A model of cost-effectiveness of tissue plasminogen activator in patient subgroups 3 to 4.5 hours after onset of acute ischemic stroke

Quality of health economic evaluations in emergency medicine journals: a systematic review

OBJECTIVE

Health economic evaluations are used in decision-making regarding resource allocation and it is imperative that they are completed with rigor. The primary objectives were to describe the characteristics and assess the quality of economic evaluations published in emergency medicine journals.

METHODS

Two reviewers independently searched 19 emergency medicine-specific journals via Medline and Embase from inception until March 3, 2022. Quality assessment was completed using the Quality of Health Economic Studies (QHES) tool, and the primary outcome was the QHES score out of 100. Additionally, we identified factors that may contribute to higher-quality publications.

RESULTS

7260 unique articles yielded 48 economic evaluations that met inclusion criteria. Most studies were cost-utility analyses and of high quality, with a median QHES score of 84 (interquartile range, IQR: 72, 90). Studies based on mathematical models and those primarily designed as an economic evaluation were associated with higher quality scores. The most commonly missed QHES items were: (i) providing and justifying the perspective of the analysis, (ii) providing justification for the primary outcome, and (iii) selecting an outcome that was long enough to allow for relevant events to occur.

CONCLUSIONS

The majority of health economic evaluations in the emergency medicine literature are cost-utility analyses and are of high quality. Decision analytic models and studies primarily designed as economic analyses were positively correlated with higher quality. To improve study quality, future EM economic evaluations should justify the choice of the perspective of the analysis and the selection of the primary outcome.

Modeling the potential efficiency of a blood biomarker-based tool to guide pre-hospital thrombolytic therapy in stroke patients

OBJECTIVES

Stroke treatment with intravenous tissue-type plasminogen activator (tPA) is effective and efficient, but as its benefits are highly time dependent, it is essential to treat the patient promptly after symptom onset. This study evaluates the cost-effectiveness of a blood biomarker test to differentiate ischemic and hemorrhagic stroke to guide pre-hospital treatment with tPA in patients with suspected stroke, compared with standard hospital management. The standard care for patients suffering stroke consists mainly in diagnosis, treatment, hospitalization and monitoring.

METHODS

A Markov model was built with four health states according to the modified Rankin scale, in adult patients with suspected moderate to severe stroke (NIHSS 4-22) within 4.5 hours after symptom onset. A Spanish Health System perspective was used. The time horizon was 15 years. Quality-adjusted life-years (QALYs) and life-years gained (LYGs) were used as a measure of effectiveness. Short- and long-term direct health costs were included. Costs were expressed in Euros (2022). A discount rate of 3% was used. Probabilistic sensitivity analysis and several one-way sensitivity analyses were conducted.

RESULTS

The use of a blood-test biomarker compared with standard care was associated with more QALYs (4.87 vs. 4.77), more LYGs (7.18 vs. 7.07), and greater costs (12,807€ vs. 12,713€). The ICER was 881€/QALY. Probabilistic sensitivity analysis showed that the biomarker test was cost-effective in 82% of iterations using a threshold of 24,000€/QALY.

CONCLUSIONS

The use of a blood biomarker test to guide pre-hospital thrombolysis is cost-effective compared with standard hospital care in patients with ischemic stroke.

The initiator of neuroexcitotoxicity and ferroptosis in ischemic stroke: Glutamate accumulation

Glutamate plays an important role in excitotoxicity and ferroptosis. Excitotoxicity occurs through over-stimulation of glutamate receptors, specifically NMDAR, while in the non-receptor-mediated pathway, high glutamate concentrations reduce cystine uptake by inhibiting the System Xc-, leading to intracellular glutathione depletion and resulting in ROS accumulation, which contributes to increased lipid peroxidation, mitochondrial damage, and ultimately ferroptosis. Oxidative stress appears to crosstalk between excitotoxicity and ferroptosis, and it is essential to maintain glutamate homeostasis and inhibit oxidative stress responses in vivo. As researchers work to develop natural compounds to further investigate the complex mechanisms and regulatory functions of ferroptosis and excitotoxicity, new avenues will be available for the effective treatment of ischaemic stroke. Therefore, this paper provides a review of the molecular mechanisms and treatment of glutamate-mediated excitotoxicity and ferroptosis.

