1
|
Ma Y, Dai Y, Zhao Y, Song Z, Hu C, Zhang Y. Radiomics model based on dual-energy CT can determine the source of thrombus in strokes with middle cerebral artery occlusion. Neuroradiology 2024:10.1007/s00234-024-03422-y. [PMID: 38985319 DOI: 10.1007/s00234-024-03422-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Accepted: 06/29/2024] [Indexed: 07/11/2024]
Abstract
PURPOSE To develop thrombus radiomics models based on dual-energy CT (DECT) for predicting etiologic cause of stroke. METHODS We retrospectively enrolled patients with occlusion of the middle cerebral artery who underwent computed tomography (NCCT) and DECT angiography (DECTA). 70 keV virtual monoenergetic images (simulate conventional 120kVp CTA images) and iodine overlay maps (IOM) were reconstructed for analysis. Five logistic regression radiomics models for predicting cardioembolism (CE) were built based on the features extracted from NCCT, CTA and IOM images. From these, the best one was selected to integrate with clinical information for further construction of the combined model. The performance of the different models was evaluated and compared using ROC curve analysis, clinical decision curves (DCA), calibration curves and Delong test. RESULTS Among all the radiomic models, model NCCT+IOM performed the best, with AUC = 0.95 significantly higher than model NCCT, model CTA, model IOM and model NCCT+CTA in the training set (AUC = 0.88, 0.78, 0.90,0.87, respectively, P < 0.05), and AUC = 0.92 in the testing set, significantly higher than model CTA (AUC = 0.71, P < 0.05). Smoking and NIHSS score were independent predictors of CE (P < 0.05). The combined model performed similarly to the model NCCT+IOM, with no statistically significant difference in AUC either in the training or test sets. (0.96 vs. 0.95; 0.94 vs. 0.92, both P > 0.05). CONCLUSION Radiomics models constructed based on NCCT and IOM images can effectively determine the source of thrombus in stroke without relying on clinical information.
Collapse
Affiliation(s)
- Yuzhu Ma
- Department of Radiology, The Fourth Affiliated Hospital of Soochow University, Suzhou, 215124, China
| | - Yao Dai
- Department of Radiology, The Fourth Affiliated Hospital of Soochow University, Suzhou, 215124, China
| | - Ying Zhao
- Department of Radiology, The Fourth Affiliated Hospital of Soochow University, Suzhou, 215124, China
| | - Ziyang Song
- Department of Radiology, The Fourth Affiliated Hospital of Soochow University, Suzhou, 215124, China
| | - Chunhong Hu
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China
| | - Yu Zhang
- Department of Radiology, The Fourth Affiliated Hospital of Soochow University, Suzhou, 215124, China.
| |
Collapse
|
2
|
Pinckaers FM, Evers SM, Olthuis SG, Boogaarts HD, Postma AA, van Oostenbrugge RJ, van Zwam WH, Grutters JP. Cost-effectiveness of endovascular treatment after 6-24 h in ischaemic stroke patients with collateral flow on CT-angiography: A model-based economic evaluation of the MR CLEAN-LATE trial. Eur Stroke J 2024; 9:348-355. [PMID: 38153049 DOI: 10.1177/23969873231220464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023] Open
Abstract
BACKGROUND The MR CLEAN-LATE trial has shown that patient selection for endovascular treatment (EVT) in the late window (6-24 h after onset or last-seen-well) based on the presence of collateral flow on CT-angiography is safe and effective. We aimed to assess the cost-effectiveness of late-window collateral-based EVT-selection compared to best medical management (BMM) over a lifetime horizon (until 95 years of age). MATERIALS AND METHODS A model-based economic evaluation was performed from a societal perspective in The Netherlands. A decision tree was combined with a state-transition (Markov) model. Health states were defined by the modified Rankin Scale (mRS). Initial probabilities at 3-months post-stroke were based on MR CLEAN-LATE data. Transition probabilities were derived from previous literature. Information on short- and long-term resource use and utilities was obtained from a study using MR CLEAN-LATE and cross-sectional data. All costs are expressed in 2022 euros. Costs and quality-adjusted life years (QALYs) were discounted at a rate of 4% and 1.5%, respectively. The effect of parameter uncertainty was assessed using probabilistic sensitivity analysis (PSA). RESULTS On average, the EVT strategy cost €159,592 (95% CI: €140,830-€180,154) and generated 3.46 QALYs (95% CI: 3.04-3.90) per patient, whereas the costs and QALYs associated with BMM were €149,935 (95% CI: €130,841-€171,776) and 2.88 (95% CI: 2.48-3.29), respectively. The incremental cost-effectiveness ratio per QALY and the incremental net monetary benefit were €16,442 and €19,710, respectively. At a cost-effectiveness threshold of €50,000/QALY, EVT was cost-effective in 87% of replications. DISCUSSION AND CONCLUSION Collateral-based selection for late-window EVT is likely cost-effective from a societal perspective in The Netherlands.
Collapse
Affiliation(s)
- Florentina Me Pinckaers
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
- Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Silvia Maa Evers
- Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
- Department of Health Services Research, Maastricht University, Maastricht, The Netherlands
- Centre of Economic Evaluation and Machine Learning, Trimbos Institute, Utrecht, The Netherlands
| | - Susanne Gh Olthuis
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Neurology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | - Alida A Postma
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
- School for Mental Health and Neuroscience (MHENS), Maastricht University, Maastricht, The Netherlands
| | - Robert J van Oostenbrugge
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Neurology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Wim H van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
| | | |
Collapse
|
3
|
Checkouri T, Sablot D, Varnier Q, Fryder I, Collemiche FL, Azais B, Dargazanli C, Leibinger F, Cagnazzo F, Mahmoudi M, Lefevre PH, Van Damme L, Gascou G, Schmidt J, Arquizan C, Plantard C, Farouil G, Costalat V. Becoming a thrombectomy-capable stroke center: Clinical and medico-economical effectiveness at the hospital level. Eur Stroke J 2024:23969873241254239. [PMID: 38760934 DOI: 10.1177/23969873241254239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2024] Open
Abstract
INTRODUCTION Too few patients benefit from endovascular therapy (EVT) in large vessel occlusion acute stroke (LVOS), and various acute stroke care paradigms are currently investigated to reduce these inequalities in health access. We aimed to investigate whether newly set-up thrombectomy-capable stroke centers (TSC) offered a safe, effective and cost-effective procedure. PATIENTS AND METHODS This French retrospective study compared the outcomes of LVOS patients with an indication for EVT and treated at the Perpignan hospital before on-site thrombectomy was available (Primary stroke center), and after formation of local radiology team for neurointervention (TSC). Primary endpoints were 3-months functional outcomes, assessed by the modified Rankin scale. Various safety endpoints for ischemic and hemorragic procedural complications were assessed. We conducted a medico-economic analysis to estimate the cost-benefit of becoming a TSC for the hospital. RESULTS The differences between 422 patients in the PSC and 266 in the TSC were adjusted by the means of weighted logistic regression. Patients treated in the TSC had higher odds of excellent functional outcome (aOR 1.77 [1.16-2.72], p = 0.008), with no significant differences in the rates of procedural complications. The TSC setting shortened onset-to-reperfusion times by 144 min (95% CI [131-155]; p < 0.0001), and was cost-effective after 21 treated LVOS patients. On-site thrombectomy saves 10.825€ per patient for the hospital. DISCUSSION Our results demonstrate that the TSC setting improves functional outcomes and reduces intra-hospital costs in LVOS patients. TSCs could play a major public health role in acute stroke care and access to EVT.
Collapse
Affiliation(s)
- Thomas Checkouri
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France
| | - Denis Sablot
- Department of Neurology, St. Jean Hospital, Perpignan, France
| | - Quentin Varnier
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France
| | - Ivan Fryder
- Department of Radiology, St. Jean Hospital, Perpignan, France
| | | | - Benoit Azais
- Department of Radiology, St. Jean Hospital, Perpignan, France
| | - Cyril Dargazanli
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France
| | | | - Federico Cagnazzo
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France
| | - Mehdi Mahmoudi
- Department of Radiology, St. Jean Hospital, Perpignan, France
| | | | | | - Gregory Gascou
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France
| | - Julia Schmidt
- Department of Neurology, St. Jean Hospital, Perpignan, France
| | - Caroline Arquizan
- Department of Neurology, Hôpital Gui de Chauliac, Montpellier, France
| | - Carole Plantard
- Department of Neurology, St. Jean Hospital, Perpignan, France
| | | | - Vincent Costalat
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France
| |
Collapse
|
4
|
Shlobin NA, Regenhardt RW, Young MJ. Ethical Considerations in Endovascular Thrombectomy for Stroke. World Neurosurg 2024; 185:126-134. [PMID: 38364896 DOI: 10.1016/j.wneu.2024.02.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 02/07/2024] [Accepted: 02/08/2024] [Indexed: 02/18/2024]
Abstract
INTRODUCTION Stroke is a leading cause of morbidity and mortality globally. Endovascular mechanical thrombectomy is considered for patients with large vessel occlusion stroke presenting up to 24 hours from onset and is being increasingly utilized across diverse clinical contexts. Proactive consideration of distinctive ethical dimensions of endovascular thrombectomy (EVT) can enable stroke care teams to deliver goal-concordant care to appropriately selected patients with stroke but have been underexplored. METHODS A narrative review with case examples was conducted. RESULTS We explain and critically evaluate the application of foundational bioethical principles and narrative ethics to the practice of EVT, highlight key ethical issues that may emerge in neuroendovascular practice and develop an ethical framework to aid in the responsible use of EVT for people with large-vessel occlusive ischemic stroke. CONCLUSIONS EVT for stroke introduces important ethical considerations. Salient challenges include decision-making capacity and informed consent, the telos of EVT, uncertainty, access to care, and resource allocation. An ethical framework focusing on combining patient values and preferences with the best available evidence in the context of a multidisciplinary care team is essential to ensure that the benefits of EVT are responsibly achieved and sustained.
Collapse
Affiliation(s)
- Nathan A Shlobin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
| | - Robert W Regenhardt
- Departments of Neurosurgery and Neurology, Neuroendovascular Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael J Young
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
5
|
Aslan A, Abuzahra S, Adeeb N, Musmar B, Salim HA, Kandregula S, Dmytriw AA, Griessenauer CJ, De Alba L, Arevalo O, Burkhardt JK, Pereira VM, Jabbour P, Guthikonda B, Cuellar HH. The feasibility of mechanical thrombectomy versus medical management for acute stroke with a large ischemic territory. J Neurointerv Surg 2024:jnis-2023-021368. [PMID: 38471764 DOI: 10.1136/jnis-2023-021368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 02/14/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND Mechanical thrombectomy (MT) for acute ischemic stroke is generally avoided when the expected infarction is large (defined as an Alberta Stroke Program Early CT Score of <6). OBJECTIVE To perform a meta-analysis of recent trials comparing MT with best medical management (BMM) for treatment of acute ischemic stroke with large infarction territory, and then to determine the cost-effectiveness associated with those treatments. METHODS A meta-analysis of the RESCUE-Japan, SELECT2, and ANGEL-ASPECT trials was conducted using R Studio. Statistical analysis employed the weighted average normal method for calculating mean differences from medians in continuous variables and the risk ratio for categorical variables. TreeAge software was used to construct a cost-effectiveness analysis model comparing MT with BMM in the treatment of ischemic stroke with large infarction territory. RESULTS The meta-analysis showed significantly better functional outcomes, with higher rates of patients achieving a modified Rankin Scale score of 0-3 at 90 days with MT as compared with BMM. In the base-case analysis using a lifetime horizon, MT led to a greater gain in quality-adjusted life-years (QALYs) of 3.46 at a lower cost of US$339 202 in comparison with BMM, which led to the gain of 2.41 QALYs at a cost of US$361 896. The incremental cost-effectiveness ratio was US$-21 660, indicating that MT was the dominant treatment at a willingness-to-pay of US$70 000. CONCLUSIONS This study shows that, besides having a better functional outcome at 90-days' follow-up, MT was more cost-effective than BMM, when accounting for healthcare cost associated with treatment outcome.
