Prescription smoking-cessation medication pharmacy claims after stroke and transient ischemic attack

Cost-Effectiveness of Smoking Cessation Interventions in Patients With Ischemic Stroke and Transient Ischemic Attack

BACKGROUND

Smoking cessation rates after stroke and transient ischemic attack are suboptimal, and smoking cessation interventions are underutilized. We performed a cost-effectiveness analysis of smoking cessation interventions in this population.

METHODS

We constructed a decision tree and used Markov models that aimed to assess the cost-effectiveness of varenicline, any pharmacotherapy with intensive counseling, and monetary incentives, compared with brief counseling alone in the secondary stroke prevention setting. Payer and societal costs of interventions and outcomes were modeled. The outcomes were recurrent stroke, myocardial infarction, and death using a lifetime horizon. Estimates and variance for the base case (35% cessation), costs and effectiveness of interventions, and outcome rates were imputed from the stroke literature. We calculated incremental cost-effectiveness ratios and incremental net monetary benefits. An intervention was considered cost-effective if the incremental cost-effectiveness ratio was less than the willingness-to-pay threshold of $100 000 per quality-adjusted life-year (QALY) or when the incremental net monetary benefit was positive. Probabilistic Monte Carlo simulations modeled the impact of parameter uncertainty.

RESULTS

From the payer perspective, varenicline and pharmacotherapy with intensive counseling were associated with more QALYs (0.67 and 1.00, respectively) at less total lifetime costs compared with brief counseling alone. Monetary incentives were associated with 0.71 more QALYs at an additional cost of $120 compared with brief counseling alone, yielding an incremental cost-effectiveness ratio of $168/QALY. From the societal perspective, all 3 interventions provided more QALYs at less total costs compared with brief counseling alone. In 10 000 Monte Carlo simulations, all 3 smoking cessation interventions were cost-effective in >89% of runs.

CONCLUSIONS

For secondary stroke prevention, it is cost-effective and potentially cost-saving to deliver smoking cessation therapy beyond brief counseling alone.

Practice Current: Variability in Smoking Cessation Intervention Practice Patterns After Ischemic Stroke and Transient Ischemic Attack

People who continue to smoke after ischemic stroke and transient ischemic attack (TIA) are at increased risk for subsequent stroke and cardiovascular events. Although effective smoking cessation strategies exist, smoking rates after stroke remain high. Through case-based discussions with 3 international vascular neurology panelists, this article seeks to explore practice patterns and barriers to smoking cessation for patients with stroke/TIA. We sought to answer these questions: What are the barriers to using smoking cessation interventions for patients with stroke/TIA? Which interventions are most used for hospitalized patients with stroke/TIA? Which interventions are most used for patients who continue smoking during follow-up? Our synthesis of panelists' commentaries is complemented by the preliminary results of an online survey posed to global readership. Together, the interviews and survey results identify practice variability and barriers to smoking cessation after stroke/TIA, suggesting that there is substantial need for research and standardization.