Cost-effectiveness of CYP2C19 genotyping to guide antiplatelet therapy for acute minor stroke and high-risk transient ischemic attack

Dual antiplatelet therapy (DAPT) with clopidogrel plus aspirin within 48 h of acute minor strokes and transient ischemic attacks (TIAs) has been indicated to effectively reduce the rate of recurrent strokes. However, the efficacy of clopidogrel has been shown to be affected by cytochrome P450 2C19 (CYP2C19) polymorphisms. Patients carrying loss-of-function alleles (LoFAs) at a low risk of recurrence (ESRS < 3) cannot benefit from clopidogrel plus aspirin at all and may have an increased bleeding risk. In order to optimize antiplatelet therapy for these patients and avoid the waste of medical resources, it is important to identify the subgroups that genuinely benefit from DAPT with clopidogrel plus aspirin through CYP2C19 genotyping. This study sought to assess the cost-effectiveness of CYP2C19 genotyping to guide drug therapy for acute minor strokes or high-risk TIAs in China. A decision tree and Markov model were constructed to evaluate the cost-effectiveness of CYP2C19 genotyping. We used a healthcare payer perspective, and the primary outcomes included quality-adjusted life years (QALYs), costs and the incremental cost-effectiveness ratio (ICER). Sensitivity analyses were performed to evaluate the robustness of the results. CYP2C19 genotyping resulted in a lifetime gain of 0.031 QALYs at an additional cost of CNY 420.13 (US$ 59.85), yielding an ICER of CNY 13,552.74 (US$ 1930.59) per QALY gained. Probabilistic sensitivity analysis showed that genetic testing was more cost-effective in 95.7% of the simulations at the willingness-to-pay threshold of CNY 72,100 (GDP per capita, US$ 10,300) per QALY. Therefore, CYP2C19 genotyping to guide antiplatelet therapy for acute minor strokes and high-risk TIAs is highly cost-effective in China.

Towards On-Demand E. coli-Based Cell-Free Protein Synthesis of Tissue Plasminogen Activator

Stroke is the leading cause of death with over 5 million deaths worldwide each year. About 80% of strokes are ischemic strokes caused by blood clots. Tissue plasminogen activator (tPa) is the only FDA-approved drug to treat ischemic stroke with a wholesale price over $6000. tPa is now off patent although no biosimilar has been developed. The production of tPa is complicated by the 17 disulfide bonds that exist in correctly folded tPA. Here, we present an Escherichia coli-based cell-free protein synthesis platform for tPa expression and report conditions which resulted in the production of active tPa. While the activity is below that of commercially available tPa, this work demonstrates the potential of cell-free expression systems toward the production of future biosimilars. The E. coli-based cell-free system is increasingly becoming an attractive platform for low-cost biosimilar production due to recent developments which enable production from shelf-stable lyophilized reagents, the removal of endotoxins from the reagents to prevent the risk of endotoxic shock, and rapid on-demand production in hours.

A systematic review and meta-analysis of interventions to increase stroke thrombolysis

Background

Although the efficacy of tissue plasminogen activator (tPA) for acute ischemic stroke is well established, rates of tPA use remain low. For clinicians, advocates, and policy-makers seeking to increase tPA treatment rates, it is important to understand what interventions exist and their relative effectiveness.

Methods

We searched PubMed and EMBASE to identify all studies published between 1995 and January 8, 2015 documenting interventions to increase the use of tPA with broadly inclusive criteria. The principal summary measure was the percentage change in rate of tPA administration. Random effects meta-analytic models were built to summarize the effect of intervention compared to control overall and for intervention characteristics.

Results

The search yielded 1457 results of which 25 met eligibility criteria. We identified 14 pre-post studies, ten randomized controlled trials, and one quasi-experiment. Included studies targeted their interventions at emergency medical services (EMS) (n = 14), telemedicine (n = 6), and public education (n = 6). In a random effects model, tPA administration was significantly higher in the intervention arm across all studies limiting enrollment to ischemic stroke patients (n = 16) with a risk ratio (RR) of 1.80 (95% confidence interval [CI], 1.45–2.22). A trend towards increased tPA administration was observed for all intervention approaches: risk ratio of 1.73 (95% CI, 1.44–2.09) for EMS, 1.58 (95% CI, 0.72–3.47) for telemedicine, and 1.89 (95% CI, 0.77–4.65) for public education, the latter not restricted to ischemic stroke patients.

Conclusions

Interventions to increase tPA use appear to have considerable effectiveness. Our findings support the use of such interventions to improve stroke outcomes.

