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Orman Z, Olaiya MT, Thrift AG, Cadilhac DA, Phan T, Nelson MR, Ung D, Srikanth VK, Bladin CF, Gerraty RP, Phillipos J, Kim J. Cost-Effectiveness of an Individualised Management Program after Stroke: A Trial-Based Economic Evaluation. Neuroepidemiology 2024; 58:156-165. [PMID: 38359812 DOI: 10.1159/000535638] [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: 07/07/2023] [Accepted: 11/20/2023] [Indexed: 02/17/2024] Open
Abstract
INTRODUCTION Evidence on the cost-effectiveness of comprehensive post-stroke programs is limited. We assessed the cost-effectiveness of an individualised management program (IMP) for stroke or transient ischaemic attack (TIA). METHODS A cost-utility analysis alongside a randomised controlled trial with a 24-month follow-up, from both societal and health system perspectives, was conducted. Adults with stroke/TIA discharged from hospitals were randomised by primary care practice to receive either usual care (UC) or an IMP in addition to UC (intervention). An IMP included stroke-specific nurse-led education and a specialist review of care plans at baseline, 3 months, and 12 months, and telephone reviews by nurses at 6 months and 18 months. Costs were expressed in 2021 Australian dollars (AUD). Costs and quality-adjusted life years (QALYs) beyond 12 months were discounted by 5%. The probability of cost-effectiveness of the intervention was determined by quantifying 10,000 bootstrapped iterations of incremental costs and QALYs below the threshold of AUD 50,000/QALY. RESULTS Among the 502 participants (65% male, median age 69 years), 251 (50%) were in the intervention group. From a health system perspective, the incremental cost per QALY gained was AUD 53,175 in the intervention compared to the UC group, and the intervention was cost-effective in 46.7% of iterations. From a societal perspective, the intervention was dominant in 52.7% of iterations, with mean per-person costs of AUD 49,045 and 1.352 QALYs compared to mean per-person costs of AUD 51,394 and 1.324 QALYs in the UC group. The probability of the cost-effectiveness of the intervention, from a societal perspective, was 60.5%. CONCLUSIONS Care for people with stroke/TIA using an IMP was cost-effective from a societal perspective over 24 months. Economic evaluations of prevention programs need sufficient time horizons and consideration of costs beyond direct healthcare utilisation to demonstrate their value to society.
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Affiliation(s)
- Zhomart Orman
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia,
| | - Muideen T Olaiya
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Amanda G Thrift
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Dominique A Cadilhac
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
- Stroke Division, Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
| | - Thanh Phan
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
- Department of Neurology, Monash Medical Centre, Clayton, Victoria, Australia
| | - Mark R Nelson
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - David Ung
- Peninsula Clinical School, Central Clinical School, Monash University, Frankston, Victoria, Australia
| | - Velandai K Srikanth
- Peninsula Clinical School, Central Clinical School, Monash University, Frankston, Victoria, Australia
| | - Christopher F Bladin
- Eastern Health Clinical School, Monash University, Box Hill, Victoria, Australia
- Victorian Stroke Telemedicine, Ambulance Victoria, Melbourne, Victoria, Australia
| | - Richard P Gerraty
- Department of Medicine, Epworth Healthcare, Richmond, Victoria, Australia
| | - Joseph Phillipos
- Department of General Surgery, Alfred Hospital, Melbourne, Victoria, Australia
| | - Joosup Kim
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
- Department of Neurology, Monash Medical Centre, Clayton, Victoria, Australia
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Tu LH, Melnick E, Venkatesh AK, Sheth KN, Navaratnam D, Yaesoubi R, Forman HP, Mahajan A. Cost-Effectiveness of CT, CTA, MRI, and Specialized MRI for Evaluation of Patients Presenting to the Emergency Department With Dizziness. AJR Am J Roentgenol 2024; 222:e2330060. [PMID: 37937837 DOI: 10.2214/ajr.23.30060] [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: 11/09/2023]
Abstract
BACKGROUND. Underlying stroke is often misdiagnosed in patients presenting with dizziness. Although such patients are usually ineligible for acute stroke treatment, accurate diagnosis may still improve outcomes through selection of patients for secondary prevention measures. OBJECTIVE. The purpose of our study was to investigate the cost-effectiveness of differing neuroimaging approaches in the evaluation of patients presenting to the emergency department (ED) with dizziness who are not candidates for acute intervention. METHODS. A Markov decision-analytic model was constructed from a health care system perspective for the evaluation of a patient presenting to the ED with dizziness. Four diagnostic strategies were compared: noncontrast head CT, head and neck CTA, conventional brain MRI, and specialized brain MRI (including multiplanar high-resolution DWI). Differing long-term costs and outcomes related to stroke detection and secondary prevention measures were compared. Cost-effectiveness was calculated in terms of lifetime expenditures in 2022 U.S. dollars for each quality-adjusted life year (QALY); deterministic and probabilistic sensitivity analyses were performed. RESULTS. Specialized MRI resulted in the highest QALYs and was the most cost-effective strategy with US$13,477 greater cost and 0.48 greater QALYs compared with noncontrast head CT. Conventional MRI had the next-highest health benefit, although was dominated by extension with incremental cost of US$6757 and 0.25 QALY; CTA was also dominated by extension, with incremental cost of US$3952 for 0.13 QALY. Non-contrast CT alone had the lowest utility among the four imaging choices. In the deterministic sensitivity analyses, specialized MRI remained the most cost-effective strategy. Conventional MRI was more cost-effective than CTA across a wide range of model parameters, with incremental cost-effectiveness remaining less than US$30,000/QALY. Probabilistic sensitivity analysis yielded similar results as found in the base-case analysis, with specialized MRI being more cost-effective than conventional MRI, which in turn was more cost-effective than CTA. CONCLUSION. The use of MRI in patients presenting to the ED with dizziness improves stroke detection and selection for subsequent preventive measures. MRI-based evaluation leads to lower long-term costs and higher cumulative QALYs. CLINICAL IMPACT. MRI, incorporating specialized protocols when available, is the preferred approach for evaluation of patients presenting to the ED with dizziness, to establish a stroke diagnosis and to select patients for secondary prevention measures.
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Affiliation(s)
- Long H Tu
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, 20 York St, New Haven, CT 06510
| | - Edward Melnick
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Arjun K Venkatesh
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Kevin N Sheth
- Department of Neurology, Yale School of Medicine, New Haven, CT
| | | | - Reza Yaesoubi
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT
| | - Howard P Forman
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, 20 York St, New Haven, CT 06510
| | - Amit Mahajan
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, 20 York St, New Haven, CT 06510
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Pouget AM, Costa N, Mounié M, Gombault-Datzenko E, Derumeaux H, Pagès A, Rouzaud-Laborde C, Molinier L. Mechanical Thrombectomy with Intravenous Thrombolysis versus Thrombolysis Alone for the Treatment of Stroke: A Systematic Review of Economic Evaluations. J Vasc Interv Radiol 2023; 34:1749-1759.e2. [PMID: 37331591 DOI: 10.1016/j.jvir.2023.06.015] [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: 12/14/2022] [Revised: 05/25/2023] [Accepted: 06/08/2023] [Indexed: 06/20/2023] Open
Abstract
Mechanical thrombectomy has revolutionized the management of stroke by improving the recanalization rates and reducing deleterious consequences. It is now the standard of care despite the high financial cost. A considerable number of studies have evaluated its cost effectiveness. Therefore, this study aimed to identify economic evaluations of mechanical thrombectomy with thrombolysis compared with thrombolysis alone to provide an update of existing evidence, focusing on the period after proof of effectiveness of mechanical thrombectomy. Twenty-one studies were included in the review: 18 were model-based economic evaluations to simulate long-term outcomes and costs, and 19 were conducted in high-income countries. Incremental cost-effectiveness ratios ranged from -$5,670 to $74,216 per quality-adjusted life year. Mechanical thrombectomy is cost-effective in high-income countries and in the populations selected for clinical trials. However, most of the studies used the same data. There is a lack of real-world and long-term data to analyze the cost effectiveness of mechanical thrombectomy in treating the global burden of stroke.
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Affiliation(s)
- Alix Marie Pouget
- Health Economic Unit, Toulouse University Hospital, Toulouse, France; Department of Pharmacy, Toulouse University Hospital, Toulouse, France; French National Institute for Health and Medical Research (INSERM), Mixed Research Unit 1297 (UMR), Institute of Metabolic and Cardiac Diseases (I2MC), Toulouse III University, Toulouse, France.
| | - Nadège Costa
- Health Economic Unit, Toulouse University Hospital, Toulouse, France; French National Institute for Health and Medical Research (INSERM), Mixed Research Unit 1297 (UMR), Centre for Epidemiology and Population Health Research (for CERPOP), Toulouse III University, Toulouse, France
| | - Michael Mounié
- Health Economic Unit, Toulouse University Hospital, Toulouse, France; French National Institute for Health and Medical Research (INSERM), Mixed Research Unit 1297 (UMR), Centre for Epidemiology and Population Health Research (for CERPOP), Toulouse III University, Toulouse, France
| | - Eugénie Gombault-Datzenko
- Health Economic Unit, Toulouse University Hospital, Toulouse, France; French National Institute for Health and Medical Research (INSERM), Mixed Research Unit 1297 (UMR), Centre for Epidemiology and Population Health Research (for CERPOP), Toulouse III University, Toulouse, France
| | - Hélène Derumeaux
- Health Economic Unit, Toulouse University Hospital, Toulouse, France; French National Institute for Health and Medical Research (INSERM), Mixed Research Unit 1297 (UMR), Centre for Epidemiology and Population Health Research (for CERPOP), Toulouse III University, Toulouse, France
| | - Arnaud Pagès
- Health Economic Unit, Toulouse University Hospital, Toulouse, France
| | - Charlotte Rouzaud-Laborde
- Department of Pharmacy, Toulouse University Hospital, Toulouse, France; French National Institute for Health and Medical Research (INSERM), Mixed Research Unit 1297 (UMR), Institute of Metabolic and Cardiac Diseases (I2MC), Toulouse III University, Toulouse, France
| | - Laurent Molinier
- Health Economic Unit, Toulouse University Hospital, Toulouse, France; French National Institute for Health and Medical Research (INSERM), Mixed Research Unit 1297 (UMR), Centre for Epidemiology and Population Health Research (for CERPOP), Toulouse III University, Toulouse, France
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Shang W, Jin H, Vastani A, Mirza AB, Fisher B, Kalra N, Anderson I, Kailaya-Vasan A. Cost-effectiveness of repeat delayed imaging for spontaneous subarachnoid hemorrhage. PLoS One 2023; 18:e0289144. [PMID: 37494367 PMCID: PMC10370759 DOI: 10.1371/journal.pone.0289144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 07/12/2023] [Indexed: 07/28/2023] Open
Abstract
BACKGROUND In patients with intracranial aneurysm presenting with spontaneous subarachnoid hemorrhage (SAH), 15% of them could be missed by the initial diagnostic imaging. Repeat delayed imaging can help to identify previously undetected aneurysms, however, the cost-effectiveness of this strategy remains uncertain. OBJECTIVE The aim of this study is to assess the cost-effectiveness of repeat delayed imaging in patients with SAH who had a negative result during their initial imaging. METHODS A Markov model was developed to estimate the lifetime costs and quality-adjusted life-year (QALY) for patients who received or not received repeat delayed imaging. The analyses were conducted from a healthcare perspective, with costs reported in UK pounds and expressed in 2020 values. Extensive sensitivity analyses were performed to assess the robustness of the results. RESULTS The base case incremental cost-effectiveness ratio (ICER) of repeat delayed imaging is £9,314 per QALY compared to no-repeat delayed imaging. This ICER is below the National Institute for Health and Care Excellence (NICE) £20,000 per QALY willingness-to-pay threshold. At the NICE willingness-to-pay threshold of £20,000 per QALY, the probability that repeat delayed imaging is most cost-effective is 0.81. The results are sensitive to age, the utility of survived patients with a favorable outcome, the sensitivity of repeat delayed imaging, and the prevalence of aneurysm. CONCLUSIONS This study showed that, in the UK, it is cost-effective to provide repeat delayed imaging using computed tomographic angiography (CTA) for patients with SAH who had a negative result in their initial imaging.
