with a cryptogenic stroke: from the UK payer perspective

AIMS

Percutaneous closure of a patent foramen ovale (PFO) is known to lower the risk of recurrent stroke in patients with a cryptogenic stroke. However, the economic implications of transcatheter PFO closure are less well known. From a UK payer perspective, a detailed economic appraisal of PFO closure was performed for prevention of recurrent ischemic stroke in patients with a PFO who had experienced a cryptogenic stroke.

MATERIALS AND METHODS

A Markov cohort model was constructed using a 5-year time-horizon with a patient mean age of 45.2 years, reflecting the characteristics reported in the REDUCE trial. Transition probabilities, clinical inputs, costs, and utility values were ascertained from published and national costing sources. Total costs, incremental costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios were calculated, utilizing a discount rate of 3.5%. A range of univariate and probabilistic sensitivity analyses were also performed.

RESULTS

When applying a willingness-to-pay (WTP) threshold of £20,000/QALY in accordance with NICE guidelines, PFO closure compared with antiplatelet therapy alone showed a beneficial cost/QALY of £18,584, attained at 4 years. Applying discount rates of 0% and 6% had a negligible effect on the base-case model findings. PFO closure demonstrated a 76.9% probability of being cost-effective at a WTP threshold of £20,000/QALY at a 5-year time-horizon.

LIMITATIONS

This model focused specifically on UK stroke patients and typically enrolled young (mean age <65 years old) patients. Hence, caution should be taken when comparing data vs non-UK populations, and it remains unclear how older patients might have affected cost-effectiveness findings, as the risk of paradoxical embolism can persist as patients age.

CONCLUSION

Percutaneous closure of a PFO is cost-effective compared with antiplatelet therapy alone, underlining the economic benefits potentially afforded by this treatment in selected patients.

Economic burden of stroke: a systematic review on post-stroke care

OBJECTIVES

Stroke is a leading cause for disability and morbidity associated with increased economic burden due to treatment and post-stroke care (PSC). The aim of our study is to provide information on resource consumption for PSC, to identify relevant cost drivers, and to discuss potential information gaps.

METHODS

A systematic literature review on economic studies reporting PSC-associated data was performed in PubMed/MEDLINE, Scopus/Elsevier and Cochrane databases, Google Scholar and gray literature ranging from January 2000 to August 2016. Results for post-stroke interventions (treatment and care) were systematically extracted and summarized in evidence tables reporting study characteristics and economic outcomes. Economic results were converted to 2015 US Dollars, and the total cost of PSC per patient month (PM) was calculated.

RESULTS

We included 42 studies. Overall PSC costs (inpatient/outpatient) were highest in the USA ($4850/PM) and lowest in Australia ($752/PM). Studies assessing only outpatient care reported the highest cost in the United Kingdom ($883/PM), and the lowest in Malaysia ($192/PM). Fifteen different segments of specific services utilization were described, in which rehabilitation and nursing care were identified as the major contributors.

CONCLUSION

The highest PSC costs were observed in the USA, with rehabilitation services being the main cost driver. Due to diversity in reporting, it was not possible to conduct a detailed cost analysis addressing different segments of services. Further approaches should benefit from the advantages of administrative and claims data, focusing on inpatient/outpatient PSC cost and its predictors, assuring appropriate resource allocation.

Cost-Effectiveness Analysis of Direct-Acting Oral Anticoagulants for Stroke Prevention in Thai Patients with Non-Valvular Atrial Fibrillation and a High Risk of Bleeding

OBJECTIVE

The objective of this study was to assess the cost effectiveness of direct-acting oral anticoagulants for stroke prevention in Thai patients with non-valvular atrial fibrillation and a HAS-BLED score of 3.

METHODS

Total costs (US$) in 2017 and quality-adjusted life-years were estimated over 20 years using a Markov model. A base-case analysis was conducted under a societal perspective, which included direct healthcare, non-healthcare and indirect costs in Thailand. Clinical events for warfarin and utilities were obtained from Thai patients whenever possible. The efficacy of direct-acting oral anticoagulants was derived from trial-based East Asian subgroups and adjusted for time in the target international normalized ratio range of warfarin.