Scoping Review of Interventions Associated with Cost Avoidance Able to Be Performed in the Intensive Care Unit and Emergency Department

A framework for evaluating pharmacists' impact on cost avoidance in the intensive care unit (ICU) and emergency department (ED) has not been established. This scoping review was registered (CRD42018091217) and conducted to identify, aggregate, and qualitatively describe the highest quality evidence for cost avoidance generated by clinical pharmacists on interventions performed in an ICU or ED. Searches were conducted in PubMed, Scopus, CINAHL, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews from inception until April 2018. The level of evidence (LOE) for each specific category of intervention was evaluated according to the Grading of Recommendations, Assessment, Development and Evaluation evidence-to-decision framework. The risks of bias for articles were evaluated using Newcastle Ottawa and Cochrane Collaboration tools. The values from all interventions were inflated to 2018 U.S. dollars using the consumer price index for medical care. Of the 464 articles initially identified, 371 were excluded and 93 were included. After reviewing references from the articles included, an additional 71 articles were also reviewed. The 38 cost intervention categories were supported by varying LOEs: IA (0 categories), IB (1 category), IIA (4 categories), IIB (0 categories), III (27 categories), and IV (6 categories), and articles mostly displayed low to moderate risks of bias. Pharmacists generate cost avoidance through a variety of interventions in critically and emergently ill patients. The quality of evidence supporting specific cost avoidance values is generally low. Quantification of and factors associated with the cost avoidance generated from pharmacists caring for these patients are of paramount importance.

Safety and cost-effectiveness thrombolysis by diffusion-weighted imaging and fluid attenuated inversion recovery mismatch for wake-up stroke

Wake-up stroke, defined as patients who wake up with stroke symptoms which were not present prior to falling asleep, accounted for 14%-25% of acute ischemic stroke. Due to the unknown time of symptom onset, wake-up stoke was not in including criteria of intravenous thrombolysis. Several large randomized stroke trials using diffusion-weighted imaging(DWI)and fluid attenuated inversion recovery(FLAIR)mismatch patient selection may identify a subset of patients with wake-up stroke that can safely and effectively benefit from intravenous thrombolysis. In addition, economic factor was another important limitation to generalize thrombolysis treatment. Fortunately, MRI-based thrombolysis was a cost-effective treatment for wake-up stroke compared to these patients with no thrombolysis.

Cost-effectiveness analysis of tissue plasminogen activator in acute ischemic stroke in Iran

AIMS

Tissue plasminogen activator (tPA) is used to treat acute ischemic stroke up to 4.5 h after symptom onset. Its cost-effectiveness in developing countries is not specified yet. This study aimed to study cost-effectiveness of tPA in Iran.

METHODS

This is a cost-effectiveness analysis from the perspective of the third party payer to compare IV tPA with no tPA of ischemic stroke. A Markov model with a lifetime horizon was used to analyze the costs and outcomes. Cost data were extracted from the 94 patients admitted in two hospitals in Iran. All costs were calculated based on US dollars in 2016. Quality-adjusted life years (QALY) were extracted from previously published literature. Cost-effectiveness was determined by calculating ICER by TreeAge Pro 2011 software.

RESULTS

Lifetime costs of no tPA strategy were higher than tPA ($10,718 in the no tPA group compared with $8,796 in the tPA group). The tPA arm gained 0.20 QALY compared with no tPA. ICER was $8,471 per QALY. ICER value suggests that tPA is cost-effective compared with no tPA.

LIMITATIONS

The limitations of the present study are the reliance on calculated QALY value of other countries and difficulty in accessing patients treated with tPA.

CONCLUSIONS

The balance of hospitalization and rehabilitation costs and QALYs support the conclusion that treatment with intravenous tPA in the 4.5-h time window is cost-effective from the perspectives of the third party payer and inclusion of tPA in the insurance benefit package being reasonable.

Age-specific Cost Effectiveness of Using Intravenous Recombinant Tissue Plasminogen Activator for Treating Acute Ischemic Stroke

INTRODUCTION

Studies have demonstrated that intravenous recombinant tissue plasminogen activator (IV rtPA) is a cost-effective treatment for acute ischemic stroke. Age-specific cost effectiveness has not been well examined. This study estimated age-specific incremental cost-effectiveness ratios (ICERs) of IV rtPA treatment versus no IV rtPA.

METHODS

A Markov model was developed to examine the economic impact of IV rtPA over a 20-year time horizon on four age groups (18-44, 45-64, 65-80, and ≥81 years) from the U.S. healthcare sector perspective. The model used health outcomes from a national stroke registry adjusted by parameters from previous literature and current hospitalization costs in 2013 U.S. dollars. Long-term annual costs and quality-adjusted life years (QALYs) in the years after a stroke were discounted at 3% per year. Incremental costs, incremental QALYs, and ICERs were estimated and sensitivity analyses were conducted between 2015 and 2017.

RESULTS

Use of IV rtPA gained 0.55 QALYs and cost $3,941 more than no IV rtPA for stroke patients aged ≥18 years over a 20-year time horizon. IV rtPA was a dominant strategy compared to no IV rtPA for patients aged 18-44 and 45-64 years. For patients aged 65-80 years, IV rtPA gained 0.44 QALYs and cost $4,872 more than no IV rtPA (ICER=$11,132/QALY). For patients aged ≥81 years, ICER was estimated at $48,676/QALY.