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Affiliation(s)
- Wenru Shang
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- WHO Collaborating Center for Guideline Implementation and Knowledge Translation, Lanzhou University, Lanzhou, China
- King's Health Economics (KHE), Institute of Psychiatry, Psychology & Neuroscience at King's College London, London, United Kingdom
| | - Huajie Jin
- King's Health Economics (KHE), Institute of Psychiatry, Psychology & Neuroscience at King's College London, London, United Kingdom
| | - Amisha Vastani
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Asfand Baig Mirza
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Benjamin Fisher
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Neeraj Kalra
- Department of Neurosurgery, Leeds Centre for Neurosciences, Leeds General Infirmary, Leeds, United Kingdom
| | - Ian Anderson
- Department of Neurosurgery, Leeds Centre for Neurosciences, Leeds General Infirmary, Leeds, United Kingdom
| | - Ahilan Kailaya-Vasan
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
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5
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Zhu J, Kamel H, Gupta A, Mushlin AI, Menzies NA, Gaziano TA, Rosenthal MB, Pandya A. Prioritizing Quality Measures in Acute Stroke Care : A Cost-Effectiveness Analysis. Ann Intern Med 2023; 176:649-657. [PMID: 37126821 PMCID: PMC10211083 DOI: 10.7326/m22-3186] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/03/2023] Open
Abstract
BACKGROUND The American Heart Association and American Stroke Association (AHA/ASA) endorsed 15 process measures for acute ischemic stroke (AIS) to improve the quality of care. Identifying the highest-value measures could reduce the administrative burden of quality measure adoption while retaining much of the value of quality improvement. OBJECTIVE To prioritize AHA/ASA-endorsed quality measures for AIS on the basis of health impact and cost-effectiveness. DESIGN Individual-based stroke simulation model. DATA SOURCES Published literature. TARGET POPULATION U.S. patients with incident AIS. TIME HORIZON Lifetime. PERSPECTIVE Health care sector. INTERVENTION Current versus complete (100%) implementation at the population level of quality measures endorsed by the AHA/ASA with sufficient clinical evidence (10 of 15). OUTCOME MEASURES Life-years, quality-adjusted life-years (QALYs), incremental cost-effectiveness ratios, and incremental net health benefits. RESULTS OF BASE-CASE ANALYSIS Discounted life-years gained from complete implementation would range from 472 (tobacco use counseling) to 34 688 (early carotid imaging) for an annual AIS patient cohort. All AIS quality measures were cost-saving or highly cost-effective by AHA standards (<$50 000 per QALY for high-value care). Early carotid imaging and intravenous tissue plasminogen activator contributed the largest fraction of the total potential value of quality improvement (measured as incremental net health benefit), accounting for 72% of the total value. The top 5 quality measures accounted for 92% of the total potential value. RESULTS OF SENSITIVITY ANALYSIS A web-based user interface allows for context-specific sensitivity and scenario analyses. LIMITATION Correlations between quality measures were not incorporated. CONCLUSION Substantial variation exists in the potential net benefit of quality improvement across AIS quality measures. Benefits were highly concentrated among 5 of 10 measures assessed. Our results can help providers and payers set priorities for quality improvement efforts and value-based payments in AIS care. PRIMARY FUNDING SOURCE National Institute of Neurological Disorders and Stroke.
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Affiliation(s)
- Jinyi Zhu
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Ajay Gupta
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | - Alvin I Mushlin
- Departments of Population Health Sciences and Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Nicolas A Menzies
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Thomas A Gaziano
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Meredith B Rosenthal
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ankur Pandya
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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6
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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.
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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
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Hajian K, Abdi Dezfouli R, Darvishi A, Radmanesh R, Heshmat R. Tenecteplase in managing acute ischemic stroke: a long-term cost-utility analysis in Iran. Expert Rev Pharmacoecon Outcomes Res 2023; 23:123-133. [PMID: 36420792 DOI: 10.1080/14737167.2023.2152008] [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: 11/25/2022]
Abstract
BACKGROUND & AIMS The advantage of tenecteplase (TNK) over alteplase (ALT) in managing acute ischemic stroke (AIS) has been reported, but the cost-effectiveness of these two strategies has not received as much attention. The objective of this study was to compare TNK and ALT for the management of AIS patients in Iran in terms of cost-effectiveness. METHODS This study was carried out from the payer's perspective in Iran, with a lifetime horizon. A full economic evaluation model was designed as a decision tree and a Markov model. After defining different Markov states, each health state was assigned a utility value, and quality-adjusted life year (QALY) was estimated using that value. The incremental cost-effectiveness ratio (ICER) was ultimately used for evaluating the comparative cost-effectiveness. Both deterministic and probabilistic sensitivity analyses were carried out. RESULTS Compared to ALT, TNK can save approximately 4333.81 USD, and is able to increase one unit of QALY while saving approximately 17,450.29 USD. So, Base-case results showed that TNK strongly dominates ALT. Moreover, the base case results were strongly confirmed by deterministic and probabilistic sensitivity analysis. CONCLUSIONS Base-case and sensitivity analysis showed that TNK is the dominant strategy compared to ALT for the management of AIS patients.
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Affiliation(s)
- Kosar Hajian
- Department of Pharmacoeconomics and Pharmaceutical Management, Faculty of Pharmacy, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran.,Chronic Diseases Research Center, Endocrinology and Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Ramin Abdi Dezfouli
- Department of Pharmacoeconomics and Pharmaceutical Management, Faculty of Pharmacy, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran.,Chronic Diseases Research Center, Endocrinology and Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Darvishi
- Chronic Diseases Research Center, Endocrinology and Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.,Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | - Ramin Radmanesh
- Department of Pharmacoeconomics and Pharmaceutical Management, Faculty of Pharmacy, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
| | - Ramin Heshmat
- Chronic Diseases Research Center, Endocrinology and Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
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8
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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.
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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
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9
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Wei N, Liu B, Ma M, Zhang X, Zhang W, Hou F, Liu F, Yu X. Patent foramen ovale closure vs. medical therapy alone after cryptogenic stroke in China: A cost-effectiveness analysis. Front Public Health 2022; 10:1016854. [PMID: 36407985 PMCID: PMC9669480 DOI: 10.3389/fpubh.2022.1016854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 09/13/2022] [Indexed: 11/06/2022] Open
Abstract
Background In 2019, there were 28. 76 million patients with stroke in China, with ~25% of them suffering from cryptogenic stroke (CS). Patent foramen ovale (PFO) is related to CS, and PFO closure can reduce recurrent stroke. To date, no study has investigated the cost-effectiveness of PFO closure vs. medical therapy among such populations in China. Methods A Markov model with a cycle length of 3 months was established to compare the 30-year cost-effectiveness of PFO closure and medical therapy. The transition probability of recurrent stroke was derived from the RESPECT study, and the costs and utility were obtained from domestic data or studies conducted in China. The primary outcome of this study was the incremental cost-effectiveness ratio (ICER), which represents the incremental cost per quality-adjusted life year (QALY). PFO closure was considered cost-effective if the ICER obtained was lower than the willingness-to-pay (WTP) threshold of 37,654 USD/QALY; otherwise, PFO closure was regarded as not being cost-effective. One-way and probabilistic sensitivity analyses were performed to test the robustness of the results. Results After a simulation of a 30-year horizon, a cryptogenic stroke patient with PFO was expected to have QALY of 13.15 (15.26 LY) if he received PFO closure and a corresponding value of 11.74 QALY (15.14 LY) after medical therapy. The corresponding costs in both cohorts are US $8,131 and US $4,186, respectively. Thus, an ICER of 2783 USD/QALY and 31264 USD/LY was obtained, which is lower than the WTP threshold. One-way and probabilistic sensitivity analyses showed that the results were robust. Conclusion With respect to the WTP threshold of three times per capita GDP in China in 2021, PFO closure is a cost-effective method for Chinese cryptogenic stroke patients with PFO, as shown in the 30-year simulation.
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Affiliation(s)
- Na Wei
- Department of Cardiology, Shaanxi Provincial People's Hospital, Xi'an, China
| | - Bo Liu
- Department of Cardiology, Shaanxi Provincial People's Hospital, Xi'an, China
| | - Meijuan Ma
- Department of Cardiology, Shaanxi Provincial People's Hospital, Xi'an, China
| | - Xuejun Zhang
- Department of Cardiology, Shaanxi Provincial People's Hospital, Xi'an, China
| | - Wei Zhang
- Department of Cardiology, Shaanxi Provincial People's Hospital, Xi'an, China
| | - Fangxia Hou
- Department of Cardiology, Shaanxi Provincial People's Hospital, Xi'an, China
| | - Fuqiang Liu
- Department of Cardiology, Shaanxi Provincial People's Hospital, Xi'an, China
| | - Xiangyou Yu
- Department of Cardiology, Shaanxi Provincial People's Hospital, Xi'an, China
- Department of Endocrinology, Shaanxi Provincial People's Hospital, Xi'an, China
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10
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Shi F, He Z, Wang L, Su H, Han S. Cost-effectiveness of edaravone dexborneol versus edaravone for the treatment of acute ischemic stroke in China: Based on the TASTE study. Front Pharmacol 2022; 13:938239. [PMID: 36330098 PMCID: PMC9622952 DOI: 10.3389/fphar.2022.938239] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 10/03/2022] [Indexed: 11/21/2022] Open
Abstract
Background and purpose: The TASTE trial indicated that patients with acute ischemic stroke (AIS) using edaravone dexborneol have a significantly higher proportion of 90-day good functional outcomes (mRS 0–1) than those using edaravone. This study compared the cost-effectiveness of the aforementioned interventions in treating AIS in the Chinese setting, aiming to inform treatment decisions in clinical practice. Methods: A model combining a decision tree and a Markov model was developed to assess the cost-effectiveness of edaravone dexborneol versus edaravone for AIS over a 30-year time horizon from the Chinese healthcare system’s perspective. Both efficacy and safety data were extracted from the TASTE study. Local costs and utilities were derived from publications and open-access databases; both cost and effectiveness were discounted at a rate of 5% per year. Sensitivity analyses were conducted to ensure robustness and identify the main drivers of the result. Results: Compared with edaravone, edaravone dexborneol for AIS was found to be cost-effective in the first year and highly cost-effective as the study time horizons extended. In the long term (30 years), edaravone dexborneol yielded a lifetime gain of 0.25 (0.07–0.45) quality-adjusted life years (QALYs) at an additional cost of CNY 2201.07 (-3,445.24–6,637.23), yielding an ICER of CNY 8823.41 per QALY gained under the willingness-to-pay (WTP) of 1.5 times per capita GDP (121,464 CNY). The result is robust in both deterministic and probabilistic sensitivity analysis (PSA) methods, with the advantage of the edaravone dexborneol strategy increasing over time. Specifically, the probability of edaravone dexborneol dominant dexborneol is 76.30%, 98.90%, and 99.50% over 1-, 5-, and 30-year time horizons. Conclusion: Both short- and long-term economic analyses suggest that edaravone dexborneol is highly likely to be a cost-effective alternative to treat AIS compared with edaravone in China.