RESULTS

In the base case, use of apixaban instead of warfarin incurred an additional cost of US$20,763 per quality-adjusted life-year gained. Substituting apixaban with rivaroxaban and rivaroxaban with high-dose edoxaban would incur an additional cost per quality-adjusted life-year by US$507 and US$434, respectively. Compared with warfarin, high-dose edoxaban had the lowest incremental cost-effectiveness ratio of US$9704/quality-adjusted life-year, followed by high-dose dabigatran (incremental cost-effectiveness ratio US$11,155/quality-adjusted life-year). The incremental cost-effectiveness ratios based on a payer perspective were similar. The incremental cost-effectiveness ratio was below Thailand's cost-effectiveness threshold when high-dose dabigatran and edoxaban prices were reduced by 50%. Changes in key parameters had a minimal impact on incremental cost-effectiveness ratios.

CONCLUSIONS

For both societal and payer perspectives, high-dose edoxaban with a price below the country cost-effectiveness threshold should be the first anticoagulant option for Thai patients with non-valvular atrial fibrillation and a high risk of bleeding.

Cost-effectiveness analysis of mechanical thrombectomy plus tissue-type plasminogen activator compared with tissue-type plasminogen activator alone for acute ischemic stroke in France

BACKGROUND AND PURPOSE

Recent studies demonstrated the benefit of mechanical thrombectomy (MT) plus intravenous tissue-type plasminogen activator (IV-tPA) (MT-IV-tPA) in acute ischemic stroke. This study aimed to estimate the cost-utility of MT-IV-tPA compared with IV-tPA alone from the perspective of the French National Health Insurance.

METHODS

We developed a decision tree for the first 3 months after stroke onset and a Markov model until 10 years post-stroke. The health states of the Markov model were according to the modified Rankin Scale (mRS): independent (mRS=0-2), dependent (mRS=3-5), dead (mRS=6). Recurrent stroke was the fourth health stage of our model. We conducted systematic literature reviews and meta-analyses to estimate the cost and utility of each health state, and the transition probabilities between health states. A microcosting study was conducted to estimate the cost of MT. We estimated the incremental cost-effectiveness ratio of MT-IV-tPA and conducted a probabilistic analysis in order to estimate the probability that MT-IV-tPA is cost-effective compared to IV-tPA, the expected value of perfect information (EVPI), and the expected value of partial perfect information (EVPPI), given the uncertainty surrounding the value of our model's parameters.

RESULTS

The total mean (standard deviation (SD) cost of MT was €6708.9 (2357.0). The incremental cost-effectiveness ratio (ICER) of the strategy using IV-tPA combined to MT costs was €14,715 per QALY gained as compared to a strategy using IV-tPA alone. The probabilistic analysis showed that the probability of MT-IV-TPA being cost-effective was 85.4% at threshold willingness-to-pay of €30,000 per QALY gained, reaching 98% at €50,000 per QALY gained.

CONCLUSION

Although there is no universally accepted willingness-to-pay threshold in France, our analysis suggest that MT combined to IV-tPA can be considered a cost-effective treatment compared with IV-tPA alone.

Health Economic Evaluations of Digital Health Interventions for Secondary Prevention in Stroke Patients: A Systematic Review

BACKGROUND

In the first 5 years after their stroke, about a quarter of patients will suffer from a recurrent stroke. Digital health interventions facilitating interactions between a caregiver and a patient from a distance are a promising approach to improve patient adherence to lifestyle changes proposed by secondary prevention guidelines. Many of these interventions are not implemented in daily practice, even though efficacy has been shown. One of the reasons can be the lack of clear economic incentives for implementation. We propose to map all health economic evidence regarding digital health interventions for secondary stroke prevention.

SUMMARY

We performed a systematic search according to PRISMA-P guidelines and searched on PubMed, Web of Science, Cochrane, and National Institute for Health Research Economic Evaluation Database. Only digital health interventions for secondary prevention in stroke patients were included and all study designs and health economic outcomes were accepted. We combined the terms "Stroke OR Cardiovascular," "Secondary prevention," "Digital health interventions," and "Cost" in one search string using the AND operator. The search performed on April 20, 2017 yielded 163 records of which 26 duplicates were removed. After abstract screening, 20 articles were retained for full-text analysis, of which none reported any health economic evidence that could be included for analysis or discussion. Key Messages: There is a lack of evidence on health economic outcomes on digital health interventions for secondary stroke prevention. Future research in this area should take health economics into consideration when designing a trial and there is a clear need for health economic evidence and models.

Cost of oropharyngeal dysphagia after stroke: protocol for a systematic review

INTRODUCTION

Oropharyngeal dysphagia (OD) is a major disorder following stroke. OD can produce alterations in both the efficacy and safety of deglutition and may result in malnutrition, dehydration, frailty, respiratory infections and pneumonia. These complications can be avoided by early detection and treatment of OD in poststroke patients, and hospital stays, medication and mortality rates can be reduced. In addition to acute in-hospital costs from OD complications, there are other costs related to poststroke OD such as direct non-healthcare costs or indirect costs. The objective of this systematic review is to assess and summarise literature on the costs related to OD in poststroke patients.