CONCLUSIONS

IV rtPA saved costs and improved health outcomes for patients aged 18-64 years and was cost effective for those aged ≥65 years. These findings support the use of IV rtPA.

Development and implementation of tPA clot lysis activity assay using ACL TOP™ hemeostasis testing system in QC laboratories

This report describes the design, development, validation and long-term performance of tPA clot lysis activity assay using Advanced Chemistry Line Total Operational Performance (ACL TOP)™ Homeostasis Testing System. The results of the study demonstrated robust and stable performance of the analytical method. The accuracy of the assay, expressed by percent recovery is 98-99%. The intermediate precision and repeatability precision, expressed as Relative Standard Deviation (RSD), was 3% and less than 2% respectively. The validated range is from 70% to 130% of the target potency of 5.8 × 10⁵ IU/mg. The linearity of this range, expressed in correlation coefficient, is 0.997. After the assay is transferred to a QC laboratory, the assay retained high accuracy and precision with a success rate of >99%.

Sex differences in ischaemic stroke: potential cellular mechanisms

Stroke remains a leading cause of mortality and disability worldwide. More women than men have strokes each year, in part because women live longer. Women have poorer functional outcomes, are more likely to need nursing home care and have higher rates of recurrent stroke compared with men. Despite continued advancements in primary prevention, innovative acute therapies and ongoing developments in neurorehabilitation, stroke incidence and mortality continue to increase due to the aging of the U.S.

POPULATION

Sex chromosomes (XX compared with XY), sex hormones (oestrogen and androgen), epigenetic regulation and environmental factors all contribute to sex differences. Ischaemic sensitivity varies over the lifespan, with females having an "ischaemia resistant" phenotype that wanes after menopause, which has recently been modelled in the laboratory. Pharmacological therapies for acute ischaemic stroke are limited. The only pharmacological treatment for stroke approved by the Food and Drug Administration (FDA) is tissue plasminogen activator (tPA), which must be used within hours of stroke onset and has a number of contraindications. Pre-clinical studies have identified a number of potentially efficacious neuroprotective agents; however, nothing has been effectively translated into therapy in clinical practice. This may be due, in part, to the overwhelming use of young male rodents in pre-clinical research, as well as lack of sex-specific design and analysis in clinical trials. The review will summarize the current clinical evidence for sex differences in ischaemic stroke, and will discuss sex differences in the cellular mechanisms of acute ischaemic injury, highlighting cell death and immune/inflammatory pathways that may contribute to these clinical differences.

A literature review of cost-effectiveness of intravenous recombinant tissue plasminogen activator for treating acute ischemic stroke

BACKGROUND

Intravenous recombinant tissue plasminogen activator (IV rtPA) is recommended treatment for acute ischemic stroke patients, but the cost-effectiveness of IV rtPA within different time windows after the onset of acute ischemic stroke is not well reviewed.

AIMS

To conduct a literature review of the cost-effectiveness studies about IV rtPA by treatment times.

SUMMARY OF REVIEW

A literature search was conducted using MEDLINE, EMBASE, CINAHL and Cochrane Library, with the key words acute ischemic stroke, tissue plasminogen activator, cost, economic benefit, saving, and incremental cost-effectiveness analysis. The review is limited to original research articles published during 1995-2016 in English-language peer-reviewed journals. We found 16 studies meeting our criteria for this review. Nine of them were cost-effectiveness studies of IV rtPA treatment within 0-3 hours after stroke onset, 2 studies within 3-4.5 hours, 3 studies within 0-4.5 hours, and 2 study within 0-6 hours. IV rtPA is a cost-saving or a cost-effectiveness strategy from most of the study results. Only one study showed incremental cost-effectiveness ratio of IV rtPA within one year was marginally above $50,000 per QALY threshold. IV rtPA within 0-3 hours after stroke led to cost savings for lifetime or 30 years, and IV rtPA within 3-4.5 hours after stroke increased costs but still was cost-effective.

CONCLUSIONS

The literature generally showed that intravenous IV rtPA was a dominant or a cost-effective strategy compared to traditional treatment for acute ischemic stroke patients without IV rtPA. The findings from the literature lacked generalizability because of limited data and various assumptions.

Real-world costs of ischemic stroke by discharge status

OBJECTIVE

The objective of this study was to estimate the acute healthcare costs of ischemic stroke during hospitalization and the quarterly all-cause healthcare costs for the first year after discharge by discharge status.