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Affiliation(s)
- Fenghao Shi
- International Research Center for Medicinal Administration, Peking University, Beijing, China
- School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Zixuan He
- International Research Center for Medicinal Administration, Peking University, Beijing, China
- School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Lin Wang
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China
| | - Hang Su
- International Research Center for Medicinal Administration, Peking University, Beijing, China
- School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Sheng Han
- International Research Center for Medicinal Administration, Peking University, Beijing, China
- School of Pharmaceutical Sciences, Peking University, Beijing, China
- *Correspondence: Sheng Han,
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11
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Chew DS, Zhou K, Pokorney SD, Matchar DB, Vemulapalli S, Allen LA, Jackson KP, Samad Z, Patel MR, Freeman JV, Piccini JP. Left Atrial Appendage Occlusion Versus Oral Anticoagulation in Atrial Fibrillation : A Decision Analysis. Ann Intern Med 2022; 175:1230-1239. [PMID: 35969865 DOI: 10.7326/m21-4653] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Left atrial appendage occlusion (LAAO) is a potential alternative to oral anticoagulants in selected patients with atrial fibrillation (AF). Compared with anticoagulants, LAAO decreases major bleeding risk, but there is uncertainty regarding the risk for ischemic stroke compared with anticoagulation. OBJECTIVE To determine the optimal strategy for stroke prevention conditional on a patient's individual risks for ischemic stroke and bleeding. DESIGN Decision analysis with a Markov model. DATA SOURCES Evidence from the published literature informed model inputs. TARGET POPULATION Women and men with nonvalvular AF and without prior stroke. TIME HORIZON Lifetime. PERSPECTIVE Clinical. INTERVENTION LAAO versus warfarin or direct oral anticoagulants (DOACs). OUTCOME MEASURES The primary end point was clinical benefit measured in quality-adjusted life-years. RESULTS OF BASE-CASE ANALYSIS The baseline risks for stroke and bleeding determined whether LAAO was preferred over anticoagulants in patients with AF. The combined risks favored LAAO for higher bleeding risk, but that benefit became less certain at higher stroke risks. For example, at a HAS-BLED score of 5, LAAO was favored in more than 80% of model simulations for CHA2DS2-VASc scores between 2 and 5. The probability of LAAO benefit in QALYs (>80%) at lower bleeding risks (HAS-BLED score of 0 to 1) was limited to patients with lower stroke risks (CHA2DS2-VASc score of 2). Because DOACs carry lower bleeding risks than warfarin, the net benefit of LAAO is less certain than that of DOACs. RESULTS OF SENSITIVITY ANALYSIS Results were consistent using the ORBIT bleeding score instead of the HAS-BLED score, as well as alternative sources for LAAO clinical effectiveness data. LIMITATION Clinical effectiveness data were drawn primarily from studies on the Watchman device. CONCLUSION Although LAAO could be an alternative to anticoagulants for stroke prevention in patients with AF and high bleeding risk, the overall benefit from LAAO depends on the combination of stroke and bleeding risks in individual patients. These results suggest the need for a sufficiently low stroke risk for LAAO to be beneficial. The authors believe that these results could improve shared decision making when selecting patients for LAAO. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Derek S Chew
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, and Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada (D.S.C.)
| | - Ke Zhou
- Duke-National University of Singapore Medical School, Singapore (K.Z.)
| | - Sean D Pokorney
- Duke Clinical Research Institute, Duke University, and Division of Cardiology, Duke University Medical Center, Durham, North Carolina (S.D.P., S.V., M.R.P., J.P.P.)
| | - David B Matchar
- Duke-National University of Singapore Medical School, Singapore, and Division of General Internal Medicine, Duke University Medical Center, Durham, North Carolina (D.B.M.)
| | - Sreekanth Vemulapalli
- Duke Clinical Research Institute, Duke University, and Division of Cardiology, Duke University Medical Center, Durham, North Carolina (S.D.P., S.V., M.R.P., J.P.P.)
| | - Larry A Allen
- University of Colorado School of Medicine, Aurora, Colorado (L.A.A.)
| | - Kevin P Jackson
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina (K.P.J.)
| | - Zainab Samad
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, and Department of Medicine, Aga Khan University, Karachi, Pakistan (Z.S.)
| | - Manesh R Patel
- Duke Clinical Research Institute, Duke University, and Division of Cardiology, Duke University Medical Center, Durham, North Carolina (S.D.P., S.V., M.R.P., J.P.P.)
| | - James V Freeman
- Yale University School of Medicine, New Haven, Connecticut (J.V.F.)
| | - Jonathan P Piccini
- Duke Clinical Research Institute, Duke University, and Division of Cardiology, Duke University Medical Center, Durham, North Carolina (S.D.P., S.V., M.R.P., J.P.P.)
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12
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Schreuder FHBM, Scholte M, Ulehake MJ, Sondag L, Rovers MM, Dammers R, Klijn CJM, Grutters JPC. Identifying the Conditions for Cost-Effective Minimally Invasive Neurosurgery in Spontaneous Supratentorial Intracerebral Hemorrhage. Front Neurol 2022; 13:830614. [PMID: 35720058 PMCID: PMC9200972 DOI: 10.3389/fneur.2022.830614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 04/19/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundIn patients with spontaneous supratentorial intracerebral hemorrhage (ICH), open craniotomy has failed to improve a functional outcome. Innovative minimally invasive neurosurgery (MIS) may improve a health outcome and reduce healthcare costs.AimsBefore starting phase-III trials, we aim to assess conditions that need to be met to reach the potential cost-effectiveness of MIS compared to usual care in patients with spontaneous supratentorial ICH.MethodsWe used a state-transition model to determine at what effectiveness and cost MIS would become cost-effective compared to usual care in terms of quality-adjusted life-years (QALYs) and direct healthcare costs. Threshold and two-way sensitivity analyses were used to determine the minimal effectiveness and maximal costs of MIS, and the most cost-effective strategy for each combination of cost and effectiveness. Scenario and probabilistic sensitivity analyses addressed model uncertainty.ResultsGiven €10,000 of surgical costs, MIS would become cost-effective when at least 0.7–1.3% of patients improve to a modified Rankin Scale (mRS) score of 0–3 compared to usual care. When 11% of patients improve to mRS 0–3, surgical costs may be up to €83,301–€164,382, depending on the population studied. The cost-effectiveness of MIS was mainly determined by its effectiveness. In lower mRS states, MIS needs to be more effective to be cost-effective compared to higher mRS states.ConclusionMIS has the potential to be cost-effective in patients with spontaneous supratentorial ICH, even with relatively low effectiveness. These results support phase-III trials to investigate the effectiveness of MIS.
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Affiliation(s)
- Floris H. B. M. Schreuder
- Department of Neurology, Center for Neuroscience, Donders Institute of Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, Netherlands
- *Correspondence: Floris H. B. M. Schreuder
| | - Mirre Scholte
- Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Marike J. Ulehake
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Lotte Sondag
- Department of Neurology, Center for Neuroscience, Donders Institute of Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, Netherlands
| | - Maroeska M. Rovers
- Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Ruben Dammers
- Department of Neurosurgery, Erasmus Medical Center, Erasmus MC Stroke Center, Rotterdam, Netherlands
| | - Catharina J. M. Klijn
- Department of Neurology, Center for Neuroscience, Donders Institute of Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, Netherlands
| | - Janneke P. C. Grutters
- Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
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Han M, Qin Y, Tong X, Ji L, Zhao S, Liu L, Chen J, Liu A. Cost-effective analysis of mechanical thrombectomy alone in the treatment of acute ischaemic stroke: a Markov modelling study. BMJ Open 2022; 12:e059098. [PMID: 35387833 PMCID: PMC8987747 DOI: 10.1136/bmjopen-2021-059098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Recently, a randomised controlled trial (DIRECT-MT) demonstrated that mechanical thrombectomy (MT) was non-inferior to MT with intravenous alteplase as to the functional outcomes. This study aims to investigate whether MT alone is cost-effective compared with MT with alteplase in China. METHODS A Markov decision analytic model was built from the Chinese healthcare perspective using a lifetime horizon. Probabilities, costs and outcomes data were obtained from the DIRECT-MT trial and other most recent/comprehensive literature. Base case calculation was conducted to compare the costs and effectiveness between MT alone and MT with alteplase. One-way and probabilistic sensitivity analyses were performed to evaluate the robustness of the results. RESULTS MT alone had a lower cost and higher effectiveness compared with MT with alteplase. The probabilistic sensitivity analysis demonstrated that, over a lifetime horizon, MT alone had a 99.5% probability of being cost-effective under the willingness-to-pay threshold of 1× gross domestic product per capita in China based on data obtained from the DIRECT-MT trial. These results remained robust under one-way sensitivity analysis. CONCLUSIONS MT alone was cost-effective compared with MT with alteplase in China. However, cautions are needed to extend this conclusion to regions outside of China.
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Affiliation(s)
- Mingyang Han
- Department of Neurosurgery, Central South University Third Xiangya Hospital, Changsha, Hunan, China
| | - Yongkai Qin
- Department of Neurosurgery, Central South University Third Xiangya Hospital, Changsha, Hunan, China
| | - Xin Tong
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, 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
| | - Lang Liu
- Department of Neurosurgery, Central South University Third Xiangya Hospital, Changsha, Hunan, China
| | - Jigang Chen
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Aihua Liu
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
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14
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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.
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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,
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15
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Puhr-Westerheide D, Froelich MF, Solyanik O, Gresser E, Reidler P, Fabritius MP, Klein M, Dimitriadis K, Ricke J, Cyran CC, Kunz WG, Kazmierczak PM. Cost-effectiveness of short-protocol emergency brain MRI after negative non-contrast CT for minor stroke detection. Eur Radiol 2021; 32:1117-1126. [PMID: 34455484 PMCID: PMC8794930 DOI: 10.1007/s00330-021-08222-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 05/23/2021] [Accepted: 06/25/2021] [Indexed: 11/29/2022]
Abstract
Objectives To investigate the cost-effectiveness of supplemental short-protocol brain MRI after negative non-contrast CT for the detection of minor strokes in emergency patients with mild and unspecific neurological symptoms. Methods The economic evaluation was centered around a prospective single-center diagnostic accuracy study validating the use of short-protocol brain MRI in the emergency setting. A decision-analytic Markov model distinguished the strategies “no additional imaging” and “additional short-protocol MRI” for evaluation. Minor stroke was assumed to be missed in the initial evaluation in 40% of patients without short-protocol MRI. Specialized post-stroke care with immediate secondary prophylaxis was assumed for patients with detected minor stroke. Utilities and quality-of-life measures were estimated as quality-adjusted life years (QALYs). Input parameters were obtained from the literature. The Markov model simulated a follow-up period of up to 30 years. Willingness to pay was set to $100,000 per QALY. Cost-effectiveness was calculated and deterministic and probabilistic sensitivity analysis was performed. Results Additional short-protocol MRI was the dominant strategy with overall costs of $26,304 (CT only: $27,109). Cumulative calculated effectiveness in the CT-only group was 14.25 QALYs (short-protocol MRI group: 14.31 QALYs). In the deterministic sensitivity analysis, additional short-protocol MRI remained the dominant strategy in all investigated ranges. Probabilistic sensitivity analysis results from the base case analysis were confirmed, and additional short-protocol MRI resulted in lower costs and higher effectiveness. Conclusion Additional short-protocol MRI in emergency patients with mild and unspecific neurological symptoms enables timely secondary prophylaxis through detection of minor strokes, resulting in lower costs and higher cumulative QALYs. Key Points • Short-protocol brain MRI after negative head CT in selected emergency patients with mild and unspecific neurological symptoms allows for timely detection of minor strokes. • This strategy supports clinical decision-making with regard to immediate initiation of secondary prophylactic treatment, potentially preventing subsequent major strokes with associated high costs and reduced QALY. • According to the Markov model, additional short-protocol MRI remained the dominant strategy over wide variations of input parameters, even when assuming disproportionally high costs of the supplemental MRI scan.