Collapse
Affiliation(s)
- Assala Aslan
- Department of Radiology, Louisiana State University Shreveport, Shreveport, Louisiana, USA
| | - Saad Abuzahra
- Department of Radiology, Louisiana State University Shreveport, Shreveport, Louisiana, USA
| | - Nimer Adeeb
- Department of Neurosurgery, Louisiana State University Health Sciences Center Shreveport, Shreveport, Louisiana, USA
| | - Basel Musmar
- Department of Neurosurgery, Louisiana State University Health Sciences Center Shreveport, Shreveport, Louisiana, USA
| | - Hamza A Salim
- Department of Neurosurgery, Louisiana State University Health Sciences Center Shreveport, Shreveport, Louisiana, USA
| | - Sandeep Kandregula
- Department of Neurosurgery, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Boston, Massachusetts, USA
- Divisions of Therapeutic Neuroradiology & Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Christoph J Griessenauer
- Department of Neurosurgery, Christian Doppler University Hospital & Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | - Luis De Alba
- Department of Radiology, Louisiana State University Shreveport, Shreveport, Louisiana, USA
| | - Octavio Arevalo
- Department of Radiology, Louisiana State University Shreveport, Shreveport, Louisiana, USA
| | - Jan Karl Burkhardt
- Department of Neurosurgery, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Vitor M Pereira
- Divisions of Therapeutic Neuroradiology & Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Bharat Guthikonda
- Department of Neurosurgery, Louisiana State University Health Sciences Center Shreveport, Shreveport, Louisiana, USA
| | - Hugo H Cuellar
- Department of Radiology, Louisiana State University Shreveport, Shreveport, Louisiana, USA
- Department of Neurosurgery, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
6
|
Jain B, Rahim FO, Thirumala PD, McGarvey ML, Balzer J, Nogueira RG, van der Goes DN, de Havenon A, Sultan I, Ney J. Cost-benefit analysis of intraoperative neuromonitoring for cardiac surgery. J Stroke Cerebrovasc Dis 2024; 33:107576. [PMID: 38232584 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 12/25/2023] [Accepted: 01/11/2024] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND Intraoperative neuromonitoring (IONM) can detect large vessel occlusion (LVO) in real-time during surgery. The aim of this study was to conduct a cost-benefit analysis of utilizing IONM among patients undergoing cardiac surgery. METHODS A decision-analysis tree with terminal Markov nodes was constructed to model functional outcome, as measured via the modified Rankin Scale (mRS), among 65-year-old patients undergoing cardiac surgery. Our cost-benefit analysis compares the use of IONM (electroencephalography and somatosensory evoked potential) against no IONM in preventing neurological complications from perioperative LVO during cardiac surgery. The study was performed over a lifetime horizon from a societal perspective in the United States. Base case and one-way probabilistic sensitivity analyses were performed. RESULTS At a baseline LVO rate of 0.31%, the mean attributable lifetime expenditure for IONM-monitored cardiac surgeries relative to unmonitored cardiac surgeries was $1047.41 (95% CI, $742.12 - $1445.10). At a critical LVO rate of approximately 3.67%, the costs of both monitored and unmonitored cardiac surgeries were the same. Above this critical rate, implementing IONM became cost-saving. On one-way sensitivity analysis, variation in LVO rate from 0% - 10% caused lifetime costs attributable to receiving IONM to range from $1150.47 - $29404.61; variations in IONM cost, percentage of intervenable LVOs, IONM sensitivity, and mechanical thrombectomy cost exerted comparably minimal influence over lifetime costs. DISCUSSION We find considerable cost savings favoring the use of IONM under certain parameters corresponding to high-risk patients. This study will provide financial perspective to policymakers, clinicians, and patients alike on the appropriate use of IONM during cardiac surgery.
Collapse
Affiliation(s)
- Bhav Jain
- Stanford University School of Medicine, Stanford, CA, United States; Massachusetts Institute of Technology, Cambridge, MA, United States
| | | | - Parthasarathy D Thirumala
- Department of Neurological Surgery and Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Michael L McGarvey
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, United States
| | - Jeffrey Balzer
- Department of Neurological Surgery and Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Raul G Nogueira
- Department of Neurological Surgery and Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States; UPMC Stroke Institute, Pittsburgh, PA, United States
| | - David N van der Goes
- Department of Economics, University of New Mexico, Albuquerque, NM, United States
| | - Adam de Havenon
- Department of Neurology, Yale University, New Haven, CT, United States
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, United States; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - John Ney
- Department of Neurology, Boston University School of Medicine, Boston, MA, United States; West Haven VA Medical Center, West Haven, CT, United States.
| |
Collapse
|
7
|
Ospel JM, Zerna C, Harrison E, Kleinig TJ, Puetz V, Kaiser DPO, Graham B, Yu AYX, van Adel B, Shankar JJ, McTaggart RA, Pereira V, Frei DF, Kunz WG, Goyal M, Hill MD. Cost-Effectiveness of Late Endovascular Thrombectomy vs. Best Medical Management in a Clinical Trial Setting and Real-World Setting. Can J Neurol Sci 2024:1-8. [PMID: 38403588 DOI: 10.1017/cjn.2024.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
BACKGROUND AND PURPOSE To assess cost-effectiveness of late time-window endovascular treatment (EVT) in a clinical trial setting and a "real-world" setting. METHODS Data are from the randomized ESCAPE trial and a prospective cohort study (ESCAPE-LATE). Anterior circulation large vessel occlusion patients presenting > 6 hours from last-known-well were included, whereby collateral status was an inclusion criterion for ESCAPE but not ESCAPE-LATE. A Markov state transition model was built to estimate lifetime costs and quality-adjusted life-years (QALYs) for EVT in addition to best medical care vs. best medical care only in a clinical trial setting (comparing ESCAPE-EVT to ESCAPE control arm patients) and a "real-world" setting (comparing ESCAPE-LATE to ESCAPE control arm patients). We performed an unadjusted analysis, using 90-day modified Rankin Scale(mRS) scores as model input and analysis adjusted for baseline factors. Acceptability of EVT was calculated using upper/lower willingness-to-pay thresholds of 100,000 USD/50,000 USD/QALY. RESULTS Two-hundred and forty-nine patients were included (ESCAPE-LATE:n = 200, ESCAPE EVT-arm:n = 29, ESCAPE control-arm:n = 20). Late EVT in addition to best medical care was cost effective in the unadjusted analysis both in the clinical trial and real-world setting, with acceptability 96.6%-99.0%. After adjusting for differences in baseline variables between the groups, late EVT was marginally cost effective in the clinical trial setting (acceptability:49.9%-61.6%), but not the "real-world" setting (acceptability:32.9%-42.6%). CONCLUSION EVT for LVO-patients presenting beyond 6 hours was cost effective in the clinical trial setting and "real-world" setting, although this was largely related to baseline patient differences favoring the "real-world" EVT group. After adjusting for these, EVT benefit was reduced in the trial setting, and absent in the real-world setting.
Collapse
Affiliation(s)
- Johanna Maria Ospel
- Department of Diagnostic Imaging, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
| | - Charlotte Zerna
- Department of Neurology, Städtisches Klinikum Dresden, Dresden, Germany
| | - Emma Harrison
- Department of Neurology, Princess Alexandra Hospital, Brisbane, QL, Australia
| | - Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, Australia
| | - Volker Puetz
- Department of Neurology, Technical University Dresden, Dresden, Germany
| | - Daniel P O Kaiser
- Department of Neurology, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Brett Graham
- Department of Neurology, Royal University Hospital of Saskatchewan, Saskatoon, Canada
| | - Amy Y X Yu
- Department of Neurology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Canada
| | - Brian van Adel
- Division of Neurology, Neurosurgery and Diagnostic Imaging, Hamilton General Hospital, McMaster University, Hamilton, Canada
| | - Jai J Shankar
- Department of Neurology, University of Manitoba, Winnipeg, Canada
| | - Ryan A McTaggart
- Department of Radiology, Rhode Island Hospital, Providence, RI, USA
| | - Vitor Pereira
- Department of Neurosurgery, St Michaels Hospital, University of Toronto, Toronto, Canada
| | | | - Wolfgang G Kunz
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Mayank Goyal
- Department of Diagnostic Imaging, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
| | - Michael D Hill
- Department of Diagnostic Imaging, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
| |
Collapse
|
8
|
Wang L, Zeng Y, Zhou L, Xu P, Guo X, Xie Y, Cai J, Pan M, Tang J, Gong Q, Su R, Liu Y, Lou Y. Cost-effectiveness of tirofiban for acute ischemic stroke without large or medium-sized vessel occlusion: A Markov modelling analysis from the Chinese and United States perspectives. PLoS One 2024; 19:e0297939. [PMID: 38363737 PMCID: PMC10871502 DOI: 10.1371/journal.pone.0297939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 01/14/2024] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND The RESCUE BT2 trial recently showcased the efficacy of tirofiban in treating acute ischemic stroke (AIS) without large or medium-sized vessel occlusion. To further assess the value of tirofiban from the perspectives of Chinese and US healthcare system, a study was conducted to evaluate its cost-effectiveness. METHODS A hybrid model, integrating a short-term decision tree with a long-term Markov model, was developed to assess cost-effectiveness between tirofiban and aspirin for stroke patients without large or medium-sized vessel occlusion. Efficacy data for tirofiban was sourced from the RESCUE BT2 trial, while cost information was derived from published papers. Outcomes measured included respective cost, effectiveness, and incremental cost-effectiveness ratio (ICER). We conducted a one-way sensitivity analysis to assess the robustness of the results. Additionally, we performed probabilistic sensitivity analysis (PSA) through 10,000 Monte Carlo simulations to evaluate the uncertainties associated with the results. RESULTS The study revealed that tirofiban treatment in AIS patients without large or medium-sized vessel occlusion led to a considerable reduction of 2141 Chinese Yuan (CNY) in total cost, along with a lifetime gain of 0.14 quality-adjusted life years (QALYs). In the US settings, tirofiban also exhibited a lower cost ($197,055 versus $201,984) and higher effectiveness (4.15 QALYs versus 4.06 QALYs) compared to aspirin. One-way sensitivity analysis revealed that post-stroke care costs and stroke utility had the greatest impact on ICER fluctuation in both Chinese and US settings. However, these variations did not exceed the willingness-to-pay threshold. PSA demonstrated tirofiban's superior acceptability over aspirin in over 95% of potential scenarios. CONCLUSION Tirofiban treatment for AIS without large or medium-sized vessel occlusion appeared dominant compared to aspirin in both China and the US.