METHODS

Adult patients with a hospitalization with a diagnosis of ischemic stroke (ICD-9-CM: 434.xx or 436.xx) between 1 January 2006 and 31 March 2015 were identified from a large US commercial claims database. Patients were classified into three cohorts based on their discharge status from the first stroke hospitalization, i.e. dead at discharge, discharged with disability, or discharged without disability. Third-party (medical and pharmacy) and out-of-pocket costs were adjusted to 2015 USD.

RESULTS

A total of 7919 patients dead at discharge, 45,695 patients discharged with disability, and 153,778 patients discharged without disability were included in this analysis. The overall average age was 59.7 years and 52.3% were male. During hospitalization, mean total costs (third-party and out-of-pocket) were $68,370 for patients dead at discharge, $73,903 for patients discharged with disability, and $24,448 for patients discharged without disability (p < .001 for each pairwise comparison); mean third-party costs were $63,605 for patients dead at discharge, $67,861 for patients discharged with disability and $19,267 for patients discharged without disability (p < .001 for each pairwise comparison). During the first year after discharge, mean total costs for patients discharged with disability vs. without disability were $46,850 vs. $30,132 (p < .001). Mean third-party costs for patients discharged with disability vs. without disability were $19,116 vs. $10,976 during the first quarter after discharge, $10,236 vs. $6926 during the second quarter, $8241 vs. $5810 during the third quarter, and $6875 vs. $5292 during the fourth quarter (p < .001 for each quarter).

CONCLUSION

The results demonstrated the high economic burden of ischemic stroke, especially among patients discharged with disability with the highest costs incurred during the inpatient stays.

The High Cost of Stroke and Stroke Cytoprotection Research

Acute ischemic stroke is inadequately treated in the USA and worldwide due to a lengthy history of neuroprotective drug failures in clinical trials. The majority of victims must endure life-long disabilities that not only affect their livelihood, but also have an enormous societal economic impact. The rapid development of a neuroprotective or cytoprotective compound would allow future stroke victims to receive a treatment to reduce disabilities and further promote recovery of function. This opinion article reviews in detail the enormous costs associated with developing a small molecule to treat stroke, as well as providing a timely overview of the cell-death time-course and relationship to the ischemic cascade. Distinct temporal patterns of cell-death of neurovascular unit components provide opportunities to intervene and optimize new cytoprotective strategies. However, adequate research funding is mandatory to allow stroke researchers to develop and test their novel therapeutic approach to treat stroke victims.

A model for priority setting of health technology assessment: the experience of AHP-TOPSIS combination approach

BACKGROUND

In recent times, the use of health technologies in the diagnosis and treatment of diseases experienced considerable and accelerated growth. The goal of the present study was to describe the designated pilot MCDM (Multiple Criteria Decision Making) model for priority setting of health technology assessment in Iran.

METHODS

Relevant articles were sought and retrieved from the most appropriate medical databases, including the Cochrane Library, PubMed and Scopus via three separate search strategies, using MESH and free text until March, 2015. Retrieved criteria were questioned from health technology assessment experts in two rounds and the relative weight for valid criteria was finally obtained from paired wise comparison method. After extraction of relative weights based on the aforementioned procedure, TOPSIS (The Technique for Order of Preference by Similarity to Ideal Solution) priority setting model was designed. The stated model was applied for assessing three technologies (adenosine, tissue plasminogen activator and mechanical thrombectomy) which were available for projects call of Iranian health technology assessment department in order to determine applicability of the model for practical purpose.

RESULTS

Nine criteria, including efficiency/effectiveness, safety, population size, vulnerable population size, availability of alternative technologies, cost effectiveness in other countries, budget impact, financial protection, quality of evidence, were extracted by the Iranian health technology assessment experts. The relative weights of these criteria were as follows 0.12, 0.2, 0.06, 0.08, 0.08, 0.13, 0.08, 0.09, and 0.15, respectively. Finally TOPSIS pilot model was designed by three health technologies and nine criteria relative weights. Results showed that, the applicability of the stated model was suitable and as the pilot testing, tissue plasminogen activator was the first priority, adenosine was second and mechanical thrombectomy was third for performing health technology assessment by the Iranian ministry of health and medical education.

CONCLUSION

According to the results of this study, this model with nine effective criteria and their relative weights and in combination with TOPSIS approach could be used with suitable applicability by health technology assessment department in deputy of curative affairs and food and drug organization for determination of research priorities in health technology assessment.

Use of intravenous tissue plasminogen activator and hospital costs for patients with acute ischaemic stroke aged 18-64 years in the USA

Introduction

Intravenous tissue plasminogen activator (IV tPA) is a globally recommended treatment for patients with acute ischaemic stroke. We examined IV tPA use among patients aged 18–64 years with a primary diagnosis of acute ischaemic stroke in the USA and inpatient costs per hospitalisation by IV tPA use status among these patients.