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Affiliation(s)
- Daniel Puhr-Westerheide
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.
| | - Matthias F Froelich
- Department of Radiology and Nuclear Medicine, University Medical Centre Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Olga Solyanik
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Eva Gresser
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Paul Reidler
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Matthias P Fabritius
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Matthias Klein
- Department of Neurology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Konstantin Dimitriadis
- Department of Neurology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.,Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Munich, Germany
| | - Jens Ricke
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Clemens C Cyran
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Wolfgang G Kunz
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Philipp M Kazmierczak
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
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16
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Cui C, Ramakrishnan G, Murphy J, Malas MB. Cost-Effectiveness of TransCarotid Artery Revascularization versus Carotid Endarterectomy. J Vasc Surg 2021; 74:1910-1918.e3. [PMID: 34182030 DOI: 10.1016/j.jvs.2021.05.051] [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: 11/08/2020] [Accepted: 05/17/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Recent studies have demonstrated that TransCarotid Artery Stenting (TCAR) has comparable outcomes to the surgical gold standard, carotid endarterectomy (CEA). However, few studies have analyzed the cost of TCAR and no study has evaluated its cost-effectiveness. The purpose of this study is to conduct a cost-effectiveness analysis comparing TCAR to CEA for carotid artery stenosis. METHODS We built a Markov microsimulation using transition probabilities and utilities from existing literature for symptomatic patients undergoing TCAR or CEA. Costs were derived from literature then converted to 2019 dollars. The model included six health states with monthly cycle lengths: surgery, death, alive after surgery, alive after myocardial infarction, alive after stroke, and alive after stroke and death. Quality adjusted life years (QALYs), costs, and incremental cost-effectiveness ratio (ICER) were analyzed over a five-year period. One-way sensitivity and probabilistic sensitivity analyses were conducted to study the impact of parameter variability on cost effectiveness. RESULTS For symptomatic patients, CEA cost $7821 for 2.85 QALYs while TCAR cost $19154 for 2. 92 QALYs, leading to an ICER of $152,229 per QALY gained in the TCAR arm Sensitivity analysis demonstrated that our model was most sensitive to probability of restenosis, costs of TCAR and costs of CEA. Probabilistic sensitivity analysis demonstrated TCAR would be considered cost effective 49% of iterations. CONCLUSIONS This study found that while five-year costs for TCAR were greater than CEA, TCAR afforded greater QALYs than CEA. TCAR became cost-effective at six-years follow-up.
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Affiliation(s)
- Christina Cui
- School of Medicine, University of California San Diego, La Jolla, Calif
| | - Ganesh Ramakrishnan
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, Calif
| | - James Murphy
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, Calif
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, Calif.
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17
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Cost Burden and Cost-Effective Analysis of the Nationwide Implementation of the Quality in Acute Stroke Care Protocol in Australia. J Stroke Cerebrovasc Dis 2021; 30:105931. [PMID: 34157669 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105931] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 05/23/2021] [Accepted: 05/31/2021] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES The Quality in Acute Stroke Care (QASC) protocol is a multidisciplinary approach to implement evidence-based treatment after acute stroke that reduces death and disability. This study sought to evaluate the cost-effectiveness of implementing the QASC protocol across Australia, from a healthcare and a societal perspective. MATERIALS AND METHODS A decision-analytic model was constructed to reflect one-year outcomes post-stroke, aligned with the stroke severity categories of the modified Rankin scale (mRS). Decision analysis compared outcomes following implementation of the QASC protocol versus no implementation. Population data were extracted from Australian databases and data inputs regarding stroke incidence, costs, and utilities were drawn from published sources. The analysis assumed a progressive uptake and efficacy of the QASC protocol over five years. Health benefits and costs were discounted by 5% annually. The cost of each year lived by an Australian, from a societal perspective, was based on the Australian Government's 'value of statistical life year' (AUD 213,000). RESULTS Over five years, the model predicted 263,722 strokes among the Australian population. The implementation of the QASC protocol was predicted to prevent 1,154 deaths and yield a gain of 876 years of life (0.003 per stroke), and 3,180 quality-adjusted life years (QALYs) (0.012 per stroke). There was an estimated net saving of AUD 65.2 million in healthcare costs (AUD 247 per stroke) and AUD 251.7 million in societal costs (AUD 955 per stroke). CONCLUSIONS Implementation of the QASC protocol in Australia represents both a dominant (cost-saving) strategy, from a healthcare and a societal perspective.
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Martinez G, Katz JM, Pandya A, Wang JJ, Boltyenkov A, Malhotra A, Mushlin AI, Sanelli PC. Cost-Effectiveness Study of Initial Imaging Selection in Acute Ischemic Stroke Care. J Am Coll Radiol 2021; 18:820-833. [PMID: 33387454 PMCID: PMC8186007 DOI: 10.1016/j.jacr.2020.12.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 12/04/2020] [Accepted: 12/06/2020] [Indexed: 12/18/2022]
Abstract
PURPOSE National guidelines recommend prompt identification of candidates for acute ischemic stroke (AIS) treatment, requiring timely neuroimaging with CT and/or MRI. CT is often preferred because of its widespread availability and rapid acquisition. Despite higher diagnostic accuracy of MRI, it commonly involves complex workflows that could potentially cause treatment time delays. The purpose of this study was to analyze the impact on outcomes of imaging utilization before treatment decisions at comprehensive stroke centers for patients presenting with suspected AIS in the anterior circulation with last-known-well-to-arrival time 0 to 24 hours. METHODS A decision simulation model based on the American Heart Association's recommendations for AIS care pathways was developed from a health care perspective to compare initial imaging strategies: (1) stepwise-CT: noncontrast CT (NCCT) at the time of presentation, with CT angiography (CTA) ± CT perfusion (CTP) only in select patients (initial imaging to exclude hemorrhage and extensive ischemia) for mechanical thrombectomy (MT) evaluation; (2) stepwise-hybrid: NCCT at the time of presentation, with MR angiography (MRA) ± MR perfusion (MRP) only for MT evaluation; (3) stepwise-advanced: NCCT + CTA at presentation, with MR diffusion-weighted imaging (MR DWI) + MRP only for MT evaluation; (4) comprehensive-CT: NCCT + CTA + CTP at the time of presentation; and (5) comprehensive-MR: MR DWI + MRA + MRP at the time of presentation. Model parameters were defined using evidence-based data. Cost-effectiveness and sensitivity analyses were performed. RESULTS The cost-effectiveness analyses revealed that comprehensive-CT and comprehensive-MR yield the highest lifetime quality-adjusted life-years (QALYs) (4.81 and 4.82, respectively). However, the incremental cost-effectiveness ratio of comprehensive-MR is $233,000/QALY compared with comprehensive-CT. Stepwise-CT, stepwise-hybrid, and stepwise-advanced strategies are dominated, yielding lower QALYs and higher costs compared with comprehensive-CT. CONCLUSIONS Performing comprehensive-CT at presentation is the most cost-effective initial imaging strategy at comprehensive stroke centers.
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Affiliation(s)
- Gabriela Martinez
- Siemens Healthineers, Malvern, Pennsylvania; Department of Radiology, Northwell Health, Manhasset, New York; Feinstein Institutes for Medical Research, Manhasset, New York.
| | - Jeffrey M Katz
- Chief, Neurovascular Services and Director Comprehensive Stroke Center at North Shore University Hospital, Department of Neurology, North Shore University Hospital, Manhasset, New York; Director of Neuroendovascular surgery, Neurology Service Line, Northwell Health, Manhasset, New York; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Ankur Pandya
- T. H. Trustee (unpaid), Society for Medical Decision Making, T.H Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - Jason J Wang
- Feinstein Institutes for Medical Research, Manhasset, New York; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Artem Boltyenkov
- Siemens Healthineers, Malvern, Pennsylvania; Department of Radiology, Northwell Health, Manhasset, New York; Feinstein Institutes for Medical Research, Manhasset, New York
| | - Ajay Malhotra
- Radiology & Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
| | - Alvin I Mushlin
- Healthcare Policy and Research, Weill Cornell Medical College, New York, New York
| | - Pina C Sanelli
- Department of Radiology, Northwell Health, Manhasset, New York; Feinstein Institutes for Medical Research, Manhasset, New York; Radiology & Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut; Healthcare Policy and Research, Weill Cornell Medical College, New York, New York; Vice Chair of Research, Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
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Abstract
Supplemental Digital Content is available in the text. There is limited data on the cost-effectiveness of continuous-flow left ventricular assist devices (LVAD) in the United States particularly for the bridge-to-transplant indication. Our objective is to study the cost-effectiveness of a small intrapericardial centrifugal LVAD compared with medical management (MM) and subsequent heart transplantation using the respective clinical trial data. We developed a Markov economic framework. Clinical inputs for the LVAD arm were based on prospective trials employing the HeartWare centrifugal-flow ventricular assist device system. To better assess survival in the MM arm, and in the absence of contemporary trials randomizing patients to LVAD and MM, estimates from the Seattle Heart Failure Model were used. Costs inputs were calculated based on Medicare claim analyses and when appropriate prior published literature. Time horizon was lifetime. Costs and benefits were appropriately discounted at 3% per year. The deterministic cost-effectiveness analyses resulted in $69,768 per Quality Adjusted Life Year and $56,538 per Life Year for the bridge-to-transplant indication and $102,587 per Quality Adjusted Life Year and $87,327 per Life Year for destination therapy. These outcomes signify a substantial improvement compared with prior studies and re-open the discussion around the cost-effectiveness of LVADs.
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20
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Tsou C, Robinson S, Boyd J, Kamath S, Yeung J, Waters S, Gifford K, Jamieson A, Hendrie D. Effectiveness and cost-effectiveness of TeleStroke consultations to support the care of patients who had a stroke presenting to regional emergency departments in Western Australia: an economic evaluation case study protocol. BMJ Open 2021; 11:e043836. [PMID: 33408213 PMCID: PMC7789446 DOI: 10.1136/bmjopen-2020-043836] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION The Western Australia (WA) Acute TeleStroke Programme commenced incrementally across regional WA during 2016-2017. Since the introduction of the TeleStroke Programme, there has been monitoring of service outputs, including regional patient access to tertiary stroke specialist advice and reperfusion treatment; however, the impact of consultation with a stroke specialist via telehealth (videoconferencing or telephone) on the effectiveness and cost-effectiveness of stroke care and the drivers of cost-effectiveness has not been systematically evaluated. METHODS AND ANALYSIS The aim of the case study was to examine the impact of consultation with a stroke specialist via telehealth on the effectiveness and cost-effectiveness of stroke and transient ischaemic attack care using a mixed methods approach. A categorical decision tree model will be constructed in collaboration with clinicians and programme managers. A before and after comparison using state-wide administrative datasets will be used to run the base model. If sample size and statistical power permits, the cases and comparators will be matched by stroke type and presence of CT scan at the initial site of presentation, age category and presenting hospital. The drivers of cost-effectiveness will be explored through stakeholder interviews. Data from the qualitative analysis will be cross-referenced with trends emerging from the quantitative dataset and used to guide the factors to be involved in subgroup and sensitivity analysis. ETHICS AND DISSEMINATION Ethics approval for this case study has been granted from the Western Australian Country Health Service Human Research and Ethics Committee (RGS3076). Reciprocal approval has been granted from Curtin University Human Research Ethics Office (HRE2019-0740). Findings will be disseminated publicly through conference presentation and peer-review publications. Interim findings will be released as internal reports to inform the service development.
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Affiliation(s)
- Christina Tsou
- School of Public Health, Curtin University, Bentley, Western Australia, Australia
| | - Suzanne Robinson
- School of Public Health, Curtin University, Bentley, Western Australia, Australia
| | - James Boyd
- School of Psychology and Public Health, La Trobe University, Melbourne, Victoria, Australia
| | - Shruthi Kamath
- Western Australia Country Health Service, Perth, Western Australia, Australia
| | - Justin Yeung
- Western Australia Country Health Service, Perth, Western Australia, Australia
| | - Stephanie Waters
- Western Australia Country Health Service, Perth, Western Australia, Australia
| | - Karen Gifford
- Western Australia Country Health Service, Perth, Western Australia, Australia
| | - Andrew Jamieson
- Western Australia Country Health Service, Perth, Western Australia, Australia
| | - Delia Hendrie
- School of Public Health, Curtin University, Bentley, Western Australia, Australia
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21
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Gao L, Moodie M, Mitchell PJ, Churilov L, Kleinig TJ, Yassi N, Yan B, Parsons MW, Donnan GA, Davis SM, Campbell BC. Cost-Effectiveness of Tenecteplase Before Thrombectomy for Ischemic Stroke. Stroke 2020; 51:3681-3689. [DOI: 10.1161/strokeaha.120.029666] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose:
Tenecteplase improved functional outcomes and reduced the requirement for endovascular thrombectomy in ischemic stroke patients with large vessel occlusion in the EXTEND-IA TNK randomized trial. We assessed the cost-effectiveness of tenecteplase versus alteplase in this trial.