Collapse
Affiliation(s)
- Li Wang
- Department of Neurology, Zigong Third People’s Hospital, Zigong, China
| | - Yuhong Zeng
- Department of Epidemiology, College of Preventive Medicine, Army Medical University (Third Military Medical University), Chongqing, People’s Republic of China
- Evidence-based Medicine and Clinical Epidemiology Center, Army Medical University (Third Military Medical University), Chongqing, People’s Republic of China
| | - Limei Zhou
- Department of Neurology, Zigong Third People’s Hospital, Zigong, China
| | - Ping Xu
- Department of Neurology, Zigong Third People’s Hospital, Zigong, China
| | - Xianbin Guo
- Department of Neurology, Zigong Third People’s Hospital, Zigong, China
| | - Yu Xie
- Department of Neurology, Zigong Third People’s Hospital, Zigong, China
| | - Junxiu Cai
- Department of Neurology, Zigong Third People’s Hospital, Zigong, China
| | - Min Pan
- Department of Neurology, Zigong Third People’s Hospital, Zigong, China
| | - Jie Tang
- Department of Neurology, Zigong Third People’s Hospital, Zigong, China
| | - Qingtao Gong
- Department of Neurology, Zigong Third People’s Hospital, Zigong, China
| | - Rong Su
- Department of Neurology, Zigong Third People’s Hospital, Zigong, China
| | - Yan Liu
- Department of Neurology, Zigong Third People’s Hospital, Zigong, China
| | - Yake Lou
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| |
Collapse
|
9
|
O’Cearbhaill RM, O’Herlihy F, Herlihy D, Alderson J, Brennan P, Power S, O’Hare A, Thornton J. Standardised aspiration first approach reduces materials used and cost of thrombectomy procedure in anterior circulation large vessel occlusion stoke. Interv Neuroradiol 2023; 29:648-654. [PMID: 36069045 PMCID: PMC10680961 DOI: 10.1177/15910199221125101] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 08/23/2022] [Indexed: 11/15/2022] Open
Abstract
PURPOSE The aim of this study is to compare the volume of equipment and equipment costs in a cohort of consecutive patients with anterior circulation large vessel occlusion treated with a standardised aspiration first approach to those treated with a stent retriever first approach. METHODS The equipment used in each case was recorded from a prospectively maintained equipment log. We then compared the volume of equipment used in each group. The cost of this equipment was calculated for each group based on local prices. Estimated equipment costs were then compared. RESULTS Our patient cohort consisted of 127 consecutive patients who were treated with a non-standardised stent retriever first technique (group A), 127 consecutive patients who underwent a new standardised aspiration first technique (group B), and 126 consecutive patients reflecting more recent practise where an aspiration first approach has been an established practise in our department (group C).Standardised aspiration first approach results in reduced equipment usage in thrombectomy procedures. The total equipment cost per case in the stent retriever first group (group A) was significantly higher at €4726.4 ($4818.3) versus €3093.1 ($3153.2) in the aspiration first group (group B), a reduction of 34.6% and €2798.5 ($2852.9) in the current practise group (group C), a reduction of 40.8%. There was no statistically significant difference in cost between groups B and C (p = 0.57). CONCLUSION The standardised aspiration first technique utilised a reduced volume of equipment and confers a 40.8% reduced cost per procedure compared to a stent retriever first approach.
Collapse
Affiliation(s)
| | | | | | - Jack Alderson
- Department of Radiology, Beaumont Hospital, Dublin, Ireland
| | - Paul Brennan
- Department of Radiology, Beaumont Hospital, Dublin, Ireland
| | - Sarah Power
- Department of Radiology, Beaumont Hospital, Dublin, Ireland
| | - Alan O’Hare
- Department of Radiology, Beaumont Hospital, Dublin, Ireland
| | - John Thornton
- Department of Radiology, Beaumont Hospital, Dublin, Ireland
| |
Collapse
|
10
|
Xia H, Yang Q, Wang Q, Jia J, Liu X, Meng S. Economic evaluation of stent retrievers in basilar artery occlusion: An analysis from Chinese healthcare system perspective. PLoS One 2023; 18:e0294929. [PMID: 38033030 PMCID: PMC10688905 DOI: 10.1371/journal.pone.0294929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 11/11/2023] [Indexed: 12/02/2023] Open
Abstract
PURPOSE This study aimed to investigate the cost-effectiveness of stent retriever (SR) versus best medical management (BMM) in patients with basilar artery occlusion (BAO) in China. METHODS We used a two-step approach to compare the cost-effectiveness of SR plus BMM with that of BMM alone over 20 years. A decision tree was initially constructed for the first 3 months, followed by a Markov model for the subsequent period. Collected data on clinical aspects were extracted from the BAOCHE investigation, while costs-related information was sourced from previously published research. The key metric for evaluating the primary outcome was the incremental cost-effectiveness ratio (ICER), achieved $/QALY. The threshold for identifying SR as highly cost-effective was set at an ICER below $12,551/QALY, SR was deemed cost-effective if the ICER ranged from $12,551 to $37,654 per QALY. Uncertainty was addressed using scenario, one-way sensitivity, and probabilistic sensitivity analyses (PSA). FINDINGS For Chinese patients with BAO, the 20-year cost per patient was $8678 with BMM alone and $21,988 for SR plus BMM. Effectiveness was 1.45 QALY for BMM alone, and 2.77 QALY for SR plus BMM. The ICER of SR + BMM versus BMM alone was $10,050 per QALY. The scenario and one-way sensitivity analyses revealed that in certain situations the ICER could exceed $12,551 per QALY, but remain below $37,654 per QALY. Results from the PSA suggested that SR was likely to be cost-effective for Chinese patients with BAO, with a probability exceeding 98% when considering a willingness-to-pay (WTP) threshold of $12,551 per QALY. IMPLICATIONS Our study indicates that SR is an intervention option that is highly likely to be cost-effective for Chinese patients with BAO, with a probability of over 98% under the current WTP threshold of $12,551 per QALY.
Collapse
Affiliation(s)
- Hailong Xia
- Department of Neurosurgery, Chongqing Red Cross Hospital(Jiangbei District People’s Hospital), Chongqing, China
| | - Qi Yang
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qibo Wang
- Department of Neurosurgery, Chongqing Red Cross Hospital(Jiangbei District People’s Hospital), Chongqing, China
| | - Jielin Jia
- Department of Neurosurgery, Chongqing Red Cross Hospital(Jiangbei District People’s Hospital), Chongqing, China
| | - Xipeng Liu
- Department of Orthopaedic, Chongqing Red Cross Hospital(Jiangbei District People’s Hospital), Chongqing, China
| | - Shu Meng
- Internal medicine department, Chongqing Red Cross Hospital(Jiangbei District People’s Hospital), Chongqing, China
| |
Collapse
|
11
|
Sanmartin MX, Katz JM, Wang J, Malhotra A, Sangha K, Bastani M, Martinez G, Sanelli PC. Cost-effectiveness of endovascular thrombectomy in acute stroke patients with large ischemic core. J Neurointerv Surg 2023; 15:e166-e171. [PMID: 36175016 DOI: 10.1136/jnis-2022-019460] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 09/14/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Evidence has shown that endovascular thrombectomy (EVT) treatment improves clinical outcomes. Yet, its benefit remains uncertain in patients with large established infarcts as defined by ASPECTS (Alberta Stroke Program Early CT Score) <6. This study evaluates the cost-effectiveness of EVT, compared with standard care (SC), in acute ischemic stroke (AIS) patients with ASPECTS 3-5. METHODS An economic evaluation study was performed combining a decision tree and Markov model to estimate lifetime costs (2021 US$) and quality-adjusted life years (QALYs) of AIS patients with ASPECTS 3-5. Incremental cost-effectiveness ratios (ICERs), net monetary benefits (NMBs), and deterministic one-way and two-way sensitivity analyses were performed. Probabilistic sensitivity analyses were also performed to evaluate the robustness of our model. RESULTS Compared with SC, the cost-effectiveness analyses revealed that EVT yields higher lifetime benefits (2.20 QALYs vs 1.41 QALYs) with higher lifetime healthcare cost per patient ($285 861 vs $272 954). The difference in health benefits between EVT and SC was 0.79 QALYs, equivalent to 288 additional days of healthy life per patient. Even though EVT is more costly than SC alone, it is still cost-effective given better outcomes with ICER of $16 239/QALY. The probabilistic sensitivity analyses indicated that EVT was the most cost-effective strategy in 98.8% (9882 of 10 000) of iterations at the willingness-to-pay threshold of $100 000 per QALY. CONCLUSIONS The results of this study suggest that EVT is cost-effective in AIS patients with a large ischemic core (ASPECTS 3-5), compared with SC alone over the patient's lifetime.
Collapse
Affiliation(s)
- Maria X Sanmartin
- Siemens Healthineers USA, Malvern, Pennsylvania, USA
- Imaging Clinical Effectiveness and Outcomes Research, Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Jeffrey M Katz
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
- Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| | - Jason Wang
- Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| | - Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Kinpritma Sangha
- Siemens Healthineers USA, Malvern, Pennsylvania, USA
- Imaging Clinical Effectiveness and Outcomes Research, Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Mehrad Bastani
- Imaging Clinical Effectiveness and Outcomes Research, Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Gabriela Martinez
- Imaging Clinical Effectiveness and Outcomes Research, Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Pina C Sanelli
- Imaging Clinical Effectiveness and Outcomes Research, Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, New York, USA
- Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| |
Collapse
|
12
|
Wang L, Yu Y, Zhou L, Xu P, Guo X, Xie Y, Cai J, Pan M, Tang J, Gong Q, Su R, Lou Y, Liu Y. Endovascular treatment for basilar artery occlusion: a cost-effectiveness analysis based on a meta-analysis. Front Neurol 2023; 14:1267554. [PMID: 37928158 PMCID: PMC10623329 DOI: 10.3389/fneur.2023.1267554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 09/28/2023] [Indexed: 11/07/2023] Open
Abstract
Objective This study aimed to investigate the efficacy and economic effect of endovascular treatment (EVT) combined with standard medical treatment (SMT) vs. SMT alone in Chinese patients with basilar artery occlusion (BAO) from the perspective of the Chinese healthcare system. Methods We conducted a cost-effectiveness analysis using the results from a meta-analysis comparing EVT and SMT efficacy in Chinese patients with BAO-induced stroke using direct medical costs from the China National Stroke Registry. The meta-analysis's primary outcome was excellent functional outcome (mRS scores of 0-2), with secondary outcomes being poor functional outcome (mRS scores of 3-5) and death (mRS score of 6). To compare EVT plus SMT's cost-effectiveness with that of SMT alone, we constructed a combined decision tree and Markov model with a lifetime duration and a 3-month cycle length. The primary cost-effectiveness outcome was the incremental cost-effectiveness ratio (ICER), representing the incremental cost per incremental quality-adjusted life year (QALY). EVT was considered cost-effective if the ICER was lower than the willingness-to-pay (WTP) threshold of three times the per capita gross domestic product (GDP) in 2021 in China; otherwise, it would not be cost-effective. Results The meta-analysis results indicated that EVT could increase the incidence of excellent functional outcomes, with a risk ratio (RR) of 2.23 (95% confidence interval, CI, 1.18-4.21), p = 0.01. Simultaneously, EVT reduced the risk of poor functional outcome and mortality in the EVT group, with RRs of 0.83 (95% CI, 0.67-1.03), p = 0.09, and 0.71 (95% CI, 0.59-0.85), p = 0.0002, respectively. The study also found that EVT plus SMT resulted in a lifetime effectiveness of 2.15 QALY (3.88 life years) for 32,213 international dollars (Intl.$) per patient with BAO. In contrast, SMT alone achieved an effectiveness of 1.46 QALY (3.03 life years) with a total cost of Intl.$ 13,592 per patient. The ICER was Intl.$ 27,265 per QALY (Intl.$ 22,098 per life-year), which fell below the WTP threshold. Conclusion Compared to SMT, EVT improves the prognosis of BAO-induced stroke. Considering the Chinese healthcare system, adding EVT to SMT proves to be cost-effective for patients with BAO compared to SMT alone.