Methods

Using the 2010–2013 MarketScan Commercial Claims and Encounters Inpatient Data, we identified 39 149 hospitalisations with a primary diagnosis of acute ischaemic stroke. We verified those with and without IV tPA by ICD-9 procedure code 99.10. We estimated trends in IV tPA use by applying logistic regression. The average inpatient costs per acute ischaemic stroke hospitalisation were assessed for subpopulations. We examined costs per acute ischaemic stroke hospitalisation using multivariate regression models controlling for IV tPA status, age, gender, urbanisation, geographic region, Charlson comorbidity index, length of hospital stays (LOS) and discharge status.

Results

2546 hospitalisations (6.5%) used IV tPA. IV tPA use increased over time (2010 vs 2013; OR 1.50). Average inpatient costs per acute ischaemic stroke hospitalisation were $20 331 ($31 369 for the IV tPA group, $19 563 for the non-tPA group). From multivariate analyses, higher costs per acute ischaemic stroke hospitalisation were associated with longer LOS, non-home discharge destination, and IV tPA use, which might be correlated with severity of stroke.

Conclusions

Findings suggest that IV tPA use has increased in recent years while the inpatient costs per acute ischaemic stroke hospitalisation using IV tPA are substantial. Those findings are useful in better understanding the overall economic burden of stroke, short-term cost implications of using IV tPA, and for estimating the accurate cost-effectiveness of stroke treatments.

Critical early thrombolytic and endovascular reperfusion therapy for acute ischemic stroke victims: a call for adjunct neuroprotection

Today, there is an enormous amount of excitement in the field of stroke victim care due to the recent success of MR. CLEAN, SWIFT PRIME, ESCAPE, EXTEND-IA, and REVASCAT endovascular trials. Successful intravenous (IV) recombinant tissue plasminogen activator (rt-PA) clinical trials [i.e., National Institute of Neurological Disorders and Stroke (NINDS) rt-PA trial, Third European Cooperative Acute Stroke Study (ECASSIII), and Third International Stroke study (IST-3)] also need to be emphasized. In the recent endovascular and thrombolytic trials, there is statistically significant improvement using both the National Institutes of Health Stroke Scale (NIHSS) and the modified Rankin Score (mRS) scale, but neither approach promotes complete recovery in patients enrolled within any particular NIHSS or mRS score tier. Absolute improvement (mRS 0-2 at 90 days) with endovascular therapy is 13.5-31 %, whereas thrombolytics alone also significantly improve patient functional independence, but to a lesser degree (NINDS rt-PA trial 13 %). This article has 3 main goals: (1) first to emphasize the utility and cost-effectiveness of rt-PA to treat stroke; (2) second to review the recent endovascular trials with respect to efficacy, safety, and cost-effectiveness as a stroke treatment; and (3) to further consider and evaluate strategies to develop novel neuroprotective drugs. A thesis will be put forth so that future stroke trials and therapy development can optimally promote recovery so that stroke victims can return to "normal" life.

Cost-effectiveness of thrombolysis within 4.5 hours of acute ischemic stroke in China

Background

Previous economic studies conducted in developed countries showed intravenous tissue-type plasminogen activator (tPA) is cost-effective for acute ischemic stroke. The present study aimed to determine the cost-effectiveness of tPA treatment in China, the largest developing country.

Methods

A combination of decision tree and Markov model was developed to determine the cost-effectiveness of tPA treatment versus non-tPA treatment within 4.5 hours after stroke onset. Outcomes and costs data were derived from the database of Thrombolysis Implementation and Monitor of acute ischemic Stroke in China (TIMS-China) study. Efficacy data were derived from a pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials. Costs and quality-adjusted life-years (QALYs) were compared in both short term (2 years) and long term (30 years). One-way and probabilistic sensitivity analyses were performed to test the robustness of the results.

Results

Comparing to non-tPA treatment, tPA treatment within 4.5 hours led to a short-term gain of 0.101 QALYs at an additional cost of CNY 9,520 (US$ 1,460), yielding an incremental cost-effectiveness ratio (ICER) of CNY 94,300 (US$ 14,500) per QALY gained in 2 years; and to a long-term gain of 0.422 QALYs at an additional cost of CNY 6,530 (US$ 1,000), yielding an ICER of CNY 15,500 (US$ 2,380) per QALY gained in 30 years. Probabilistic sensitivity analysis showed that tPA treatment is cost-effective in 98.7% of the simulations at a willingness-to-pay threshold of CNY 105,000 (US$ 16,200) per QALY.

Conclusions

Intravenous tPA treatment within 4.5 hours is highly cost-effective for acute ischemic strokes in China.