Methods:
Post hoc within-trial economic analysis included costs of index emergency department and inpatient stroke hospitalization, rehabilitation/subacute care, and rehospitalization due to stroke within 90 days. Sources for cost included key study site complemented by published literature and government websites. Quality-adjusted life-years were estimated using utility scores derived from the modified Rankin Scale score at 90 days. Long-term modeled cost-effectiveness analysis used a Markov model with 7 health states corresponding to 7 modified Rankin Scale scores. Probabilistic sensitivity analyses were performed.
Results:
Within the 202 patients in the randomized controlled trial, total cost was nonsignificantly lower in the tenecteplase-treated patients (40 997 Australian dollars [AUD]) compared with alteplase-treated patients (46 188 AUD) for the first 90 days(
P
=0.125). Tenecteplase was the dominant treatment strategy in the short term, with similar cost (5412 AUD [95% CI, −13 348 to 2523];
P
=0.181) and higher benefits (0.099 quality-adjusted life-years [95% CI, 0.001–0.1967];
P
=0.048), with a 97.4% probability of being cost-effective. In the long-term, tenecteplase was associated with less additional lifetime cost (96 357 versus 106 304 AUD) and greater benefits (quality-adjusted life-years, 7.77 versus 6.48), and had a 100% probability of being cost-effective. Both deterministic sensitivity analysis and probabilistic sensitivity analyses yielded similar results.
Conclusions:
Both within-trial and long-term economic analyses showed that tenecteplase was highly likely to be cost-effective for patients with acute stroke before thrombectomy. Recommending the use of tenecteplase over alteplase could lead to a cost saving to the healthcare system both in the short and long term.
Registration:
URL:
https://www.clinicaltrials.gov
. Unique identifier: NCT02388061.
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Affiliation(s)
- Lan Gao
- Deakin Health Economics, Institute of Health Transformation, School of Health and Social Development, Faculty of Health, Deakin University, Melbourne, Australia (L.G., M.M.)
| | - Marj Moodie
- Deakin Health Economics, Institute of Health Transformation, School of Health and Social Development, Faculty of Health, Deakin University, Melbourne, Australia (L.G., M.M.)
| | - Peter J. Mitchell
- Department of Radiology, Royal Melbourne Hospital (P.J.M.), University of Melbourne, Parkville, Australia
| | - Leonid Churilov
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital (L.C., N.Y., B.Y., M.W.P., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Parkville, Australia
- Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Australia (L.C.)
| | - Timothy J. Kleinig
- Department of Neurology, Royal Adelaide Hospital, South Australia, Australia (T.J.K.)
| | - Nawaf Yassi
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital (L.C., N.Y., B.Y., M.W.P., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Parkville, Australia
- Florey Institute of Neuroscience and Mental Health (N.Y., B.C.V.C.), University of Melbourne, Parkville, Australia
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia (N.Y.)
| | - Bernard Yan
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital (L.C., N.Y., B.Y., M.W.P., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Parkville, Australia
| | - Mark W. Parsons
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital (L.C., N.Y., B.Y., M.W.P., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Parkville, Australia
| | - Geoffrey A. Donnan
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital (L.C., N.Y., B.Y., M.W.P., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Parkville, Australia
| | - Stephen M. Davis
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital (L.C., N.Y., B.Y., M.W.P., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Parkville, Australia
| | - Bruce C.V. Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital (L.C., N.Y., B.Y., M.W.P., G.A.D., S.M.D., B.C.V.C.), University of Melbourne, Parkville, Australia
- Florey Institute of Neuroscience and Mental Health (N.Y., B.C.V.C.), University of Melbourne, Parkville, Australia
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Peultier AC, Pandya A, Sharma R, Severens JL, Redekop WK. Cost-effectiveness of Mechanical Thrombectomy More Than 6 Hours After Symptom Onset Among Patients With Acute Ischemic Stroke. JAMA Netw Open 2020; 3:e2012476. [PMID: 32840620 PMCID: PMC7448828 DOI: 10.1001/jamanetworkopen.2020.12476] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
IMPORTANCE Two 2018 randomized controlled trials (DAWN and DEFUSE 3) demonstrated the clinical benefit of mechanical thrombectomy (MT) more than 6 hours after onset in acute ischemic stroke (AIS). Health-economic evidence is needed to determine whether the short-term health benefits of late MT translate to a cost-effective option during a lifetime in the United States. OBJECTIVE To compare the cost-effectiveness of 2 strategies (MT added to standard medical care [SMC] vs SMC alone) for various subgroups of patients with AIS receiving care more than 6 hours after symptom onset. DESIGN, SETTING, AND PARTICIPANTS This economic evaluation study used the results of the DAWN and DEFUSE 3 trials to populate a cost-effectiveness model from a US health care perspective combining a decision tree and Markov trace. The DAWN and DEFUSE 3 trials enrolled 206 international patients from 2014 to 2017 and 182 US patients from 2016 to 2017, respectively. Patients were followed until 3 months after stroke. The clinical outcome at 3 months was available for 29 subgroups of patients with AIS and anterior circulation large vessel occlusions. Data analysis was conducted from July 2018 to October 2019. EXPOSURES MT with SMC in the extended treatment window vs SMC alone. MAIN OUTCOMES AND MEASURES Expected costs and quality-adjusted life-years (QALYs) during lifetime were estimated. Deterministic results (incremental costs and effectiveness, incremental cost-effectiveness ratios, and net monetary benefit) were presented, and probabilistic analyses were performed for the total populations and 27 patient subgroups. RESULTS In the DAWN study, the MT group had a mean (SD) age of 69.4 (14.1) years and 42 of 107 (39.3%) were men, and the control group had a mean (SD) age of 70.7 (13.2) years and 51 of 99 (51.5%) were men. In the DEFUSE 3 study, the MT group had a median (interquartile range) age of 70 (59-79) years, and 46 of 92 (50.0%) were men, and the control group had a median (interquartile range) age of 71 (59-80) years, and 44 of 90 (48.9%) were men. For the total trial population, incremental cost-effectiveness ratios were $662/QALY and $13 877/QALY based on the DAWN and DEFUSE 3 trials, respectively. MT with SMC beyond 6 hours had a probability greater than 99.9% of being cost-effective vs SMC alone at a willingness-to-pay threshold of $100 000/QALY. Subgroup analyses showed a wide range of probabilities for MT with SMC to be cost-effective at a willingness-to-pay threshold of $50 000/QALY, with the greatest uncertainty observed for patients with a National Institute of Health Stroke Scale score of at least 16 and for those aged 80 years or older. CONCLUSIONS AND RELEVANCE The results of this study suggest that late MT added to SMC is cost-effective in all subgroups evaluated in the DAWN and DEFUSE 3 trials, with most results being robust in probabilistic sensitivity analyses. Future MT evidence-gathering could focus on older patients and those with National Institute of Health Stroke Scale scores of 16 and greater.
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Affiliation(s)
- Anne-Claire Peultier
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Ankur Pandya
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Richa Sharma
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut
| | - Johan L. Severens
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - W. Ken Redekop
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, the Netherlands
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23
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Pan Y, Zhang L, Li Z, Meng X, Wang Y, Li H, Liu L, Wang Y. Cost-Effectiveness of a Multifaceted Quality Improvement Intervention for Acute Ischemic Stroke in China. Stroke 2020; 51:1265-1271. [PMID: 32019480 DOI: 10.1161/strokeaha.119.027980] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Multifaceted quality improvement interventions of stroke care have been shown to improve hospital personnel adherence to evidence-based performance measures and subsequent stroke outcomes. This study aimed to evaluate the cost-effectiveness of a multifaceted quality improvement intervention for stroke care in China, the world's largest low- and middle-income country. Methods- A short-term decision tree model and a long-term Markov model were used to analyze the cost-effectiveness of a multifaceted quality improvement intervention for patients with acute ischemic stroke. Outcomes, transition probability, and cost data were obtained from a recent clinical trial and the published literature. The benefit of the intervention was assessed by the costs per quality-adjusted life-years gained in the short- and long-term. One-way and probabilistic sensitivity analyses were performed to assess the uncertainty of the findings. Results- Compared with usual care, a multifaceted quality improvement intervention for stroke care was found to be cost-effective in the first year and highly cost-effective from the second year onward. In the long-term, the intervention yielded a lifetime gain of 0.246 quality-adjusted life-years at an additional cost of Chinese Yuan Renminbi 1510 (US $230), resulting in a cost of Chinese Yuan Renminbi 6138 (US $940) per quality-adjusted life-year gained. Probabilistic sensitivity analysis indicated that the intervention was highly cost-effective in 99.9% of the simulation runs at a willingness-to-pay threshold of Chinese Yuan Renminbi 59 700 (1× gross domestic product per capita of China in 2017, US $9200) per quality-adjusted life-year. Conclusions- A multifaceted quality improvement intervention for stroke care was highly cost-effective in China. The results of this study may be used as a reference for delivering such interventions in low- and middle-income countries and in underserved areas of high-income countries.
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Affiliation(s)
- Yuesong Pan
- From the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (Y.P., L.Z., Z.L., X.M., Y.W., H.L., L.L., Y.W.).,China National Clinical Research Centre for Neurological Diseases, Beijing (Y.P., L.Z., Z.L., X.M., Y.W., H.L., L.L., Y.W.)
| | - Lei Zhang
- From the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (Y.P., L.Z., Z.L., X.M., Y.W., H.L., L.L., Y.W.).,China National Clinical Research Centre for Neurological Diseases, Beijing (Y.P., L.Z., Z.L., X.M., Y.W., H.L., L.L., Y.W.).,Changping District Hospital, Beijing, China (L.Z.)
| | - Zixiao Li
- From the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (Y.P., L.Z., Z.L., X.M., Y.W., H.L., L.L., Y.W.).,China National Clinical Research Centre for Neurological Diseases, Beijing (Y.P., L.Z., Z.L., X.M., Y.W., H.L., L.L., Y.W.)
| | - Xia Meng
- From the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (Y.P., L.Z., Z.L., X.M., Y.W., H.L., L.L., Y.W.).,China National Clinical Research Centre for Neurological Diseases, Beijing (Y.P., L.Z., Z.L., X.M., Y.W., H.L., L.L., Y.W.)
| | - Yilong Wang
- From the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (Y.P., L.Z., Z.L., X.M., Y.W., H.L., L.L., Y.W.).,China National Clinical Research Centre for Neurological Diseases, Beijing (Y.P., L.Z., Z.L., X.M., Y.W., H.L., L.L., Y.W.)
| | - Hao Li
- From the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (Y.P., L.Z., Z.L., X.M., Y.W., H.L., L.L., Y.W.).,China National Clinical Research Centre for Neurological Diseases, Beijing (Y.P., L.Z., Z.L., X.M., Y.W., H.L., L.L., Y.W.)
| | - Liping Liu
- From the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (Y.P., L.Z., Z.L., X.M., Y.W., H.L., L.L., Y.W.).,China National Clinical Research Centre for Neurological Diseases, Beijing (Y.P., L.Z., Z.L., X.M., Y.W., H.L., L.L., Y.W.)
| | - Yongjun Wang
- From the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (Y.P., L.Z., Z.L., X.M., Y.W., H.L., L.L., Y.W.).,China National Clinical Research Centre for Neurological Diseases, Beijing (Y.P., L.Z., Z.L., X.M., Y.W., H.L., L.L., Y.W.)