Collapse
Affiliation(s)
- Li Wang
- Department of Neurology, Zigong Third People’s Hospital, Zigong, China
| | - Ying Yu
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Limei Zhou
- Department of Neurology, Zigong Third People’s Hospital, Zigong, China
| | - Ping Xu
- Department of Neurology, Zigong Third People’s Hospital, Zigong, China
| | - Xianbin Guo
- Department of Neurology, Zigong Third People’s Hospital, Zigong, China
| | - Yu Xie
- Department of Neurology, Zigong Third People’s Hospital, Zigong, China
| | - Junxiu Cai
- Department of Neurology, Zigong Third People’s Hospital, Zigong, China
| | - Min Pan
- Department of Neurology, Zigong Third People’s Hospital, Zigong, China
| | - Jie Tang
- Department of Neurology, Zigong Third People’s Hospital, Zigong, China
| | - Qingtao Gong
- Department of Neurology, Zigong Third People’s Hospital, Zigong, China
| | - Rong Su
- Department of Neurology, Zigong Third People’s Hospital, Zigong, China
| | - Yake Lou
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yan Liu
- Department of Neurology, Zigong Third People’s Hospital, Zigong, China
| |
Collapse
|
13
|
Ren Z, Wangqin R, Demiraj F, Li W, Mokin M, Wang A, Miao Z, Wang Y, Burgin WS. Derivation and validation of a predictive scale to expedite endovascular intervention for acute stroke patients with an intervenable vessel occlusion. J Neurointerv Surg 2023:jnis-2023-020871. [PMID: 37734930 DOI: 10.1136/jnis-2023-020871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 08/27/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Early endovascular intervention team mobilization may reduce reperfusion times and improve clinical outcomes for patients with acute ischemic stroke (AIS) with a possible intervenable vessel occlusion (IVO). In an emergency department or mobile stroke unit, incorporating rapidly available non-contrast CT (NCCT) information with examination findings may improve the accuracy of arterial occlusion prediction scales. For this purpose, we developed a rapid and straightforward IVO predictive instrument-the T3AM2PA1 scale. METHODS The T3AM2PA1 scale was retrospectively derived from our 'Get with the Guidelines' database. We included all patients with acute stroke alert between January 2017 and August 2018 with a National Institutes of Health Stroke Scale (NIHSS) score between 5 and 25 inclusive. Different pre-intervention variables were collected, including itemized NIHSS and NCCT information. The T3AM2PA1 scale was also compared with other commonly used scales and was validated in a separate sequential retrospective cohort of patients with a full range of NIHSS scores. RESULTS 574 eligible patients from 2115 acute stroke alerts were identified. The scale was established with five items (CT hyperdense sign, parenchymal hypodensity, lateralizing hemiparesis, gaze deviation, and language disturbance), with a total score of 9. To minimize unnecessary angiography, a cut-off of ≥5 for IVO detection yielded a sensitivity of 52%, a specificity of 90%, and a positive predictive value of 76%. CONCLUSIONS The T3AM2PA1 scale accurately predicts the presence of clinical IVO in patients with AIS. Adopting the T3AM2PA1 scale could reduce revascularization times, improve treatment outcomes, and potentially reduce disability.
Collapse
Affiliation(s)
- Zeguang Ren
- Department of Neurosurgery, the Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Runqi Wangqin
- Duke Clinical Research Institute, Duke Univeristy Medical Center, Durham, North Carolina, USA
| | - Francis Demiraj
- Department of Neurology, FAU Schmidt College of Medicine, Boca Raton, Florida, USA
| | - Weizhe Li
- Department of Neurology, Duke University, Durham, North Carolina, USA
| | - Maxim Mokin
- Department of Neurosurgery and Neurology, University of South Florida, Tampa, Florida, USA
| | - Anxin Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Zhongrong Miao
- Department of Neurological Intervention, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yongjun Wang
- China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, China
| | - W Scott Burgin
- Department of Neurology, University of South Florida, Tampa, Florida, USA
| |
Collapse
|
14
|
Nguyen CP, Lahr MMH, van der Zee DJ, van Voorst H, Roos YBWEM, Uyttenboogaart M, Buskens E. Cost-effectiveness of tenecteplase versus alteplase for acute ischemic stroke. Eur Stroke J 2023; 8:638-646. [PMID: 37641549 PMCID: PMC10472948 DOI: 10.1177/23969873231174943] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 04/24/2023] [Indexed: 08/31/2023] Open
Abstract
INTRODUCTION Alteplase is widely used as an intravenous thrombolytic drug in acute ischemic stroke (AIS). Recently however, tenecteplase, a modified form of tissue plasminogen activator, has been shown to increase early recanalization rate and has proven to be non-inferior with a similar safety profile compared to alteplase. This study aims to evaluate the cost-effectiveness of 0.25 mg/kg tenecteplase versus 0.9 mg/kg alteplase for intravenous thrombolysis in AIS patients from the Dutch healthcare payer perspective. METHODS A Markov decision-analytic model was constructed to assess total costs, total quality-adjusted life year (QALY), an incremental cost-effectiveness ratio, and incremental net monetary benefit (INMB) of two treatments at willingness-to-pay (WTP) thresholds of €50,000/QALY and €80,000/QALY over a 10-year time horizon. One-way sensitivity analysis, probabilistic sensitivity analysis, and scenario analysis were conducted to test the robustness of results. Clinical data were obtained from large randomized controlled trials and real-world data. RESULTS Treatment with tenecteplase saved €21 per patient while gaining 0.05 QALYs, resulting in INMB of €2381, clearly rendering tenecteplase cost-effective compared to alteplase. Importantly, tenecteplase remained the cost-effective alternative in all scenarios, including AIS patients due to large vessel occlusion (LVO). Probabilistic sensitivity analysis proved tenecteplase to be cost-effective with a 71.0% probability at a WTP threshold of €50,000/QALY. CONCLUSIONS Tenecteplase treatment was cost-effective for all AIS patients (including AIS patients with LVO) compared to alteplase. The finding supports the broader use of tenecteplase in acute stroke care, as health outcomes improve at acceptable costs while having practical advantages, and a similar safety profile.
Collapse
Affiliation(s)
- Chi Phuong Nguyen
- Department of Operations, Faculty of Economics and Business, University of Groningen, Groningen, The Netherlands
- Health Technology Assessment, Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Pharmaceutical Management and Economic, Hanoi University of Pharmacy, Vietnam
| | - Maarten MH Lahr
- Health Technology Assessment, Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Durk-Jouke van der Zee
- Department of Operations, Faculty of Economics and Business, University of Groningen, Groningen, The Netherlands
- Health Technology Assessment, Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Henk van Voorst
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, Location University of Amsterdam, Amsterdam, The Netherlands
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Center, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Yvo BWEM Roos
- Department of Neurology, Amsterdam University Medical Center, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Maarten Uyttenboogaart
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Radiology, Medical Imaging Center, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Erik Buskens
- Department of Operations, Faculty of Economics and Business, University of Groningen, Groningen, The Netherlands
- Health Technology Assessment, Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| |
Collapse
|
15
|
Lim J, Monteiro A, Ruggiero N, Baig AA, Aguirre AO, McPheeters MJ, Waqas M, Vakharia K, Snyder KV, Siddiqui AH, Levy EI, Davies JM. Mechanical Thrombectomy Versus Best Medical Management for Acute Ischemic Stroke in Elderly Patients: A Cost-Effectiveness Analysis. World Neurosurg 2023; 175:e730-e737. [PMID: 37037370 DOI: 10.1016/j.wneu.2023.04.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 04/03/2023] [Accepted: 04/04/2023] [Indexed: 04/12/2023]
Abstract
OBJECTIVE To determine the cost-effectiveness of mechanical thrombectomy (MT) versus best medical management (BMM) in patients aged ≥80 years. METHODS We performed a systematic literature review to identify comparative studies of MT versus BMM with or without intravenous tissue-type plasminogen activator (IV tPA) in patients ≥80 years. Clinical data including outcomes and mortality categorized as modified Rankin scale scores 0-2, 3-5, and 6, were collected from identified studies, and effectiveness scores were assigned to each outcome. Costs associated with stroke outcomes were derived from previous literature, including costs associated with initial and follow-up imaging, hospitalization, physicians/associated personnel, and MT. TreeAge Pro software was used to construct a cost-effectiveness analysis model of clinical data from studies and costs derived from the literature. RESULTS The review identified 1 relevant comparative study. The cost model demonstrated total annual cumulative overall per-patient costs of $30,064.21 for BMM with IV tPA and $21,940.36 for BMM without IV tPA. Overall effectiveness scores were 0.61 and 0.62, respectively. MT had a cumulative total annual per-patient cost of $47,849.54 and an overall effectiveness score of 0.40. The cost-effectiveness ratios of total cumulative patient cost to overall outcome effectiveness score for the 3 treatments were as follows: BMM with IV tPA = $49,285.59, BMM without IV tPA = $35,387.58, and MT = $119,623.85. BMM with or without IV tPA was found to be more cost-effective than MT. CONCLUSIONS This study utilized stroke outcomes data for patients aged ≥80 years to conduct a cost-effectiveness analysis. MT was found to be less cost-effective than BMM with and without IV tPA.