METHODS AND ANALYSIS

A systematic review of studies on the cost of OD and its complications (aspiration, malnutrition, dehydration, aspiration pneumonia and death) in patients who had a stroke will be performed from the perspectives of the hospital, the healthcare system and/or the society. The main outcomes of interest are the costs related to poststroke OD. We will search MEDLINE, Embase and the National Health Service Economic Evaluation Database. Studies will be included if they are partial economic evaluation studies, studies that provide information on costs in adult (>17 years) poststroke patients with OD and/or its complications (malnutrition, dehydration, frailty, respiratory infections and pneumonia) or economic evaluation studies in which the cost of this condition has been estimated. Studies will be excluded if they refer to oesophageal dysphagia or OD caused by causes other than stroke. Main study information will be presented and summarised in tables, separately for studies that provide incremental costs attributable to OD or its complications and studies that report the effect of OD or its complications on total costs of stroke, and according to the perspective from which costs were measured.

ETHICS AND DISSEMINATION

The results of this systematic review will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42018099977.

Economic burden of thromboembolic and hemorrhagic complications in non-valvular atrial fibrillation in Algeria (the ELRAGFA study)

BACKGROUND

Atrial fibrillation (AF) is the most common cardiac arrhythmia, with substantial public health and economic impact on healthcare systems due to the prevention and management of thromboembolic and hemorrhagic complications. In Algeria, stroke is a leading cause of death, representing 15.6% of all deaths in 2012. Current data on the epidemiology and costs associated with non-valvular AF (NVAF) in Algeria are not available.

METHODS

A three-step approach was undertaken to estimate the economic burden of NVAF in Algeria. First, a literature review identified the epidemiological burden of the disease. Second, expert clinicians practicing in Algerian hospitals were surveyed on consumed resources and unit costs of treatment and management of complications and prevention. Finally, these data were combined with event probabilities in an economic model to estimate the annual cost of NVAF prevention and complications for the Algerian healthcare system.

RESULTS

Based on literature and demographics data, it was estimated that there are currently 187,686 subjects with NVAF in Algeria. Seventy per cent of this population was treated for prevention, half of which were controlled. Cost of prevention was estimated at 203 million DZD (€1.5 million) for drugs and 349 million DZD (€2.6 million) for examinations. Mean hospitalization costs for complications ranged between 123,500 and 435,500 DZD (€910-3,209), according to the type and severity of complications. Hospitalization costs for thromboembolic and hemorrhagic complications were estimated at 8,313 million DZD (€62 million), half of which was for untreated patients. Finally, the economic burden of NVAF was estimated at 8,865 million DZD (>€65 million) annually.

CONCLUSION

The economic burden of NVAF is important in Algeria, largely driven by untreated and INR-uncontrolled patients. There is a lack of information on the Algerian healthcare system that could increase uncertainty around this assessment, but it clearly establishes the importance of NVAF as a public health concern.

Cost-Utility Analysis of Apixaban versus Warfarin in Atrial Fibrillation Patients with Chronic Kidney Disease

BACKGROUND

Warfarin use for stroke prevention in atrial fibrillation (AF) patients with chronic kidney disease is debated. Apixaban was shown to be safer than warfarin, with superior reduction in the risk of stroke, systemic embolism, mortality, and major bleeding irrespective of kidney function.

OBJECTIVES

To evaluate the cost-utility of apixaban compared with warfarin in AF patients at different levels of kidney function.

METHODS

A Markov model was used to estimate the cost effectiveness of apixaban compared with warfarin in AF patients at three levels of kidney function: estimated glomerular filtration rate (eGFR) of more than 80 ml/min, 50 to 80 ml/min, and 50 ml/min or less. Event rates and associated utilities were obtained from previous literature. The model adopted the US health care system perspective, with hospitalization costs extracted from the Healthcare and Utilization Project. Treatment costs were obtained from official price lists. Univariate and probabilistic sensitivity analyses were performed to evaluate the robustness of results.

RESULTS

Apixaban was a dominant treatment strategy compared with warfarin in AF patients with eGFR levels of 50 ml/min or less and 50 to 80 ml/min. In patients with an eGFR of more than 80 ml/min, apixaban was cost-effective compared with warfarin, costing $6307 per quality-adjusted life-year gained. Results were consistent assuming anticoagulant discontinuation after major bleeding events. Compared with dabigatran and rivaroxaban, apixaban was the only cost-effective anticoagulant strategy relative to warfarin in both mild and moderate renal impairment settings.