The Effect of tPA on Inpatient Rehabilitation after Stroke: A Cost Comparison

Background:

Tissue plasminogen activator has been found to significantly improve patient outcomes post stroke. Previous economic evaluations have adjusted for fewer admissions to inpatient rehabilitation but not for decreased length of stay in rehabilitation. Our objective was to estimate the potential cost savings associated with a decreased length of stay in inpatient rehabilitation for patients who receive tissue plasminogen activator compared to those who do not, in a Canadian context.

Methods:

Decreased length of stay in inpatient rehabilitation for patients who received tissue plasminogen activator compared to controls was reported previously in a population of 1962 patients admitted to hospital with an ischemic stroke in Ontario between July 1, 2003 and March 31, 2008. Average per diem cost savings associated with the use of tissue plasminogen activator were calculated using a literature based cost estimate. Sensitivity analysis varying the length of stay in inpatient rehabilitation was performed.

Results:

The estimated mean per diem cost of inpatient rehabilitation derived from the literature was $626. Based on previously reported estimates for reduced length of stay, receipt of tissue plasminogen activator was estimated to result in savings of $939 per patient during inpatient rehabilitation. Sensitivity analysis suggested that these cost savings could range from $501 to $1377 per patient on average.

Conclusions:

Future economic evaluations of tissue plasminogen activator should consider adjusting for shortened length of stay in inpatient rehabilitation for patients who receive tissue plasminogen activator.

Cost-Effectiveness of Recombinant Tissue-Type Plasminogen Activator Within 3 Hours of Acute Ischemic Stroke

Background and Purpose—

Despite the availability of results from multiple newer clinical trials and changing healthcare costs, the cost-effectiveness of recombinant tissue-type plasminogen activator (r-tPA) for treatment of acute ischemic stroke within 0 to 3 hours of symptom onset was last evaluated in 1998 for the United States Using current evidence, we evaluate the long-term cost-effectiveness of r-tPA administered 0 to 3 hours after acute ischemic stroke onset versus no r-tPA.

Methods—

A disease-based decision model to project lifetime outcomes of patients after acute ischemic stroke by r-tPA treatment status from the US payer perspective was developed. Model inputs were derived from a recent meta-analysis of r-tPA trials, cohort studies, and health state preference studies. Cost data, inflated to 2013 dollars, were based on drug wholesale acquisition cost and the literature. To compare r-tPA to no r-tPA, we calculated incremental total direct costs, incremental quality-adjusted life years, and incremental cost-effectiveness ratios. We performed 1-way and probabilistic sensitivity analyses to evaluate uncertainty in the results.

Results—

r-tPA resulted in a gain of 0.39 quality-adjusted life years (95% confidence range, 0.16–0.66) on average per patient and a lifetime cost-saving of $25 000 (95% confidence range, −$42 500 to −$11 000) compared with no r-tPA. In probabilistic sensitivity analyses, r-tPA was dominant compared with no r-tPA in ≈100% of simulations. The model was sensitive to inputs for r-tPA efficacy, healthcare costs for disabled patients, mortality rates for disabled and nondisabled patients, and quality of life estimates.

Conclusions—

Our analysis supports earlier economic evaluations that r-tPA is a cost-effective method to treat stroke. Appropriate use of r-tPA should be prioritized nationally.

Clinical trials in acute ischemic stroke

Acute ischemic stroke (AIS) is a major cause of mortality and disability and remains a serious and significant global health problem. The development of neurovascular protectants to treat AIS successfully has been beset by disappointments and setbacks. Many promising candidates have lacked significant pleiotropic protective activity for brain tissue and cerebral blood vessels in clinical trials, while those with protective activity have had poor bioavailability or high toxicity. Moreover, the majority of agents did not confer significant neurovascular protection or clinical efficacy, as measured by standard behavioral endpoints in clinical trials of heterogeneous populations of patients with AIS. The recombinant tissue plasminogen activator alteplase is approved in many countries for the treatment of AIS in the first 3 h after symptom onset. Many drug candidates have been subject to clinical trials, including those with anti-excitotoxic, anti-inflammatory, antioxidant, antiapoptotic/regenerative, calcium/adrenergic-modulating/antihypertensive, thrombolytic, nootropic/stimulant, fluid regulatory, or oxygen-delivering mechanisms of action. Some agents, such as tenecteplase, edaravone and minocycline, may be approved for global use in the future. This review evaluates almost all neurovascular protectants subject to clinical trial evaluation for the treatment of AIS, and includes 241 studies conducted between 1978 and 2014. The development of agents that reduce brain injury after AIS will require new and different approaches based on a deeper understanding of the pathophysiology of AIS. Moreover, the future treatment for AIS is likely to lie in combination therapy rather than monotherapy. Additional approaches to the testing and use of neurovascular protectants should be considered.

Cost and health care utilization in ARDS--different from other critical illness?