Collapse
Affiliation(s)
- Jaims Lim
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Andre Monteiro
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Nicco Ruggiero
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Ammad A Baig
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Alexander O Aguirre
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Matthew J McPheeters
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Muhammad Waqas
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Kunal Vakharia
- Department of Neurosurgery, University of South Florida, Tampa Bay, Florida, USA
| | - Kenneth V Snyder
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA; Jacobs Institute, Buffalo, New York, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA; Jacobs Institute, Buffalo, New York, USA; Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA; Jacobs Institute, Buffalo, New York, USA; Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Jason M Davies
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA; Jacobs Institute, Buffalo, New York, USA; Department of Biomedical Informatics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.
| |
Collapse
|
16
|
Lucas-Noll J, Clua-Espuny JL, Lleixà-Fortuño M, Gavaldà-Espelta E, Queralt-Tomas L, Panisello-Tafalla A, Carles-Lavila M. The costs associated with stroke care continuum: a systematic review. HEALTH ECONOMICS REVIEW 2023; 13:32. [PMID: 37193926 DOI: 10.1186/s13561-023-00439-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 04/18/2023] [Indexed: 05/18/2023]
Abstract
Stroke, a leading cause of death and long-term disability, has a considerable social and economic impact. It is imperative to investigate stroke-related costs. The main goal was to conduct a systematic literature review on the described costs associated with stroke care continuum to better understand the evolution of the economic burden and logistic challenges. This research used a systematic review method. We performed a search in PubMed/MEDLINE, ClinicalTrial.gov, Cochrane Reviews, and Google Scholar confined to publications from January 2012 to December 2021. Prices were adjusted using consumer price indices of the countries in the studies in the years the costs were incurred to 2021 Euros using the World Bank and purchasing power parity exchange rate in 2020 from the Organization for Economic Co-operation and Development with the XE Currency Data API. The inclusion criteria were all types of publications, including prospective cost studies, retrospective cost studies, database analyses, mathematical models, surveys, and cost-of-illness (COI) studies. Were excluded studies that (a) were not about stroke, (b) were editorials and commentaries, (c) were irrelevant after screening the title and abstract,(d) grey literature and non-academic studies, (e) reported cost indicators outside the scope of the review, (f) economic evaluations (i.e., cost-effectiveness or cost-benefit analyses); and (g) studies not meeting the population inclusion criteria. There may be risk of bias because the effects are dependent on the persons delivering the intervention. The results were synthetized by PRISMA method. A total of 724 potential abstracts were identified of which 25 articles were pulled for further investigation. The articles were classified into the following categories: 1)stroke primary prevention, 2) expenditures related to acute stroke care, 3) expenditures for post-acute strokes, and 4) global average stroke cost. The measured expenditures varied considerably among these studies with a global average cost from €610-€220,822.45. Given the great variability in the costs in different studies, we can conclude that we need to define a common system for assessing the costs of strokes. Possible limitations are related to clinical choices exposed to decision rules that trigger decisions alerts within stroke events in a clinical setting. This flowchart is based on the guidelines for acute ischemic stroke treatment but may not be applicable to all institutions.
Collapse
Affiliation(s)
- Jorgina Lucas-Noll
- Department of Primary Care, Institut Català de La Salut, Av. de Cristòfol Colom, 20, Tortosa, Tarragona, 43500, Spain.
- University Institute for Primary Health Care Research Jordi Gol I Gurina (IDIAPJGol), Barcelona, Spain.
| | - José L Clua-Espuny
- Department of Primary Care, Institut Català de La Salut, Av. de Cristòfol Colom, 20, Tortosa, Tarragona, 43500, Spain
- University Institute for Primary Health Care Research Jordi Gol I Gurina (IDIAPJGol), Barcelona, Spain
| | - Mar Lleixà-Fortuño
- Department of Nursing, Universitat Rovira I Virgili, Tarragona, Tarragona, Spain
| | - Ester Gavaldà-Espelta
- Department of Primary Care, Institut Català de La Salut, Av. de Cristòfol Colom, 20, Tortosa, Tarragona, 43500, Spain
- Department of Nursing, Universitat Rovira I Virgili, Tarragona, Tarragona, Spain
| | - Lluïsa Queralt-Tomas
- Department of Primary Care, Institut Català de La Salut, Av. de Cristòfol Colom, 20, Tortosa, Tarragona, 43500, Spain
- University Institute for Primary Health Care Research Jordi Gol I Gurina (IDIAPJGol), Barcelona, Spain
| | - Anna Panisello-Tafalla
- Department of Primary Care, Institut Català de La Salut, Av. de Cristòfol Colom, 20, Tortosa, Tarragona, 43500, Spain
- University Institute for Primary Health Care Research Jordi Gol I Gurina (IDIAPJGol), Barcelona, Spain
| | | |
Collapse
|
17
|
Kim DD, Do LA, Synnott PG, Lavelle TA, Prosser LA, Wong JB, Neumann PJ. Developing Criteria for Health Economic Quality Evaluation Tool. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023:S1098-3015(23)02561-5. [PMID: 37068557 DOI: 10.1016/j.jval.2023.04.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 03/01/2023] [Accepted: 04/04/2023] [Indexed: 05/08/2023]
Abstract
OBJECTIVES Because existing publication guidelines and checklists have limitations when used to assess the quality of cost-effectiveness analysis, we developed a novel quality assessment tool for cost-effectiveness analyses, differentiating methods and reporting quality and incorporating the relative importance of different quality attributes. METHODS We defined 15 quality domains from a scoping review and identified 72 methods and reporting quality attributes (36 each). After designing a best-worst scaling survey, we fielded an online survey to researchers and practitioners to estimate the relative importance of the attributes in February 2021. We analyzed the survey data using a sequential conditional logit model. The final tool included 48 quality attributes deemed most important for assessing methods and reporting quality (24 each), accompanied by a free and web-based scoring system. RESULTS A total of 524 participants completed the methodology section, and 372 completed both methodology and reporting sections. Quality attributes pertaining to the "modeling" and "data inputs and evidence synthesis" domains were deemed most important for methods quality, including "structure of the model reflects the underlying condition and intervention's impact" and "model validation is conducted." Quality attributes pertaining to "modeling" and "Intervention/comparator(s)" domains were considered most important for reporting quality, including "model descriptions are detailed enough for replication." Despite its growing prominence, "equity considerations" were not deemed as important as other quality attributes. CONCLUSIONS The Criteria for Health Economic Quality Evaluation tool allows users to differentiate methods and reporting as well as quantifies the relative importance of quality attributes. Alongside other considerations, it could help assess and improve the quality of cost-effectiveness evidence to inform value-based decisions.
Collapse
Affiliation(s)
- David D Kim
- Section of Hospital Medicine, Department of Medicine, The University of Chicago, Chicago, IL, USA.
| | - Lauren A Do
- Center for the Evaluation of Value and Risk in Health (CEVR), Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Patricia G Synnott
- Center for the Evaluation of Value and Risk in Health (CEVR), Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Tara A Lavelle
- Center for the Evaluation of Value and Risk in Health (CEVR), Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA; Department of Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Lisa A Prosser
- The Susan B. Meister Child Health Evaluation and Research (CHEAR) Center, Michigan Medicine, Ann Arbor, MI, USA; Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA; Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - John B Wong
- Department of Medicine, Tufts University School of Medicine, Boston, MA, USA; Division of Clinical Decision Making, Tufts Medical Center, Boston, MA, USA
| | - Peter J Neumann
- Center for the Evaluation of Value and Risk in Health (CEVR), Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA; Department of Medicine, Tufts University School of Medicine, Boston, MA, USA
| |
Collapse
|
18
|
Jiang J, Wei J, Zhu Y, Wei L, Wei X, Tian H, Zhang L, Wang T, Cheng Y, Zhao Q, Sun Z, Du H, Huang Y, Liu H, Li Y. Clot-based radiomics model for cardioembolic stroke prediction with CT imaging before recanalization: a multicenter study. Eur Radiol 2023; 33:970-980. [PMID: 36066731 DOI: 10.1007/s00330-022-09116-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 07/11/2022] [Accepted: 08/12/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To develop a clot-based radiomics model using CT imaging radiomic features and machine learning to identify cardioembolic (CE) stroke before mechanical thrombectomy (MTB) in patients with acute ischemic stroke (AIS). MATERIALS AND METHODS This retrospective four-center study consecutively included 403 patients with AIS who sequentially underwent CT and MTB between April 2016 and July 2021. These were grouped into training, testing, and external validation cohorts. Thrombus-extracted radiomic features and basic information were gathered to construct a machine learning model to predict CE stroke. The radiological characteristics and basic information were used to build a routine radiological model. A combined radiomics and radiological features model was also developed. The performances of all models were evaluated and compared in the validation cohort. A histological analysis helped further assess the proposed model in all patients. RESULTS The radiomics model yielded an area under the curve (AUC) of 0.838 (95% confidence interval [CI], 0.771-0.891) for predicting CE stroke in the validation cohort, significantly higher than the radiological model (AUC, 0.713; 95% CI, 0.636-0.781; p = 0.007) but similar to the combined model (AUC, 0.855; 95% CI, 0.791-0.906; p = 0.14). The thrombus radiomic features achieved stronger correlations with red blood cells (|rmax|, 0.74 vs. 0.32) and fibrin and platelet (|rmax|, 0.68 vs. 0.18) than radiological characteristics. CONCLUSION The proposed CT-based radiomics model could reliably predict CE stroke in AIS, performing better than the routine radiological method. KEY POINTS • Admission CT imaging could offer valuable information to identify the acute ischemic stroke source by radiomics analysis. • The proposed CT imaging-based radiomics model yielded a higher area under the curve (0.838) than the routine radiological method (0.713; p = 0.007). • Several radiomic features showed significantly stronger correlations with two main thrombus constituents (red blood cells, |rmax|, 0.74; fibrin and platelet, |rmax|, 0.68) than routine radiological characteristics.
Collapse
Affiliation(s)
- Jingxuan Jiang
- Institute of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600 Yishan Road, Shanghai, 200233, China.,Department of Radiology, Affiliated Hospital of Nantong University, Nantong, 226001, China
| | - Jianyong Wei
- Clinical Research Center, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, 200233, China
| | - Yueqi Zhu
- Institute of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600 Yishan Road, Shanghai, 200233, China
| | - Liming Wei
- Institute of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600 Yishan Road, Shanghai, 200233, China
| | - Xiaoer Wei
- Institute of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600 Yishan Road, Shanghai, 200233, China
| | - Hao Tian
- Department of Radiology, Affiliated Hospital of Nantong University, Nantong, 226001, China
| | - Lei Zhang
- Department of Radiology, Wuxi Second People's Hospital, Wuxi, 214000, China
| | - Tianle Wang
- Department of Radiology, Affiliated No. 1 People's Hospital of Nantong University, Nantong, 226001, China
| | - Yue Cheng
- Department of Radiology, Wuxi Second People's Hospital, Wuxi, 214000, China
| | - Qianqian Zhao
- Institute of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600 Yishan Road, Shanghai, 200233, China
| | - Zheng Sun
- Institute of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600 Yishan Road, Shanghai, 200233, China
| | - Haiyan Du
- Institute of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600 Yishan Road, Shanghai, 200233, China
| | - Yu Huang
- Institute of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600 Yishan Road, Shanghai, 200233, China
| | - Hui Liu
- Institute of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600 Yishan Road, Shanghai, 200233, China
| | - Yuehua Li
- Institute of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600 Yishan Road, Shanghai, 200233, China.