CONCLUSIONS

Apixaban is a favorably cost-effective alternative to warfarin in AF patients with normal kidney function and potentially cost-saving in those with renal impairment.

Healthcare utilization and cost trajectories post-stroke: role of caregiver and stroke factors

BACKGROUND

It is essential to study post-stroke healthcare utilization trajectories from a stroke patient caregiver dyadic perspective to improve healthcare delivery, practices and eventually improve long-term outcomes for stroke patients. However, literature addressing this area is currently limited. Addressing this gap, our study described the trajectory of healthcare service utilization by stroke patients and associated costs over 1-year post-stroke and examined the association with caregiver identity and clinical stroke factors.

METHODS

Patient and caregiver variables were obtained from a prospective cohort, while healthcare data was obtained from the national claims database. Generalized estimating equation approach was used to get the population average estimates of healthcare utilization and cost trend across 4 quarters post-stroke.

RESULTS

Five hundred ninety-two stroke patient and caregiver dyads were available for current analysis. The highest utilization occurred in the first quarter post-stroke across all service types and decreased with time. The incidence rate ratio (IRR) of hospitalization decreased by 51, 40, 11 and 1% for patients having spouse, sibling, child and others as caregivers respectively when compared with not having a caregiver (p = 0.017). Disability level modified the specialist outpatient clinic usage trajectory with increasing difference between mildly and severely disabled sub-groups across quarters. Stroke type and severity modified the primary care cost trajectory with expected cost estimates differing across second to fourth quarters for moderately-severe ischemic (IRR: 1.67, 1.74, 1.64; p = 0.003), moderately-severe non-ischemic (IRR: 1.61, 3.15, 2.44; p = 0.001) and severe non-ischemic (IRR: 2.18, 4.92, 4.77; p = 0.032) subgroups respectively, compared to first quarter.

CONCLUSION

Highlighting the quarterly variations, we reported distinct utilization trajectories across subgroups based on clinical characteristics. Caregiver availability reducing hospitalization supports revisiting caregiver's role as potential hidden workforce, incentivizing their efforts by designing socially inclusive bundled payment models for post-acute stroke care and adopting family-centered clinical care practices.

Effect of Comorbidity Assessed by the Charlson Comorbidity Index on the Length of Stay, Costs and Mortality among Older Adults Hospitalised for Acute Stroke

The burden of comorbidity among stroke patients is high. The aim of this study was to examine the effect of comorbidity on the length of stay (LOS), costs, and mortality among older adults hospitalised for acute stroke. Among 776 older adults (mean age 80.1 ± 8.3 years; 46.7% female) hospitalised for acute stroke during July 2013 to December 2015 at a tertiary hospital in Melbourne, Australia, we collected data on LOS, costs, and discharge outcomes. Comorbidity was assessed via the Charlson Comorbidity Index (CCI), where a CCI score of 0⁻1 was considered low and a CCI ≥ 2 was high. Negative binomial regression and quantile regression were applied to examine the association between CCI and LOS and cost, respectively. Survival was evaluated with the Kaplan⁻Meier and Cox regression analyses. The median LOS was 1.1 days longer for patients with high CCI than for those with low CCI. In-hospital mortality rate was 18.2% (22.1% for high CCI versus 11.8% for low CCI, p < 0.0001). After controlling for confounders, high CCI was associated with longer LOS (incidence rate ratio [IRR]; 1.35, p < 0.0001) and increased likelihood of in-hospital death (hazard ratio [HR]; 1.91, p = 0.003). The adjusted median, 25th, and 75th percentile costs were AUD$2483 (26.1%), AUD$1446 (28.1%), and AUD$3140 (27.9%) higher for patients with high CCI than for those with low CCI. Among older adults hospitalised for acute stroke, higher global comorbidity (CCI ≥ 2) was associated adverse clinical outcomes. Measures to better manage comorbidities should be considered as part of wider strategies towards mitigating the social and economic impacts of stroke.

Annual costs attributed to atrial fibrillation management: cross-sectional study of primary healthcare electronic records

Atrial fibrillation (AF) is the most common chronic arrhythmia, with increasing healthcare and economic burden and a prevalence which increases with progressive ageing. This study aims to describe overall annual costs per patient for management of non-valvular AF in a primary healthcare (PHC) setting and compare these costs between the groups of patients treated with vitamin K antagonists, antiplatelets or non-treated through a population-based study conducted with electronic health records. We analysed annual costs per person of 19,787 patients in 2012; PHC visits, hospital admissions, AF-related events requiring hospital admission, referrals to secondary specialists, sick leave, diagnostic tests and laboratory tests at PHC level, including INR determinations performed in PHC, and drug therapy. Higher costs of AF management were associated with increasing age, male sex, stroke and bleeding risks, comorbidities and occurrence of events associated to AF. The sensitivity analyses conducted showed that PHC visits and hospitalizations represented the most important part of overall costs for all patients.

