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Ye Z, Zhou T, Zhang M, Zhou J, Xie F, Hill MD, Smith EE, Busse JW, Zhang Y, Liu Y, Wang X, Ma Z, An Z. Cost-effectiveness of endovascular thrombectomy with alteplase versus endovascular thrombectomy alone for acute ischemic stroke secondary to large vessel occlusion. CMAJ Open 2023; 11:E443-E450. [PMID: 37192770 DOI: 10.9778/cmajo.20220096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2023] Open
Abstract
BACKGROUND Recent randomized trials have suggested that endovascular thrombectomy (EVT) alone may provide similar functional outcomes as the current standard of care, EVT combined with intravenous alteplase treatment, for acute ischemic stroke secondary to large vessel occlusion. We conducted an economic evaluation of these 2 therapeutic options. METHODS We constructed a decision analytic model with a hypothetical cohort of 1000 patients to assess the cost-effectiveness of EVT with intravenous alteplase treatment versus EVT alone for acute ischemic stroke secondary to large vessel occlusion from both the societal and public health care payer perspectives. We used studies and data published in 2009-2021 for model inputs, and acquired cost data for Canada and China, representing high- and middle-income countries, respectively. We calculated incremental cost-effectiveness ratios (ICERs) using a lifetime horizon and accounted for uncertainty using 1-way and probabilistic sensitivity analyses. All costs are reported in 2021 Canadian dollars. RESULTS In Canada, the difference in quality-adjusted life-years (QALYs) gained between EVT with alteplase and EVT alone was 0.10 from both the societal and health care payer perspectives. The difference in cost was $2847 from a societal perspective and $2767 from the payer perspective. In China, the difference in QALYs gained was 0.07 from both perspectives, and the difference in cost was $1550 from the societal perspective and $1607 from the payer perspective. One-way sensitivity analyses showed that the distributions of modified Rankin Scale scores at 90 days after stroke were the most influential factor on ICERs. For Canada, compared to EVT alone, the probability that EVT with alteplase would be cost-effective at a willingness-to-pay threshold of $50 000 per QALY gained was 58.7% from a societal perspective and 58.4% from a payer perspective. The corresponding values for at a willingness-to-pay threshold of $47 185 (3 times the Chinese gross domestic product per capita in 2021) were 65.2% and 67.4%. INTERPRETATION For patients with acute ischemic stroke due to large vessel occlusion eligible for immediate treatment with both EVT alone and EVT with intravenous alteplase treatment, it is uncertain whether EVT with alteplase is cost-effective compared to EVT alone in Canada and China.
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Affiliation(s)
- Zhikang Ye
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Ting Zhou
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Mengmeng Zhang
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Junwen Zhou
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Feng Xie
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Michael D Hill
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Eric E Smith
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Jason W Busse
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Yi Zhang
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Ying Liu
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Xin Wang
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Zhuo Ma
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Zhuoling An
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont.
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Waqas M, Gong AD, Levy BR, Dossani RH, Vakharia K, Cappuzzo JM, Becker A, Sonig A, Tutino VM, Almayman F, Davies JM, Snyder KV, Siddiqui AH, Levy EI. Is Endovascular Therapy for Stroke Cost-Effective Globally? A Systematic Review of the Literature. J Stroke Cerebrovasc Dis 2021; 30:105557. [PMID: 33556672 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105557] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 12/11/2020] [Accepted: 12/13/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Cost-effectiveness of endovascular therapy (EVT) is a key consideration for broad use of this approach for emergent large vessel occlusion stroke. We evaluated the evidence on cost-effectiveness of EVT in comparison with best medical management from a global perspective. MATERIALS AND METHODS This systematic review of studies published between January 2010 and May 2020 evaluated the cost effectiveness of EVT for patients with large vessel occlusion acute ischemic stroke. The gain in quality adjusted life year (QALY) and incremental cost-effectiveness ratio (ICER), expressed as cost per QALY resulting from EVT, were recorded. The study setting (country, economic perspective), decision model, and data sources used in economic models of EVT cost-effectiveness were recorded. RESULTS Twenty-five original studies from 12 different countries were included in our review. Five of these studies were reported from a societal perspective; 18 were reported from a healthcare system perspective. Two studies used real-world data. The time horizon varied from 1 year to a lifetime; however, 18 studies reported a time horizon of >10 years. Twenty studies reported using outcome data from randomized, controlled clinical trials for their models. Nineteen studies reported using a Markov model. Incremental QALYs ranged from 0.09-3.5. All studies but 1 reported that EVT was cost-effective. CONCLUSIONS Evidence from different countries and economic perspectives suggests that EVT for stroke treatment is cost-effective. Most cost-effectiveness studies are based on outcome data from randomized clinical trials. However, there is a need to study the cost-effectiveness of EVT based solely on real-world outcome data.
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Affiliation(s)
- Muhammad Waqas
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA.
| | - Andrew D Gong
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA.
| | - Bennett R Levy
- George Washington School of Medicine and Health Sciences, Washington, DC, USA.
| | - Rimal H Dossani
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA
| | - Kunal Vakharia
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA.
| | - Justin M Cappuzzo
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA.
| | - Alexander Becker
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA.
| | - Ashish Sonig
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA.
| | - Vincent M Tutino
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Biomedical Engineering, University at Buffalo, Buffalo, NY, USA; Department of Pathology and Anatomical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY USA.
| | - Faisal Almayman
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA.
| | - Jason M Davies
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY USA; Department of Bioinformatics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Kenneth V Snyder
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY USA.
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY USA; Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA.
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY USA; Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA.
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