| |
Collapse
|
19
|
Chen J, Liang X, Tong X, Han M, Ji L, Zhao S, Hu Z, Liu A. Economic evaluation of intravenous alteplase for stroke with the time of onset between 4.5 and 9 hours. J Neurointerv Surg 2023; 15:46-51. [PMID: 35074896 DOI: 10.1136/neurintsurg-2021-018420] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 12/26/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND A clinical trial proved the clinical effectiveness of perfusion imaging-guided intravenous thrombolysis with alteplase for patients with acute ischemic stroke (AIS) with the time of onset between 4.5 and 9 hours. This study aimed to assess the lifetime cost-effectiveness of alteplase versus placebo from the perspective of Chinese and United States (US) healthcare payers. METHODS A decision-analytic model was built to estimate lifetime costs and quality-adjusted life-years (QALYs) associated with alteplase or placebo. Model inputs were extracted from published sources. Incremental costs, incremental QALYs, and incremental cost-effectiveness ratio (ICER) were calculated to evaluate the base-case scenario. One-way and probabilistic sensitivity analysis were performed to evaluate uncertainty in the results. RESULTS In China, alteplase yielded an additional lifetime QALY of 0.126 with an additional cost of Chinese Yuan (¥) ¥9552 compared with placebo, and the ICER was ¥83 950 (US$12 157)/QALY. In the US, alteplase had a higher QALY (difference: 0.193) with a lower cost (difference: US$-2024) compared with placebo. In probabilistic sensitivity analyses, alteplase had a 42.54% to 78.3% probability of being cost-effective compared with placebo in China when the willingness-to-pay (WTP) threshold ranged from ¥72 447/QALY to ¥217 341/QALY. In the US, alteplase had a 93.47% to 93.57% probability of being cost-effective under the WTP threshold of US$100 000/QALY to US$150 000/QALY. These findings remained robust under one-way sensitivity analysis. CONCLUSION For patients with AIS with a time of onset between 4.5 and 9 hours, perfusion imaging-guided intravenous alteplase was likely to be cost-effective in China and was cost-effective in the US when compared with placebo.
Collapse
Affiliation(s)
- Jigang Chen
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xin Liang
- Beijing Shijitan Hospital, Capital Medical University, Beijing, China.,Department of Neurosurgery, Capital Medical University Affiliated Beijing Shijitan Hospital, Beijing, China
| | - Xin Tong
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Mingyang Han
- Department of Neurosurgery, Central South University Third Xiangya Hospital, Changsha, Hunan, China
| | - Linjin Ji
- Department of Neurosurgery, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Songfeng Zhao
- Department of Neurosurgery, Central South University Third Xiangya Hospital, Changsha, Hunan, China
| | - Zhiqiang Hu
- Beijing Shijitan Hospital, Capital Medical University, Beijing, China .,Department of Neurosurgery, Capital Medical University Affiliated Beijing Shijitan Hospital, Beijing, China
| | - Aihua Liu
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China .,Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
20
|
Levy EI, Monteiro A, Waqas M, Siddiqui AH. Access to Mechanical Thrombectomy for Stroke: Center Qualifications, Prehospital Management, and Geographic Disparities. Neurosurgery 2023; 92:3-9. [PMID: 36519855 DOI: 10.1227/neu.0000000000002206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 08/25/2022] [Indexed: 12/23/2022] Open
Abstract
Mechanical thrombectomy (MT) became the "gold-standard" treatment for most patients with acute ischemic stroke due to anterior circulation large vessel occlusion. With such a remarkable paradigm shift, it is important that this modality of treatment becomes widely and homogeneously available throughout the United States and other countries. Although the time window for MT is large (24 hours in selected patients), time is still a major determinant of outcome. Several variables are involved in achieving timely access of MT for the majority of the population: prehospital management systems, transportation models, in-hospital workflow organization, accreditation and infrastructure of centers, training of neurointervention professionals, and geographic distribution of centers. The current situation in the United States regarding MT access is marked by geographic and socioeconomic disparities. We provide an overview of current challenges and solutions in achieving more universal access to MT for the population.
Collapse
Affiliation(s)
- Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA.,Jacobs Institute, Buffalo, New York, USA
| | - Andre Monteiro
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Muhammad Waqas
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA.,Jacobs Institute, Buffalo, New York, USA
| |
Collapse
|
21
|
Zhao S, Cheng Y, Tong X, Han M, Ji L, Che Y, Hu W, Liu A. Cost-effectiveness of recombinant tissue-type plasminogen activator for acute ischaemic stroke with unknown time of onset: a Markov modelling analysis from the Chinese and US perspectives. BMJ Open 2022; 12:e065133. [PMID: 36375982 PMCID: PMC9664282 DOI: 10.1136/bmjopen-2022-065133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE The effectiveness of MRI-guided intravenous recombinant tissue-type plasminogen activator (r-tPA) for acute ischaemic stroke (AIS) with an unknown time of onset has been demonstrated by the WAKE-UP Trial. We aim to evaluate its long-term cost-effectiveness from the perspective of Chinese and US healthcare payers. METHODS A combination of decision tree and Markov model was built to project lifetime costs and quality-adjusted life-years (QALYs) associated with intravenous r-tPA or placebo treatment. Model inputs including the transition probabilities, costs and utilities were derived from the WAKE-UP Trial, similar cost-effectiveness studies and other published sources. To compare intravenous r-tPA to placebo, we calculated incremental costs, incremental QALYs and incremental cost-effectiveness ratio (ICER). One-way sensitivity, probabilistic sensitivity and subgroup analyses were performed to evaluate uncertainty in the results. RESULTS In China, intravenous r-tPA gained an additional lifetime QALY of 0.293 with an additional cost of the Chinese Yuan (¥) of 7871 when compared with placebo, resulting in an ICER of ¥26 870 (US$3894)/QALY. In the USA, intravenous r-tPA yielded a higher QALY (difference: 0.430) and lower cost (difference: ¥-4563) when compared with placebo. In probabilistic sensitivity analyses, intravenous r-tPA had a 97.8% and 99.8% probability of being cost-effective or cost-saving in China and the USA, respectively. These findings remained robust under one-way sensitivity and subgroup analysis except for patients with a National Institute of Health Stroke Scale Score of less than 4, between 11 and 16, and over 16. CONCLUSIONS MRI-guided intravenous r-tPA for patients with AIS with an unknown time of onset is cost-effective in China and cost-saving in the USA.
Collapse
Affiliation(s)
- Songfeng Zhao
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurosurgery, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Yuhong Cheng
- Department of Neurosurgery, Linfen Central Hospital, Linfen, China
| | - Xin Tong
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Mingyang Han
- Department of Neurosurgery, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Linjin Ji
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yuxiong Che
- Department of Neurology, Changde First Hospital of Traditional Chinese Medicine, Changde, China
| | - Weiwu Hu
- Department of Neurology, Changde First Hospital of Traditional Chinese Medicine, Changde, China
| | - Aihua Liu
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurosurgery, The Third Xiangya Hospital, Central South University, Changsha, China
| |
Collapse
|
22
|
Feng L, He Y, Dong S, Wang R, Long S, He L. An exploratory descriptive cohort study of 90-day prognosis after acute ischaemic stroke with mechanical thrombectomy. Contemp Nurse 2022; 58:264-275. [PMID: 36052463 DOI: 10.1080/10376178.2022.2107038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIM To evaluate the relationship between nursing assessment findings at discharge and acute ischaemic stroke (AIS) patient prognosis after mechanical thrombectomy (MT). METHODS We analysed the characteristics of 144 AIS patients with MT treatment admitted to a university affiliated teaching hospital in Chengdu, Sichuan Province China, from January 2020 to December 2020. The modified Rankin Scale (mRS) score was used to assess outcomes 90-days after discharge. Exploratory analyses were undertaken using IBM SPSS Statistics (Version 26.0). RESULTS At 90-days, 47.9% (n = 69) had a good prognosis (mRS ≤ 2) including 22.2%(n = 32) fully recovered patients. There were 5 (3.5%) deceased patients and 48.6% (n =70) of patients had a poor prognosis (mRS ≥ 3). In univariate analysis, clinical prognosis correlated with the need for inpatient endotracheal intubation (p = 0.02), nasogastric tube (p<0.001), indwelling urinary catheter (p<0.001), central venous catheter (p = 0.03), health knowledge needs of pressure injury prevention (p = 0.03), National Institute of Health Stroke Scale (NIHSS) score (p<0.001) and Activities of Daily Living (ADL) score (p<0.001) at the time of discharge from hospital. The average hospitalisation time of the 144 patients was 12[IQR, 9-25] days, and the average cost of hospitalisation was $Y$21291.93 (SD 9165.01). CONCLUSION Almost half of the surviving patients had a poor prognosis. In our country, this surgery and rehabilitation impose a significant financial burden that needs to be addressed. However, the longer length of hospital stay and higher costs at discharge may be contributing factors to worse outcomes. The outcomes of comprehensive nursing assessment of the patients, including nursing needs, activities of daily living, and neurological function, can predict their outcome. IMPACT STATEMENT We recommend a comprehensive nursing assessment at discharge that predicts patient outcomes and can be used for subsequent targeted interventions. The prognosis of patients with acute ischaemic stroke after mechanical thrombectomy is poor, and the financial burden needs to be considered.
Collapse
Affiliation(s)
- Ling Feng
- West China School of Nursing,Sichuan University/Department of Neurology,West China Hospital,Sichuan University, Chengdu China
| | - Yueyue He
- West China School of Nursing,Sichuan University/Department of Neurology,West China Hospital,Sichuan University, Chengdu China
| | - Shuju Dong
- Department of Neurology, West China Hospital, Sichuan University, Chengdu China
| | - Rui Wang
- West China School of Nursing,Sichuan University/Department of Neurology,West China Hospital,Sichuan University, Chengdu China
| | - Shiyan Long
- West China School of Nursing,Sichuan University/Department of Neurology,West China Hospital,Sichuan University, Chengdu China
| | - Li He
- Department of Neurology, West China Hospital, Sichuan University, Chengdu China
| |
Collapse
|
23
|
Kuo S, Yang CT, Herman WH, Lisabeth LD, Ye W. National Trends in the Achievement of Recommended Strategies for Stroke Prevention in U.S. Adults With Type 2 Diabetes, 2001-2018. Diabetes Care 2022; 45:2003-2011. [PMID: 35834174 PMCID: PMC9472506 DOI: 10.2337/dc21-2283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 06/07/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To assess the national prevalence of and trends in achieving current guideline-recommended treatment goals and pharmacotherapies for primary and secondary prevention of stroke among U.S. adults with type 2 diabetes (T2D). RESEARCH DESIGN AND METHODS We performed serial cross-sectional analyses in 4,834 adults aged ≥45 years with T2D who participated in the 2001-2018 National Health and Nutrition Examination Survey. With stratification by stroke history, we estimated the proportion of adults with T2D who achieved current guideline-recommended strategies for stroke prevention. Preventive strategies for stroke were benchmarked against diabetes care and cardiovascular risk reduction guidelines. RESULTS Overall in 2001-2018, among those without stroke history, the proportion who achieved primary stroke prevention strategies ranged from 8.4% (95% CI 6.8-10.1) for aspirin/clopidogrel treatment in those with a higher cardiovascular disease risk to 80.5% (78.8-82.2) for nonsmoking. Among those with stroke history, the proportion who achieved secondary stroke prevention strategies ranged from 11.8% (8.7-14.8) for weight control to 80.0% (74.9-84.9) for glycemic control. From 2001 to 2018, among those without stroke history, there was a significant increase in statin therapy (Ptrend < 0.0001), smoking abstinence (Ptrend = 0.01), and ACE inhibitor/angiotensin receptor blocker treatment for hypertension (Ptrend = 0.04) but a substantial decline in weight control (Ptrend < 0.001). Among those with stroke history, only statin therapy (Ptrend = 0.01) increased significantly over time. CONCLUSIONS During 2001-2018, the achievement of some current guideline-recommended strategies for stroke prevention among U.S. adults with T2D improved but remains a challenge overall. Efforts are needed to improve implementation of strategies for stroke prevention in this population.