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Levi CR, Attia JA, D'Este C, Ryan AE, Henskens F, Kerr E, Parsons MW, Sanson‐Fisher RW, Bladin CF, Lindley RI, Middleton S, Paul CL. Cluster-Randomized Trial of Thrombolysis Implementation Support in Metropolitan and Regional Australian Stroke Centers: Lessons for Individual and Systems Behavior Change. J Am Heart Assoc 2020; 9:e012732. [PMID: 31973599 PMCID: PMC7033885 DOI: 10.1161/jaha.119.012732] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 11/15/2019] [Indexed: 12/21/2022]
Abstract
Background Intravenous thrombolytic therapy (IVT) with tissue plasminogen activator for acute ischemic stroke is underutilized in many parts of the world. Randomized trials to test the effectiveness of thrombolysis implementation strategies are limited. Methods and Results This study aimed to test the effectiveness of a multicomponent, multidisciplinary tissue plasminogen activator implementation package in increasing the proportion of thrombolyzed cases while maintaining accepted benchmarks for low rates of intracranial hemorrhage and high rates of functional outcomes at 3 months. A cluster randomized controlled trial of 20 hospitals in the early stages of thrombolysis implementation across 3 Australian states was undertaken. Monitoring of IVT rates during the baseline period allowed hospitals (the unit of randomization) to be grouped into 3 baseline IVT strata-very low rates (0% to ≤4.0%); low rates (>4.0% to ≤10.0%); and moderate rates (>10.0%). Hospitals were randomized to an implementation package (experimental group) or usual care (control group) using a 1:1 ratio. The 16-month intervention was based on behavioral theory and analysis of the steps, roles, and barriers to rapid assessment for thrombolysis eligibility and involved comprehensive strategies addressing individual and system-level change. The primary outcome was the difference in tissue plasminogen activator proportions between the 2 groups postintervention. The absolute difference in postintervention IVT rates between intervention and control hospitals adjusted for baseline IVT rate and stratum was not significant (primary outcome rate difference=1.1% (95% CI -1.5% to 3.7%; P=0.38). Rates of intracranial hemorrhage remained below international benchmarks. Conclusions The implementation package resulted in no significant change in tissue plasminogen activator implementation, suggesting that ongoing support is needed to sustain initial modifications in behavior. Clinical Trial Registration URL: www.anzctr.org.au Unique identifiers: ACTRN12613000939796 and U1111-1145-6762.
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Affiliation(s)
- Christopher R. Levi
- The University of Newcastle, School of Medicine and Public HealthCallaghanAustralia
- Hunter Medical Research InstituteNew Lambton HeightsAustralia
- Hunter New England HealthNew Lambton HeightsAustralia
| | - John A. Attia
- The University of Newcastle, School of Medicine and Public HealthCallaghanAustralia
- Hunter Medical Research InstituteNew Lambton HeightsAustralia
| | - Cate D'Este
- The University of Newcastle, School of Medicine and Public HealthCallaghanAustralia
- National Centre for Epidemiology and Population HealthThe Australian National UniversityActonAustralia
| | - Annika E. Ryan
- The University of Newcastle, School of Medicine and Public HealthCallaghanAustralia
- Hunter Medical Research InstituteNew Lambton HeightsAustralia
| | - Frans Henskens
- The University of Newcastle, School of Medicine and Public HealthCallaghanAustralia
- Hunter Medical Research InstituteNew Lambton HeightsAustralia
| | - Erin Kerr
- Hunter New England HealthNew Lambton HeightsAustralia
| | | | - Robert W. Sanson‐Fisher
- The University of Newcastle, School of Medicine and Public HealthCallaghanAustralia
- Hunter Medical Research InstituteNew Lambton HeightsAustralia
| | | | - Richard I. Lindley
- The George Institute for Global HealthSydneyAustralia
- The University of SydneyDarlingtonAustralia
| | - Sandy Middleton
- Nursing Research InstituteAustralian Catholic University and St Vincent's Health AustraliaSydney and DarlinghurstAustralia
| | - Christine L. Paul
- The University of Newcastle, School of Medicine and Public HealthCallaghanAustralia
- Hunter Medical Research InstituteNew Lambton HeightsAustralia
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Venema E, Lingsma HF, Chalos V, Mulder MJHL, Lahr MMH, van der Lugt A, van Es ACGM, Steyerberg EW, Hunink MGM, Dippel DWJ, Roozenbeek B. Personalized Prehospital Triage in Acute Ischemic Stroke. Stroke 2019; 50:313-320. [PMID: 30661502 PMCID: PMC6358183 DOI: 10.1161/strokeaha.118.022562] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose— Direct transportation to a center with facilities for endovascular treatment might be beneficial for patients with acute ischemic stroke, but it can also cause harm by delay of intravenous treatment. Our aim was to determine the optimal prehospital transportation strategy for individual patients and to assess which factors influence this decision. Methods— We constructed a decision tree model to compare outcome of ischemic stroke patients after transportation to a primary stroke center versus a more distant intervention center. The optimal strategy was estimated based on individual patient characteristics, geographic location, and workflow times. In the base case scenario, the primary stroke center was located at 20 minutes and the intervention center at 45 minutes. Additional sensitivity analyses included an urban scenario (10 versus 20 minutes) and a rural scenario (30 versus 90 minutes). Results— Direct transportation to the intervention center led to better outcomes in the base case scenario when the likelihood of a large vessel occlusion as a cause of the ischemic stroke was >33%. With a high likelihood of large vessel occlusion (66%, comparable with a Rapid Arterial Occlusion Evaluation score of 5 or above), the benefit of direct transportation to the intervention center was 0.10 quality-adjusted life years (=36 days in full health). In the urban scenario, direct transportation to an intervention center was beneficial when the risk of large vessel occlusion was 24% or higher. In the rural scenario, this threshold was 49%. Other factors influencing the decision included door-to-needle times, door-to-groin times, and the door-in-door-out time. Conclusions— The preferred prehospital transportation strategy for suspected stroke patients depends mainly on the likelihood of large vessel occlusion, driving times, and in-hospital workflow times. We constructed a robust model that combines these characteristics and can be used to personalize prehospital triage, especially in more remote areas.
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Affiliation(s)
- Esmee Venema
- From the Department of Public Health (E.V., H.F.L., V.C., E.W.S.), Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Neurology (E.V., V.C., M.J.H.L.M., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Hester F Lingsma
- From the Department of Public Health (E.V., H.F.L., V.C., E.W.S.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Vicky Chalos
- From the Department of Public Health (E.V., H.F.L., V.C., E.W.S.), Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Neurology (E.V., V.C., M.J.H.L.M., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Radiology and Nuclear Medicine (V.C., M.J.H.L.M., A.v.d.L., A.C.G.M.v.E., M.G.M.H., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Maxim J H L Mulder
- Department of Neurology (E.V., V.C., M.J.H.L.M., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Radiology and Nuclear Medicine (V.C., M.J.H.L.M., A.v.d.L., A.C.G.M.v.E., M.G.M.H., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Maarten M H Lahr
- Department of Epidemiology, University Medical Center Groningen, the Netherlands (M.M.H.L.)
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine (V.C., M.J.H.L.M., A.v.d.L., A.C.G.M.v.E., M.G.M.H., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Adriaan C G M van Es
- Department of Radiology and Nuclear Medicine (V.C., M.J.H.L.M., A.v.d.L., A.C.G.M.v.E., M.G.M.H., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Ewout W Steyerberg
- From the Department of Public Health (E.V., H.F.L., V.C., E.W.S.), Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Biomedical Data Sciences, Leiden University Medical Center, the Netherlands (E.W.S.)
| | - M G Myriam Hunink
- Department of Radiology and Nuclear Medicine (V.C., M.J.H.L.M., A.v.d.L., A.C.G.M.v.E., M.G.M.H., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Epidemiology (M.G.M.H.), Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Centre for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA (M.G.M.H.)
| | - Diederik W J Dippel
- Department of Neurology (E.V., V.C., M.J.H.L.M., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Bob Roozenbeek
- Department of Neurology (E.V., V.C., M.J.H.L.M., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Radiology and Nuclear Medicine (V.C., M.J.H.L.M., A.v.d.L., A.C.G.M.v.E., M.G.M.H., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
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Peultier AC, Redekop WK, Allen M, Peters J, Eker OF, Severens JL. Exploring the Cost-Effectiveness of Mechanical Thrombectomy Beyond 6 Hours Following Advanced Imaging in the United Kingdom. Stroke 2019; 50:3220-3227. [PMID: 31637975 PMCID: PMC6824506 DOI: 10.1161/strokeaha.119.026816] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Supplemental Digital Content is available in the text. In the United Kingdom, mechanical thrombectomy (MT) for acute ischemic stroke patients assessed beyond 6 hours from symptom onset will be commissioned up to 12 hours provided that advanced imaging (AdvImg) demonstrates salvageable brain tissue. While the accuracy of AdvImg differs across technologies, evidence is limited regarding the proportion of patients who would benefit from late MT. We compared the cost-effectiveness of 2 care pathways: (1) MT within and beyond 6 hours based on AdvImg selection versus (2) MT only within 6 hours based on conventional imaging selection. The impact of varying AdvImg accuracy and prior probability for acute ischemic stroke patients to benefit from late MT was assessed.
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Affiliation(s)
- Anne-Claire Peultier
- From Erasmus School of Health Policy and Management (A.-C.P., W.K.R., J.L.S.), Erasmus University Rotterdam, the Netherlands
| | - William K Redekop
- From Erasmus School of Health Policy and Management (A.-C.P., W.K.R., J.L.S.), Erasmus University Rotterdam, the Netherlands.,Institute for Medical Technology Assessment (W.K.R., J.L.S.), Erasmus University Rotterdam, the Netherlands
| | - Michael Allen
- University of Exeter Medical School, United Kingdom (M.A.).,National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South West Peninsula, United Kingdom (M.A.)
| | - Jaime Peters
- Exeter Test Group, University of Exeter Medical School, United Kingdom (J.P.)
| | - Omer Faruk Eker
- Department of Neuroradiology, Lyon University Hospital, France (O.F.E.)
| | - Johan L Severens
- From Erasmus School of Health Policy and Management (A.-C.P., W.K.R., J.L.S.), Erasmus University Rotterdam, the Netherlands.,Institute for Medical Technology Assessment (W.K.R., J.L.S.), Erasmus University Rotterdam, the Netherlands
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27
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Benoit JL, Khatri P, Adeoye OM, Broderick JP, McMullan JT, Scheitz JF, Vagal AS, Eckman MH. Prehospital Triage of Acute Ischemic Stroke Patients to an Intravenous tPA-Ready versus Endovascular-Ready Hospital: A Decision Analysis. PREHOSP EMERG CARE 2018; 22:722-733. [DOI: 10.1080/10903127.2018.1465500] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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28
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Pan Y, Cai X, Huo X, Zhao X, Liu L, Wang Y, Miao Z, Wang Y. Cost-effectiveness of mechanical thrombectomy within 6 hours of acute ischaemic stroke in China. BMJ Open 2018; 8:e018951. [PMID: 29472264 PMCID: PMC5855394 DOI: 10.1136/bmjopen-2017-018951] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 12/29/2017] [Accepted: 01/17/2018] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Endovascular mechanical thrombectomy is an effective but expensive therapy for acute ischaemic stroke with proximal anterior circulation occlusion. This study aimed to determine the cost-effectiveness of mechanical thrombectomy in China, which is the largest developing country. DESIGN A combination of decision tree and Markov model was developed. Outcome and cost data were derived from the published literature and claims database. The efficacy data were derived from the meta-analyses of nine trials. One-way and probabilistic sensitivity analyses were performed in order to assess the uncertainty of the results. SETTING Hospitals in China. PARTICIPANTS The patients with acute ischaemic stroke caused by proximal anterior circulation occlusion within 6 hours. INTERVENTIONS Mechanical thrombectomy within 6 hours with intravenous tissue plasminogen activator (tPA) treatment within 4.5 hours versus intravenous tPA treatment alone. OUTCOME MEASURES The benefit conferred by the treatment was assessed by estimating the cost per quality-adjusted life-year (QALY) gained in the long term (30 years). RESULTS The addition of mechanical thrombectomy to intravenous tPA treatment compared with standard treatment alone yielded a lifetime gain of 0.794 QALYs at an additional cost of CNY 50 000 (US$7700), resulting in a cost of CNY 63 010 (US$9690) per QALY gained. The probabilistic sensitivity analysis indicated that mechanical thrombectomy was cost-effective in 99.9% of the simulation runs at a willingness-to-pay threshold of CNY 125 700 (US$19 300) per QALY. CONCLUSIONS Mechanical thrombectomy for acute ischaemic stroke caused by proximal anterior circulation occlusion within 6 hours was cost-effective in China. The data may be used as a reference with regard to medical resources allocation for stroke treatment in low-income and middle-income countries as well as in the remote areas in the developed countries.