Costs of care in the intensive care unit are a frequent target for concern in the current health care system. Utilization of critical care services in the United States is increasing and will continue to do so. Acute respiratory distress syndrome (ARDS) is a common and important complication of critical illness. Patients with ARDS frequently have long hospitalizations and consume a significant amount of health care resources. Many patients are discharged with functional limitations and high susceptibility to new complications that require significant additional health care resources. There is increasing literature on the cost-effectiveness of the treatment of ARDS, and despite its high costs, treatment remains a cost-effective intervention by current societal standards. However, when ARDS leads to prolonged mechanical ventilation, treatment becomes less cost-effective. Current research seeks to find interventions that lead to reductions in duration of mechanical ventilation and intensive care unit (ICU) length of stay. Limited reductions in ICU length of stay have benefits for the patient, but they do not lead to significant reductions in overall hospital costs. Early discharge to post-acute care facilities can reduce hospital costs but are unlikely to decrease costs for an entire episode of illness. Improved effectiveness of communication between clinicians and patients or their surrogates could help avoid costly interventions with poor expected outcomes.

Cost-Effectiveness of Thrombolysis Within 4.5 Hours of Acute Ischemic Stroke

Background and Purpose—

Previous economic studies outside Australia have demonstrated that patients treated with tissue-type plasminogen activator (tPA) within 4.5 hours of stroke onset have lower healthcare costs than those not. We aim to perform cost-effectiveness analysis of intravenous tPA in an Australian setting.

Methods—

Data on clinical outcomes and costs were derived for 378 patients who received intravenous tPA within 4.5 hours of stroke onset at Royal Melbourne Hospital (Australia) between January 2003 and December 2011. To simulate clinical outcomes and costs for a hypothetical control group assumed not to have received tPA, we applied efficacy data from a meta-analysis of randomized trials to outcomes observed in the tPA group. During a 1-year time-horizon, net costs, years of life lived, and quality-adjusted life-years were compared and incremental cost-effectiveness ratios derived for tPA versus no tPA.

Results—

In the study population, mean (SD) age was 68.2 (13.5) years and 206 (54.5%) were men. Median National Institutes of Health Stroke Scale score (interquartile range) at presentation was 12.5 (8–18). Compared with no tPA, we estimated that tPA would result in 0.02 life-years and 0.04 quality-adjusted life-years saved per person >1 year. The net cost of tPA was AUD $55.61 per patient. The incremental cost-effectiveness ratios were AUD $2377 per life-year saved and AUD $1478 per quality-adjusted life-years saved. Because the costs of tPA are incurred only once, the incremental cost-effectiveness ratios would decrease with increasing time-horizon. Uncertainty analyses indicated the results to be robust.

Conclusions—

Intravenous tPA within 4.5 hours represents a cost-effective intervention for acute ischemic stroke.

RIGOR guidelines: escalating STAIR and STEPS for effective translational research

Stroke continues to be a serious and significant health problem in the USA and worldwide. This article will emphasize the need for good laboratory practices, transparent scientific reporting, and the use of translational research models representative of the disease state to develop effective treatments. This will allow for the testing and development of new innovative strategies so that efficacious therapies can be developed to treat ischemic and hemorrhagic stroke. This article recommends guidelines for effective translational research, most importantly, the need for study blinding, study group randomization, power analysis, accurate statistical analysis, and a conflict of interest statement. Additional guidelines to ensure reproducibility of results and confirmation of efficacy in multiple species are discussed.

Scientific Rigor Recommendations for Optimizing the Clinical Applicability of Translational Research

The approval of new therapies to treat neurodegenerative disease conditions by the Food and Drug administration (FDA) has been hindered by many failed clinical trials, which were based upon "significant" efficacy in preclinical or translational studies. Additional problems during drug development related to significant adverse events and unforeseen toxicity have also hampered drug development. Recent reviews of preclinical data suggests that many studies have over-estimated efficacy due to poor or inadequate study design, exclusion of important data (negative or neutral) and lack of study randomization and blinding. This article describes in detail a set of recommendations to improve the quality of science being conducted in laboratories worldwide, with the goal of documenting in the peer-reviewed literature, including Journal of Neurology and Neurophysiology, the scientific basis for the continued development of specific strategies to treat neurodegenerative diseases such as Stroke, Alzheimer's disease, Huntington's disease, Parkinson's disease, Spinal cord injury, and Amyotrophic lateral sclerosis. The minimum recommendations for effective translational research include the need for model justification, study group randomization and blinding, power analysis calculations, appropriate statistical analysis of all data sets, and a conflict of interest statement by investigators. It will also be beneficial to demonstrate reproducible efficacy in multiple species and in studies done by independent laboratories.