Collapse
Affiliation(s)
- Shihchen Kuo
- Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chun-Ting Yang
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - William H. Herman
- Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Lynda D. Lisabeth
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Wen Ye
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| |
Collapse
|
24
|
Chen J, Ji L, Tong X, Han M, Zhao S, Qin Y, He Z, Jiang Z, Liu A. Economic Evaluation of Ticagrelor Plus Aspirin Versus Aspirin Alone for Acute Ischemic Stroke and Transient Ischemic Attack. Front Pharmacol 2022; 13:790048. [PMID: 35370758 PMCID: PMC8971565 DOI: 10.3389/fphar.2022.790048] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 01/31/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Although ticagrelor plus aspirin is more effective than aspirin alone in preventing the 30-day risk of a composite of stroke or death in patients with an acute mild-to-moderate ischemic stroke (IS) or transient ischemic attack (TIA), the cost-effectiveness of this combination therapy remains unknown. This study aims to determine the cost-effectiveness of ticagrelor plus aspirin compared with aspirin alone. Methods: A combination of decision tree and Markov model was built to estimate the expected costs and quality-adjusted life-years (QALYs) associated with ticagrelor plus aspirin and aspirin alone in the treatment of patients with an acute mild-to-moderate IS or TIA. Model inputs were extracted from published sources. One-way sensitivity, probabilistic sensitivity, and subgroup analyses were performed to test the robustness of the findings. Results: Compared with aspirin alone, ticagrelor plus aspirin gained an additional lifetime QALY of 0.018 at an additional cost of the Chinese Yuan Renminbi (¥) of 269, yielding an incremental cost-effectiveness ratio of ¥15,006 (US$2,207)/QALY. Probabilistic sensitivity analysis showed that ticagrelor plus aspirin had a probability of 99.99% being highly cost-effective versus aspirin alone at the current willingness-to-pay threshold of ¥72,447 (US$10,500)/QALY in China. These findings remain robust under one-way sensitivity and subgroup analyses. Conclusions: The results indicated that early treatment with a 30-days ticagrelor plus aspirin for an acute mild-to-moderate IS or TIA is highly cost-effective in a Chinese setting.
Collapse
Affiliation(s)
- Jigang Chen
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Linjin Ji
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xin Tong
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Mingyang Han
- Department of Neurosurgery, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Songfeng Zhao
- Department of Neurosurgery, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Yongkai Qin
- Department of Neurosurgery, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Zilong He
- Department of Neurosurgery, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Zhiqun Jiang
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
- *Correspondence: Aihua Liu, ; Zhiqun Jiang,
| | - Aihua Liu
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- China NationalClinical Research Centre for Neurological Diseases, Beijing, China
- *Correspondence: Aihua Liu, ; Zhiqun Jiang,
| |
Collapse
|
25
|
Nivelle E, Dewilde S, Peeters A, Vanhooren G, Thijs V. Thrombectomy is a cost-saving procedure up to 24 h after onset. Acta Neurol Belg 2022; 122:163-171. [PMID: 34586595 DOI: 10.1007/s13760-021-01810-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 09/16/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION AND AIM The treatment of ischemic stroke due to large-vessel occlusion has been revolutionized by mechanical thrombectomy (MT), as multiple trials have consistently shown improved functional outcomes compared to standard medical management both in the early and late time windows after symptom onset. However, MT is an interventional procedure that is more costly than best supportive care (BSC). METHODS We set out to study the cost-utility and budget impact of MT + BSC versus BSC alone for large-vessel occlusion using a combined decision tree and Markov model. The analysis was conducted from a Belgian payer perspective over a lifetime horizon, and health states were defined by the modified Rankin Scale (mRS). The treatment effect of MT + BSC combined clinical outcomes from all published early and late treatment window studies showing improved mRS after 90 days. Resource use and utilities were informed by an observational Belgian study of 569 stroke patients. Long-term mRS transitions were sourced from the Oxford Vascular study. RESULTS MT + BSC generated 1.31 additional quality-adjusted life years and resulted in cost savings of €10,216 per patient over lifetime. Deterministic sensitivity analyses demonstrated dominance of MT over a wide range of parameter inputs. In a Belgian setting, adding MT to BSC within an early time window for 1575 eligible stroke patients every year produced cost savings between €6.3 million (year 1) and €14.6 million (year 5), or a total cost saving of €56.2 million over 5 years. CONCLUSION Mechanical thrombectomy is a highly cost-effective treatment for ischemic stroke patients, providing quality-adjusted survival at lower health care cost, both when given in an early time window, as well as in a late time window.
Collapse
Affiliation(s)
| | - Sarah Dewilde
- Services in Health Economics (SHE), Brussels, Belgium
- Department of Public Health, University of Ghent, Ghent, Belgium
| | - André Peeters
- Service de Neurologie, UCL St Luc, Unité Neuro-Vasculaire, Avenue Hippocrate 10, Brussels, Belgium
| | - Geert Vanhooren
- Department of Neurology, AZ Sint-Jan Brugge-Oostende, Ruddershove 10, Bruges, Belgium
| | - Vincent Thijs
- Stroke Theme, Florey Institute of Neuroscience and Mental Health, University of Melbourne, 245 Burgundy Street, Heidelberg, VIC, Australia.
- Department of Neurology, Austin Health, 145 Studley Road, Heidelberg, VIC, Australia.
| |
Collapse
|
26
|
Gao L, Bivard A, Parsons M, Spratt NJ, Levi C, Butcher K, Kleinig T, Yan B, Dong Q, Cheng X, Lou M, Yin C, Chen C, Wang P, Lin L, Choi P, Miteff F, Moodie M. Real-World Cost-Effectiveness of Late Time Window Thrombectomy for Patients With Ischemic Stroke. Front Neurol 2022; 12:780894. [PMID: 34970213 PMCID: PMC8712752 DOI: 10.3389/fneur.2021.780894] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 10/26/2021] [Indexed: 11/13/2022] Open
Abstract
Background: To compare the cost-effectiveness of providing endovascular thrombectomy (EVT) for patients with ischemic stroke in the >4.5 h time window between patient groups who met and did not meet the perfusion imaging trial criteria. Methods: A discrete event simulation (DES) model was developed to simulate the long-term outcome post EVT in patients meeting or not meeting the extended time window clinical trial perfusion imaging criteria at presentation, vs. medical treatment alone (including intravenous thrombolysis). The effectiveness of thrombectomy in patients meeting the landmark trial criteria (DEFUSE 3 and DAWN) was derived from a prospective cohort study of Australian patients who received EVT for ischemic stroke, between 2015 and 2019, in the extended time window (>4.5 h). Results: Endovascular thrombectomy was shown to be a cost-effective treatment for patients satisfying the clinical trial criteria in our prospective cohort [incremental cost-effectiveness ratio (ICER) of $11,608/quality-adjusted life year (QALY) for DEFUSE 3-postive or $34,416/QALY for DAWN-positive]. However, offering EVT to patients outside of clinical trial criteria was associated with reduced benefit (−1.02 QALY for DEFUSE 3; −1.43 QALY for DAWN) and higher long-term patient costs ($8,955 for DEFUSE 3; $9,271 for DAWN), thereby making it unlikely to be cost-effective in Australia. Conclusions: Treating patients not meeting the DAWN or DEFUSE 3 clinical trial criteria in the extended time window for EVT was associated with less gain in QALYs and higher cost. Caution should be exercised when considering this procedure for patients not satisfying the trial perfusion imaging criteria for EVT.
Collapse
Affiliation(s)
- Lan Gao
- Deakin Health Economics, Institute for Health Transformation, Deakin University, Geelong, VIC, Australia
| | - Andrew Bivard
- Melbourne Brain Centre, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Mark Parsons
- Melbourne Brain Centre, Royal Melbourne Hospital, Parkville, VIC, Australia.,Departments of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, NSW, Australia.,Department of Neurology, UNSW South Western Clinical School, Liverpool Hospital, University of New South Wales, Kensington, NSW, Australia
| | - Neil J Spratt
- Departments of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, NSW, Australia
| | - Christopher Levi
- Departments of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, NSW, Australia
| | - Kenneth Butcher
- Department of Neurology, Prince of Wales Hospital, University of New South Wales, Sydney, NSW, Australia
| | - Timothy Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Bernard Yan
- Melbourne Brain Centre, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Qiang Dong
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xin Cheng
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Min Lou
- Department of Neurology, Second Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Congguo Yin
- Department of Neurology, Hangzhou First Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chushuang Chen
- Departments of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, NSW, Australia
| | - Peng Wang
- Zhejiang Provincial People's Hospital, Zhejiang, China
| | - Longting Lin
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
| | - Philip Choi
- Department of Neurology, Box Hill Hospital, Eastern Health, Box Hill, VIC, Australia
| | - Ferdinand Miteff
- Departments of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, NSW, Australia
| | - Marj Moodie
- Deakin Health Economics, Institute for Health Transformation, Deakin University, Geelong, VIC, Australia
| |
Collapse
|
27
|
van den Berg LA, Berkhemer OA, Fransen PSS, Beumer D, Lingsma H, Majoie CBM, Dippel DWJ, van der Lugt A, van Oostenbrugge RJ, van Zwam WH, Roos YB, Dijkgraaf MGW. Economic Evaluation of Endovascular Treatment for Acute Ischemic Stroke. Stroke 2021; 53:968-975. [PMID: 34645287 DOI: 10.1161/strokeaha.121.034599] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE Endovascular treatment for acute ischemic stroke has been proven clinically effective, but evidence of the cost-effectiveness based on real-world data is scarce. The aim of this study was to assess whether endovascular therapy plus usual care is cost-effective in comparison to usual care alone in acute ischemic stroke patients. METHODS An economic evaluation was performed from a societal perspective with a 2-year time horizon. Empirical data on health outcomes and the use of resources following endovascular treatment were gathered parallel to the MR CLEAN trial (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) and its 2-year follow-up study. Incremental cost-effectiveness ratios were calculated as the extra costs per additional patient with functional independence (modified Rankin Scale score 0-2) and the extra cost per quality-adjusted life year gained. RESULTS The mean costs per patient in the intervention group were $126 494 versus $143 331 in the control group (mean difference, -$16 839 [95% CI, -$38 113 to $5456]). Compared with patients in the control group, more patients in the intervention group achieved functional independence, 37.2% versus 23.9% (absolute difference, 13.3% [95% CI, 4.0%-22.0%]) and they generated more quality-adjusted life years, 0.99 versus 0.83 (mean difference of 0.16 [95% CI, 0.04-0.29]). Endovascular treatment dominated standard treatment with $18 233 saved per extra patient with a good outcome and $105 869 saved per additional quality-adjusted life year. CONCLUSIONS Endovascular treatment added to usual care is clinically effective, and cost saving in comparison to usual care alone in patients with acute ischemic stroke. REGISTRATION URL: https://www.trialregister.nl/trial/695; Unique identifier: NL695. https://www.isrctn.com/ISRCTN10888758; Unique identifier: ISRCTN10888758.