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Affiliation(s)
- Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
- Centre of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China
| | - Xueli Cai
- Department of Neurology, Lishui Hospital of Zhejiang University (the Central Hospital of Lishui), Lishui, China
| | - Xiaochuan Huo
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
- Centre of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
- Centre of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
- Centre of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
- Centre of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Zhongrong Miao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
- Centre of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
- Centre of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
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29
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Nguyen E, Coleman CI, Nair S, Weeda ER. Cost-utility of empagliflozin in patients with type 2 diabetes at high cardiovascular risk. J Diabetes Complications 2018; 32:210-215. [PMID: 29157870 DOI: 10.1016/j.jdiacomp.2017.10.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 10/11/2017] [Accepted: 10/11/2017] [Indexed: 01/09/2023]
Abstract
AIMS In the Empagliflozin, Cardiovascular Outcomes, and Mortality in Type 2 Diabetes (EMPA-REG) trial, empagliflozin reduced cardiovascular and all-cause mortality in type 2 diabetes (T2D) patients at high cardiovascular risk. We sought to estimate the cost-effectiveness of empagliflozin versus standard treatment for the prevention of cardiovascular morbidity and mortality in patients with T2D. METHODS A Markov model was developed to assess the cost-effectiveness of empagliflozin (versus standard treatment) for the prevention of cardiovascular morbidity and mortality in patients with T2D using a 3-month cycle length and a lifetime horizon. Data sources included the EMPA-REG randomized clinical trial and other published epidemiological studies. Outcomes included treatment costs (in 2016 US$), quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs). Probabilistic sensitivity analysis (PSA) was performed to test the robustness of conclusions. RESULTS Empagliflozin use resulted in higher total lifetime treatment costs ($371,450 versus $272,966) but yielded greater QALYs (10.712 vs. 9.419) compared to standard treatment. This corresponded to an ICER of $76,167 per QALY gained. PSA suggested empagliflozin would be cost-effective in 96% of 10,000 iterations assuming a willingness-to-pay threshold of $100,000 per QALY gained. CONCLUSION Empagliflozin may be cost-effective compared to standard treatment in T2D patients at high cardiovascular risk.
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Affiliation(s)
- Elaine Nguyen
- Idaho State University, College of Pharmacy, Meridian, ID, USA
| | - Craig I Coleman
- University of Connecticut, Hartford Hospital Evidence-Based Practice Center, Hartford, CT, USA
| | - Suresh Nair
- University of Connecticut, School of Business, Hartford, CT, USA
| | - Erin R Weeda
- Medical University of South Carolina, College of Pharmacy, Charleston, SC, USA.
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30
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Campbell BCV, Mitchell PJ, Churilov L, Keshtkaran M, Hong KS, Kleinig TJ, Dewey HM, Yassi N, Yan B, Dowling RJ, Parsons MW, Wu TY, Brooks M, Simpson MA, Miteff F, Levi CR, Krause M, Harrington TJ, Faulder KC, Steinfort BS, Ang T, Scroop R, Barber PA, McGuinness B, Wijeratne T, Phan TG, Chong W, Chandra RV, Bladin CF, Rice H, de Villiers L, Ma H, Desmond PM, Meretoja A, Cadilhac DA, Donnan GA, Davis SM. Endovascular Thrombectomy for Ischemic Stroke Increases Disability-Free Survival, Quality of Life, and Life Expectancy and Reduces Cost. Front Neurol 2017; 8:657. [PMID: 29312109 PMCID: PMC5735082 DOI: 10.3389/fneur.2017.00657] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 11/22/2017] [Indexed: 12/02/2022] Open
Abstract
Background Endovascular thrombectomy improves functional outcome in large vessel occlusion ischemic stroke. We examined disability, quality of life, survival and acute care costs in the EXTEND-IA trial, which used CT-perfusion imaging selection. Methods Large vessel ischemic stroke patients with favorable CT-perfusion were randomized to endovascular thrombectomy after alteplase versus alteplase-only. Clinical outcome was prospectively measured using 90-day modified Rankin scale (mRS). Individual patient expected survival and net difference in Disability/Quality-adjusted life years (DALY/QALY) up to 15 years from stroke were modeled using age, sex, 90-day mRS, and utility scores. Level of care within the first 90 days was prospectively measured and used to estimate procedure and inpatient care costs (US$ reference year 2014). Results There were 70 patients, 35 in each arm, mean age 69, median NIHSS 15 (IQR 12–19). The median (IQR) disability-weighted utility score at 90 days was 0.65 (0.00–0.91) in the alteplase-only versus 0.91 (0.65–1.00) in the endovascular group (p = 0.005). Modeled life expectancy was greater in the endovascular versus alteplase-only group (median 15.6 versus 11.2 years, p = 0.02). The endovascular thrombectomy group had fewer simulated DALYs lost over 15 years [median (IQR) 5.5 (3.2–8.7) versus 8.9 (4.7–13.8), p = 0.02] and more QALY gained [median (IQR) 9.3 (4.2–13.1) versus 4.9 (0.3–8.5), p = 0.03]. Endovascular patients spent less time in hospital [median (IQR) 5 (3–11) days versus 8 (5–14) days, p = 0.04] and rehabilitation [median (IQR) 0 (0–28) versus 27 (0–65) days, p = 0.03]. The estimated inpatient costs in the first 90 days were less in the thrombectomy group (average US$15,689 versus US$30,569, p = 0.008) offsetting the costs of interhospital transport and the thrombectomy procedure (average US$10,515). The average saving per patient treated with thrombectomy was US$4,365. Conclusion Thrombectomy patients with large vessel occlusion and salvageable tissue on CT-perfusion had reduced length of stay and overall costs to 90 days. There was evidence of clinically relevant improvement in long-term survival and quality of life. Clinical Trial Registration http://www.ClinicalTrials.gov NCT01492725 (registered 20/11/2011).
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Affiliation(s)
- Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Peter J Mitchell
- Department of Radiology, The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Leonid Churilov
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia
| | - Mahsa Keshtkaran
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia
| | - Keun-Sik Hong
- Department of Neurology, Ilsan Paik Hospital, Inje University, Gyeonggi-do, South Korea
| | | | - Helen M Dewey
- Department of Neurosciences, Eastern Health and Eastern Health Clinical School, Monash University, Clayton, VIC, Australia
| | - Nawaf Yassi
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia.,The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia
| | - Bernard Yan
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Richard J Dowling
- Department of Radiology, The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Mark W Parsons
- Priority Research Centre for Brain and Mental Health Research, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Teddy Y Wu
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | | | | | - Ferdinand Miteff
- Priority Research Centre for Brain and Mental Health Research, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia.,Department of Radiology, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Christopher R Levi
- Priority Research Centre for Brain and Mental Health Research, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Martin Krause
- Department of Neurology, Royal North Shore Hospital, Kolling Institute, University of Sydney, St Leonards, NSW, Australia
| | - Timothy J Harrington
- Department of Radiology, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Kenneth C Faulder
- Department of Radiology, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Brendan S Steinfort
- Department of Radiology, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Timothy Ang
- Priority Research Centre for Brain and Mental Health Research, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | | | - P Alan Barber
- Centre for Brain Research, University of Auckland, Auckland City Hospital, Auckland, New Zealand
| | | | | | - Thanh G Phan
- Monash Medical Centre, Monash University, Clayton, VIC, Australia
| | - Winston Chong
- Monash Medical Centre, Monash University, Clayton, VIC, Australia
| | - Ronil V Chandra
- Monash Medical Centre, Monash University, Clayton, VIC, Australia
| | - Christopher F Bladin
- Department of Neurosciences, Eastern Health and Eastern Health Clinical School, Monash University, Clayton, VIC, Australia
| | - Henry Rice
- Gold Coast University Hospital, Southport, QLD, Australia
| | | | - Henry Ma
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia.,Monash Medical Centre, Monash University, Clayton, VIC, Australia
| | - Patricia M Desmond
- Department of Radiology, The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Atte Meretoja
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia.,Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Dominique A Cadilhac
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia.,Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
| | - Geoffrey A Donnan
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia
| | - Stephen M Davis
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
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Systematic Review of the Cost and Cost-Effectiveness of Rapid Endovascular Therapy for Acute Ischemic Stroke. Stroke 2017; 48:2519-2526. [DOI: 10.1161/strokeaha.117.017199] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 06/04/2017] [Accepted: 06/14/2017] [Indexed: 11/16/2022]
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Soeteman DI, Menzies NA, Pandya A. Would a Large tPA Trial for Those 4.5 to 6.0 Hours from Stroke Onset Be Good Value for Information? VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2017; 20:894-901. [PMID: 28712618 DOI: 10.1016/j.jval.2017.03.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 02/21/2017] [Accepted: 03/03/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To quantify the potential value of new research in patients treated with thrombolytic treatment (tissue-type plasminogen activator [tPA]) in the 4.5- to 6.0-hour time window after stroke onset and to determine the optimal size of a future trial using value of information analysis. METHODS Expected value of partial perfect and sample information (EVPPI and EVSI) analyses were conducted using a probabilistic Markov model. Data for modified Rankin Scale (mRS) distributions in patients 4.5 to 6.0 hours since stroke onset for tPA (n = 576) and placebo (n = 543) were obtained from pooled randomized controlled trials. EVSI was quantified with net monetary benefit (assuming willingness to pay for health as $100,000/QALY). We calculated discounted population-level EVSI by multiplying per-person EVSI by the annual number of eligible patients with stroke in the United States and assuming a 10-year time frame of treatment use. Study costs were based on administrative costs and the costs of tPA. RESULTS The base-case lifetime cost-effectiveness analysis showed that tPA was dominated by placebo in this patient group. EVPPI for mRS distributions was $1003 per person. On the basis of EVSI, the optimal sample size of a new trial collecting data on tPA efficacy in these patients would be 5600 across study arms with expected population-level societal returns (EVSI minus study costs) of $68.7 million. CONCLUSIONS Expanding research attention to the 4.5- to 6.0-hour time window for tPA treatment of patients with acute ischemic stroke is justified because the expected returns are substantial. Even a relatively large trial in which more information on treatment efficacy on the basis of mRS scores is collected would represent good value for information.
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Affiliation(s)
- Djøra I Soeteman
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Nicolas A Menzies
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ankur Pandya
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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33
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Ganesh A, Luengo-Fernandez R, Wharton RM, Gutnikov SA, Silver LE, Mehta Z, Rothwell PM. Time Course of Evolution of Disability and Cause-Specific Mortality After Ischemic Stroke: Implications for Trial Design. J Am Heart Assoc 2017; 6:JAHA.117.005788. [PMID: 28603141 PMCID: PMC5669183 DOI: 10.1161/jaha.117.005788] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Background Outcome in stroke trials is often based on a 3‐month modified Rankin scale (mRS). How 3‐month mRS relates to longer‐term outcomes will depend on late recovery, delayed stroke‐related deaths, recurrent strokes, and nonstroke deaths. We evaluated 3‐month mRS and death/disability at 1 and 5 years in a population‐based cohort study. Methods and Results In 3‐month survivors of ischemic stroke (Oxford Vascular Study; 2002‐2014), we related 3‐month mRS to disability (defined as mRS >2) at 1 and 5 years and/or death rates (age/sex adjusted). Accrual of disability and index‐stroke‐related and nonstroke deaths in each poststroke year was categorized according to 3‐month mRS. Among 1606 patients with acute ischemic stroke, 181 died within 3 months, but 126 index‐stroke‐related deaths and 320 other deaths occurred during the subsequent 4866 patient‐years of follow‐up up to 5 years. Although 69/126 (54.8%) post‐3‐month index‐stroke‐related deaths occurred after 1 year, mRS>2 at 1 year strongly predicted these deaths (adjusted hazard ratio=21.94, 95%CI 7.88‐61.09, P<0.0001). Consequently, a 3‐month mRS >2 was a strong independent predictor of death at both 1 year (adjusted hazard ratio=6.67, 95%CI 4.16‐10.69, P<0.0001) and 5 years (adjusted hazard ratio=2.93, 95%CI 2.38‐3.60, P<0.0001). Although mRS improved by ≥1 point from 3 months to 1 year in 317/1266 (25.0%) patients with 3‐month mRS ≥1, improvement in mRS after 1 year was limited (improvement by ≥1 point: 91/858 [10.6%]; improvement to mRS ≤2: 13/353 [3.7%]). Conclusions Our results reaffirm use of the 3‐month mRS outcome in stroke trials. Although later recovery does occur, extending follow‐up to 1 year would capture most long‐term stroke‐related disability. However, administrative mortality follow‐up beyond 1 year has the potential to demonstrate translation of early disability gains into additional reductions in long‐term mortality without much erosion by non‐stroke‐related deaths.