Event simulation and external validation applied in published health economic models for obesity: a systematic review

INTRODUCTION

This study aims to determine methodological variations in the event simulation approaches of published health economic decision models, in the field of obesity, and to investigate whether their predictiveness and validity were investigated via external event validation techniques, which investigate how well the model reproduces reality.

AREAS COVERED

A systematic review identified a total of 87 relevant papers, of which 72 that simulated obesity-associated events were included. Most frequently simulated events were coronary heart disease (≈ 83%), type 2 diabetes (≈ 74%), and stroke (≈ 66%). Only for ten published model-based health economic assessments in obesity an external event validation was performed (14%; 10 of 72), and only for one the predictiveness and validity of the event simulation was investigated in a cohort of obese subjects.

EXPERT COMMENTARY

We identified a wide range of obesity related event simulation approaches. Published obesity models lack information on the predictive quality and validity of the applied event simulation approaches. Further work on comparing and validating these event simulation approaches is required to investigate their predictiveness and validity, which will offer guidance future modelling in the field of obesity.

Costs, outcome and cost-effectiveness of neurocritical care: a multi-center observational study

BACKGROUND

Neurocritical illness is a growing healthcare problem with profound socioeconomic effects. We assessed differences in healthcare costs and long-term outcome for different forms of neurocritical illnesses treated in the intensive care unit (ICU).

METHODS

We used the prospective Finnish Intensive Care Consortium database to identify all adult patients treated for traumatic brain injury (TBI), intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH) and acute ischemic stroke (AIS) at university hospital ICUs in Finland during 2003-2013. Outcome variables were one-year mortality and permanent disability. Total healthcare costs included the index university hospital costs, rehabilitation hospital costs and social security costs up to one year. All costs were converted to euros based on the 2013 currency rate.

RESULTS

In total 7044 patients were included (44% with TBI, 13% with ICH, 27% with SAH, 16% with AIS). In comparison to TBI, ICH was associated with the highest risk of death and permanent disability (OR 2.6, 95% CI 2.1-3.2 and OR 1.7, 95% CI 1.4-2.1), followed by AIS (OR 1.9, 95% CI 1.5-2.3 and OR 1.5, 95% CI 1.3-1.8) and SAH (OR 1.8, 95% CI 1.5-2.1 and OR 0.8, 95% CI 0.6-0.9), after adjusting for severity of illness. SAH was associated with the highest mean total costs (€51,906) followed by ICH (€47,661), TBI (€43,916) and AIS (€39,222). Cost per independent survivor was lower for TBI (€58,497) and SAH (€96,369) compared to AIS (€104,374) and ICH (€178,071).

CONCLUSION

Neurocritical illnesses are costly and resource-demanding diseases associated with poor outcomes. Intensive care of patients with TBI or SAH more commonly result in independent survivors and is associated with lower total treatments costs compared to ICH and AIS.

Inpatient Cost of Stroke in Beijing: A Descriptive Analysis

BACKGROUND

Stroke has been the leading cause of death in China and contributed almost one-third to stroke deaths worldwide. The rising cost of stroke treatment is of great concern, but has not been thoroughly studied. This study aimed to analyze stroke in-hospital charges by subtypes, age, and sex and investigate potential factors associated with the cost of per stay.

METHODS

The research was a retrospective observational study based on patients with a primary diagnosis of stroke from 31 hospitals in Beijing. Characteristics of total treatment cost and cost of per stay were analyzed. The potential influences on hospital charges were explored using a stepwise multiple regression model.

RESULTS

A total of 16,111 stroke in-patient admissions were identified among which 8.3% was subarachnoid hemorrhage, 22.4% intracerebral hemorrhage, and 69.1% cerebral infarction. The average length of stay (LoS) was 14.5 (11.9) days. The cost of per stay was USD 4,423.9 (6,684.4) among which the out-of-pocket expenses were USD 1,640.2 (3,118.0). Stroke type, age, medical insurance, treatment results, and hospital level were significantly associated with the cost of stroke (p < 0.001).

CONCLUSION

Hospitalization cost of stroke was substantial. These findings provide health policymakers and healthcare professionals with evidence to help guide future spending.