Collapse
Affiliation(s)
- Lucie A van den Berg
- Departments of Neurology, Amsterdam University Medical Center, the Netherlands. (L.A.v.d.B., Y.B.R.)
| | - Olvert A Berkhemer
- Radiology and Nuclear Medicine, Amsterdam University Medical Center, the Netherlands. (C.B.M.M., O.A.B.).,Department of Neurology, Erasmus MC University Medical Center Rotterdam, the Netherlands. (O.A.B., P.S.S.F., D.W.J.D.).,Department of Radiology, Erasmus MC University Medical Center Rotterdam, the Netherlands. (O.A.B., A.v.d.L.).,Department of Radiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, the Netherlands. (O.A.B., W.H.v.Z.)
| | - Puck S S Fransen
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, the Netherlands. (O.A.B., P.S.S.F., D.W.J.D.)
| | - Debbie Beumer
- Department of Neurology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, the Netherlands. (D.B., R.J.v.O.)
| | - Hester Lingsma
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, the Netherlands. (H.L.)
| | - Charles B M Majoie
- Radiology and Nuclear Medicine, Amsterdam University Medical Center, the Netherlands. (C.B.M.M., O.A.B.)
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, the Netherlands. (O.A.B., P.S.S.F., D.W.J.D.)
| | - Aad van der Lugt
- Department of Radiology, Erasmus MC University Medical Center Rotterdam, the Netherlands. (O.A.B., A.v.d.L.)
| | - Robert J van Oostenbrugge
- Department of Neurology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, the Netherlands. (D.B., R.J.v.O.)
| | - Wim H van Zwam
- Department of Radiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, the Netherlands. (O.A.B., W.H.v.Z.)
| | - Yvo B Roos
- Departments of Neurology, Amsterdam University Medical Center, the Netherlands. (L.A.v.d.B., Y.B.R.)
| | - Marcel G W Dijkgraaf
- Clinical Epidemiology, Biostatistics, and Bioinformatics, Amsterdam University Medical Center, the Netherlands. (M.G.W.D.)
| | | |
Collapse
|
28
|
Hendrix P, Chaudhary D, Avula V, Abedi V, Zand R, Noto A, Melamed I, Goren O, Schirmer CM, Griessenauer CJ. Outcomes of Mechanical Thrombectomy in the Early (<6-hour) and Extended (≥6-hour) Time Window Based Solely on Noncontrast CT and CT Angiography: A Propensity Score-Matched Cohort Study. AJNR Am J Neuroradiol 2021; 42:1979-1985. [PMID: 34556475 DOI: 10.3174/ajnr.a7271] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 06/29/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Current stroke care recommendations for patient selection for mechanical thrombectomy in the extended time window demand advanced imaging to determine the stroke core volume and hypoperfusion mismatch, which may not be available at every center. We aimed to determine outcomes in patients selected for mechanical thrombectomy solely on the basis of noncontrast CT and CTA in the early (<6-hour) and extended (≥6-hour) time windows. MATERIALS AND METHODS Consecutive mechanical thrombectomies performed for acute large-vessel occlusion ischemic (ICA, M1, M2) stroke between February 2016 and August 2020 were retrospectively reviewed. Eligibility was based solely on demographics and noncontrast CT (ASPECTS) and CTA, due to the limited availability of perfusion imaging during the study period. Propensity score matching was performed to compare outcomes between time windows. RESULTS Of 417 mechanical thrombectomies performed, 337 met the inclusion criteria, resulting in 205 (60.8%) and 132 (39.2%) patients in the 0- to 6- and 6- to 24-hour time windows, respectively. The ASPECTS was higher in the early time window (9; interquartile range = 8-10) than the extended time window (9; interquartile range = 7-10; P = .005). Propensity score matching yielded 112 well-matched pairs. Equal rates of TICI 2b/3 revascularization and symptomatic intracranial hemorrhage were observed. A favorable functional outcome (mRS 0-2) at 90 days was numerically more frequent in the early window (45.5% versus 33.9%, P = .091). Mortality was numerically more frequent in the early window (25.9% versus 17.0%, P = .096). CONCLUSIONS Patients selected for mechanical thrombectomy in the extended time window solely on the basis of noncontrast CT and CTA still achieved decent rates of favorable 90-day functional outcomes, not statistically different from patients in the early time window.
Collapse
Affiliation(s)
- P Hendrix
- From the Department of Neurosurgery (P.H., I.M., O.G., C.M.S., C.J.G.).,Department of Neurosurgery (P.H.), Saarland University Hospital, Homburg, Germany
| | - D Chaudhary
- Department of Neurology (D.C., R.Z., A.N.), Geisinger Neuroscience Institute
| | - V Avula
- Department of Molecular and Functional Genomics (V. Avula, V. Abedi), Geisinger Health System, Danville, Pennsylvania
| | - V Abedi
- Department of Molecular and Functional Genomics (V. Avula, V. Abedi), Geisinger Health System, Danville, Pennsylvania.,Biocomplexity Institute (V. Abedi), Virginia Polytechnic Institute and State University, Blacksburg, Virginia
| | - R Zand
- Department of Neurology (D.C., R.Z., A.N.), Geisinger Neuroscience Institute
| | - A Noto
- Department of Neurology (D.C., R.Z., A.N.), Geisinger Neuroscience Institute
| | - I Melamed
- From the Department of Neurosurgery (P.H., I.M., O.G., C.M.S., C.J.G.)
| | - O Goren
- From the Department of Neurosurgery (P.H., I.M., O.G., C.M.S., C.J.G.)
| | - C M Schirmer
- From the Department of Neurosurgery (P.H., I.M., O.G., C.M.S., C.J.G.).,Research Institute of Neurointervention (C.M.S., C.J.G.)
| | - C J Griessenauer
- From the Department of Neurosurgery (P.H., I.M., O.G., C.M.S., C.J.G.) .,Research Institute of Neurointervention (C.M.S., C.J.G.).,Department of Neurosurgery (C.J.G.), Christian Doppler University Hospital, Paracelsus Medical University, Salzburg, Austria
| |
Collapse
|
29
|
Magoufis G, Safouris A, Raphaeli G, Kargiotis O, Psychogios K, Krogias C, Palaiodimou L, Spiliopoulos S, Polizogopoulou E, Mantatzis M, Finitsis S, Karapanayiotides T, Ellul J, Bakola E, Brountzos E, Mitsias P, Giannopoulos S, Tsivgoulis G. Acute reperfusion therapies for acute ischemic stroke patients with unknown time of symptom onset or in extended time windows: an individualized approach. Ther Adv Neurol Disord 2021; 14:17562864211021182. [PMID: 34122624 PMCID: PMC8175833 DOI: 10.1177/17562864211021182] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 05/10/2021] [Indexed: 02/05/2023] Open
Abstract
Recent randomized controlled clinical trials (RCTs) have revolutionized acute ischemic stroke care by extending the use of intravenous thrombolysis and endovascular reperfusion therapies in time windows that have been originally considered futile or even unsafe. Both systemic and endovascular reperfusion therapies have been shown to improve outcome in patients with wake-up strokes or symptom onset beyond 4.5 h for intravenous thrombolysis and beyond 6 h for endovascular treatment; however, they require advanced neuroimaging to select stroke patients safely. Experts have proposed simpler imaging algorithms but high-quality data on safety and efficacy are currently missing. RCTs used diverse imaging and clinical inclusion criteria for patient selection during the dawn of this novel stroke treatment paradigm. After taking into consideration the dismal prognosis of nonrecanalized ischemic stroke patients and the substantial clinical benefit of reperfusion therapies in selected late presenters, we propose rescue reperfusion therapies for acute ischemic stroke patients not fulfilling all clinical and imaging inclusion criteria as an option in a subgroup of patients with clinical and radiological profiles suggesting low risk for complications, notably hemorrhagic transformation as well as local or remote parenchymal hemorrhage. Incorporating new data to treatment algorithms may seem perplexing to stroke physicians, since treatment and imaging capabilities of each stroke center may dictate diverse treatment pathways. This narrative review will summarize current data that will assist clinicians in the selection of those late presenters that will most likely benefit from acute reperfusion therapies. Different treatment algorithms are provided according to available neuroimaging and endovascular treatment capabilities.
Collapse
Affiliation(s)
- Georgios Magoufis
- Interventional Neuroradiology Unit, Metropolitan Hospital, Piraeus, Greece
| | - Apostolos Safouris
- Stroke Unit, Metropolitan Hospital, Piraeus, Greece
- Interventional Neuroradiology Unit, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Guy Raphaeli
- Interventional Neuroradiology Unit, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel
| | | | - Klearchos Psychogios
- Stroke Unit, Metropolitan Hospital, Piraeus, Greece
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Christos Krogias
- Department of Neurology, St. Josef-Hospital, Ruhr University Bochum, Bochum, Germany
| | - Lina Palaiodimou
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Stavros Spiliopoulos
- Second Department of Radiology, Interventional Radiology Unit, “ATTIKON” University General Hospital, Athens, Greece
| | - Eftihia Polizogopoulou
- Emergency Medicine Clinic, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Michael Mantatzis
- Department of Radiology, University Hospital of Alexandroupolis, Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece
| | - Stephanos Finitsis
- Department of Interventional Radiology, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Theodore Karapanayiotides
- Second Department of Neurology, Aristotle University of Thessaloniki, School of Medicine, Faculty of Health Sciences, AHEPA University Hospital, Thessaloniki, Greece
| | - John Ellul
- Department of Neurology, University Hospital of Patras, School of Medicine, University of Patras, Patras, Greece
| | - Eleni Bakola
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Elias Brountzos
- Second Department of Radiology, Interventional Radiology Unit, “ATTIKON” University General Hospital, Athens, Greece
| | - Panayiotis Mitsias
- Department of Neurology Medical School, University of Crete, Heraklion, Crete, Greece
| | - Sotirios Giannopoulos
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, National & Kapodistrian, University of Athens, School of Medicine, “Attikon” University Hospital, Iras 39, Gerakas Attikis, Athens, 15344, Greece
- Department of Neurology, The University of Tennessee Health Science Center, Memphis, TN, USA
| |
Collapse
|
30
|
Thomas SM. Re: Patterns of Mechanical Thrombectomy for Stroke Before and After the 2015 Pivotal Trials and US National Guideline Update. J Stroke Cerebrovasc Dis 2020; 30:105493. [PMID: 33253983 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 11/19/2020] [Indexed: 10/22/2022] Open
Affiliation(s)
- Steven Mulackal Thomas
- Department of Population and Family Health, Columbia University Mailman School of Public Health, 722 West 168th Street, New York, NY, 10032, USA.
| |
Collapse
|