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Affiliation(s)
- Aravind Ganesh
- Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom
| | - Ramon Luengo-Fernandez
- Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom.,Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, United Kingdom
| | - Rose M Wharton
- Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom
| | - Sergei A Gutnikov
- Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom
| | - Louise E Silver
- Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom
| | - Ziyah Mehta
- Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom
| | - Peter M Rothwell
- Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom
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Berger I, Nayak N, Schuster J, Lee J, Stein S, Malhotra NR. Microvascular Decompression Versus Stereotactic Radiosurgery for Trigeminal Neuralgia: A Decision Analysis. Cureus 2017; 9:e1000. [PMID: 28280653 PMCID: PMC5325747 DOI: 10.7759/cureus.1000] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Both microvascular decompression (MVD) and stereotactic radiosurgery (SRS) have been demonstrated to be effective in treating medically refractory trigeminal neuralgia. However, there is controversy over which one offers more durable pain relief and the patient selection for each treatment. We used a decision analysis model to calculate the health-related quality of life (QOL) for each treatment. METHODS We searched PubMed and the Cochrane Database of Systematic Reviews for relevant articles on MVD or SRS for trigeminal neuralgia published between 2000 and 2015. Using data from these studies, we modeled pain relief and complication outcomes and assigned QOL values. A sensitivity analysis using a Monte Carlo simulation determined which procedure led to the greatest QOL. RESULTS MVD produced a significantly higher QOL than SRS at a seven-year follow-up. Additionally, MVD patients had a significantly higher rate of complete pain relief and a significantly lower rate of complications and recurrence. CONCLUSIONS With a decision-analytic model, we calculated that MVD provides more favorable outcomes than SRS for the treatment of trigeminal neuralgia.
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Affiliation(s)
- Ian Berger
- School of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Nikhil Nayak
- Neurological Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - James Schuster
- Neurological Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - John Lee
- Neurological Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Sherman Stein
- Neurological Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Neil R Malhotra
- Neurological Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
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Shireman TI, Wang K, Saver JL, Goyal M, Bonafé A, Diener HC, Levy EI, Pereira VM, Albers GW, Cognard C, Hacke W, Jansen O, Jovin TG, Mattle HP, Nogueira RG, Siddiqui AH, Yavagal DR, Devlin TG, Lopes DK, Reddy VK, du Mesnil de Rochemont R, Jahan R, Vilain KA, House J, Lee JM, Cohen DJ. Cost-Effectiveness of Solitaire Stent Retriever Thrombectomy for Acute Ischemic Stroke: Results From the SWIFT-PRIME Trial (Solitaire With the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke). Stroke 2016; 48:379-387. [PMID: 28028150 DOI: 10.1161/strokeaha.116.014735] [Citation(s) in RCA: 103] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 10/14/2016] [Accepted: 11/11/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Clinical trials have demonstrated improved 90-day outcomes for patients with acute ischemic stroke treated with stent retriever thrombectomy plus tissue-type plasminogen activator (SST+tPA) compared with tPA. Previous studies suggested that this strategy may be cost-effective, but models were derived from pooled data and older assumptions. METHODS In this prospective economic substudy conducted alongside the SWIFT-PRIME trial (Solitaire With the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke), in-trial costs were measured for patients using detailed medical resource utilization and hospital billing data. Utility weights were assessed at 30 and 90 days using the EuroQol-5 dimension questionnaire. Post-trial costs and life-expectancy were estimated for each surviving patient using a model based on trial data and inputs derived from a contemporary cohort of ischemic stroke survivors. RESULTS Index hospitalization costs were $17 183 per patient higher for SST+tPA than for tPA ($45 761 versus $28 578; P<0.001), driven by initial procedure costs. Between discharge and 90 days, costs were $4904 per patient lower for SST+tPA than for tPA ($11 270 versus $16 174; P=0.014); total 90-day costs remained higher with SST+tPA ($57 031 versus $44 752; P<0.001). Higher utility values for SST+tPA led to higher in-trial quality-adjusted life years (0.131 versus 0.105; P=0.005). In lifetime projections, SST+tPA was associated with substantial gains in quality-adjusted life years (6.79 versus 5.05), cost savings of $23 203 per patient and was economically dominant when compared with tPA in 90% of bootstrap replicates. CONCLUSIONS Among patients with acute ischemic stroke enrolled in the SWIFT-PRIME trial, SST increased initial treatment costs, but was projected to improve quality-adjusted life-expectancy and reduce healthcare costs over a lifetime horizon compared with tPA. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01657461.
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Affiliation(s)
- Theresa I Shireman
- From the Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (T.I.S.); Department of Cardiovascular Research (K.W., K.A.V., J.H.) and Department of Cardiology (D.J.C.), Saint Luke's Mid America Heart Institute, Kansas City, MO; Department of Neurology and Comprehensive Stroke Center (J.L.S.) and Division of Interventional Neuroradiology (R.J.), University of California Los Angeles; Departments of Radiology and Clinical Neurosciences, University of Calgary, Alberta, Canada (M.G.); Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada (V.M.P.); Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.); Department of Neurology, University of Heidelberg, Germany (W.H.); Department of Radiology and Neuroradiology, Christian-Albrechts-University Kiel, Germany (O.J.); Department of Neurology, University of Pittsburgh Medical Center, PA (T.G.J., V.K.R.); Department of Neurology, Inselspital, University of Bern, Switzerland (H.P.M.); Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Department of Neurology, Emory University School of Medicine, Atlanta, GA (R.G.N.); Department of Neurosurgery, Toshiba Stroke and Vascular Research Center, University at Buffalo State University of New York at Buffalo (A.H.S.); Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, FL (D.R.Y.); Division of Neurology, Erlanger Hospital at University of Tennessee, Chattanooga (T.G.D.); Department of Neurosurgery, Rush University Medical Center, Chicago, IL (D.K.L.); Institute of Neuroradiology, Klinikum der Goethe-Universität, Frankfurt, Germany (R.d.M.d.R.); Department of Neurology, Washington University in Saint Louis, MO (J.-M.L.); and Department of Medicine, University of Missouri-Kansas City School of Medicine (D.J.C.)
| | - Kaijun Wang
- From the Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (T.I.S.); Department of Cardiovascular Research (K.W., K.A.V., J.H.) and Department of Cardiology (D.J.C.), Saint Luke's Mid America Heart Institute, Kansas City, MO; Department of Neurology and Comprehensive Stroke Center (J.L.S.) and Division of Interventional Neuroradiology (R.J.), University of California Los Angeles; Departments of Radiology and Clinical Neurosciences, University of Calgary, Alberta, Canada (M.G.); Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada (V.M.P.); Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.); Department of Neurology, University of Heidelberg, Germany (W.H.); Department of Radiology and Neuroradiology, Christian-Albrechts-University Kiel, Germany (O.J.); Department of Neurology, University of Pittsburgh Medical Center, PA (T.G.J., V.K.R.); Department of Neurology, Inselspital, University of Bern, Switzerland (H.P.M.); Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Department of Neurology, Emory University School of Medicine, Atlanta, GA (R.G.N.); Department of Neurosurgery, Toshiba Stroke and Vascular Research Center, University at Buffalo State University of New York at Buffalo (A.H.S.); Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, FL (D.R.Y.); Division of Neurology, Erlanger Hospital at University of Tennessee, Chattanooga (T.G.D.); Department of Neurosurgery, Rush University Medical Center, Chicago, IL (D.K.L.); Institute of Neuroradiology, Klinikum der Goethe-Universität, Frankfurt, Germany (R.d.M.d.R.); Department of Neurology, Washington University in Saint Louis, MO (J.-M.L.); and Department of Medicine, University of Missouri-Kansas City School of Medicine (D.J.C.)
| | - Jeffrey L Saver
- From the Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (T.I.S.); Department of Cardiovascular Research (K.W., K.A.V., J.H.) and Department of Cardiology (D.J.C.), Saint Luke's Mid America Heart Institute, Kansas City, MO; Department of Neurology and Comprehensive Stroke Center (J.L.S.) and Division of Interventional Neuroradiology (R.J.), University of California Los Angeles; Departments of Radiology and Clinical Neurosciences, University of Calgary, Alberta, Canada (M.G.); Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada (V.M.P.); Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.); Department of Neurology, University of Heidelberg, Germany (W.H.); Department of Radiology and Neuroradiology, Christian-Albrechts-University Kiel, Germany (O.J.); Department of Neurology, University of Pittsburgh Medical Center, PA (T.G.J., V.K.R.); Department of Neurology, Inselspital, University of Bern, Switzerland (H.P.M.); Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Department of Neurology, Emory University School of Medicine, Atlanta, GA (R.G.N.); Department of Neurosurgery, Toshiba Stroke and Vascular Research Center, University at Buffalo State University of New York at Buffalo (A.H.S.); Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, FL (D.R.Y.); Division of Neurology, Erlanger Hospital at University of Tennessee, Chattanooga (T.G.D.); Department of Neurosurgery, Rush University Medical Center, Chicago, IL (D.K.L.); Institute of Neuroradiology, Klinikum der Goethe-Universität, Frankfurt, Germany (R.d.M.d.R.); Department of Neurology, Washington University in Saint Louis, MO (J.-M.L.); and Department of Medicine, University of Missouri-Kansas City School of Medicine (D.J.C.)
| | - Mayank Goyal
- From the Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (T.I.S.); Department of Cardiovascular Research (K.W., K.A.V., J.H.) and Department of Cardiology (D.J.C.), Saint Luke's Mid America Heart Institute, Kansas City, MO; Department of Neurology and Comprehensive Stroke Center (J.L.S.) and Division of Interventional Neuroradiology (R.J.), University of California Los Angeles; Departments of Radiology and Clinical Neurosciences, University of Calgary, Alberta, Canada (M.G.); Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada (V.M.P.); Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.); Department of Neurology, University of Heidelberg, Germany (W.H.); Department of Radiology and Neuroradiology, Christian-Albrechts-University Kiel, Germany (O.J.); Department of Neurology, University of Pittsburgh Medical Center, PA (T.G.J., V.K.R.); Department of Neurology, Inselspital, University of Bern, Switzerland (H.P.M.); Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Department of Neurology, Emory University School of Medicine, Atlanta, GA (R.G.N.); Department of Neurosurgery, Toshiba Stroke and Vascular Research Center, University at Buffalo State University of New York at Buffalo (A.H.S.); Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, FL (D.R.Y.); Division of Neurology, Erlanger Hospital at University of Tennessee, Chattanooga (T.G.D.); Department of Neurosurgery, Rush University Medical Center, Chicago, IL (D.K.L.); Institute of Neuroradiology, Klinikum der Goethe-Universität, Frankfurt, Germany (R.d.M.d.R.); Department of Neurology, Washington University in Saint Louis, MO (J.-M.L.); and Department of Medicine, University of Missouri-Kansas City School of Medicine (D.J.C.)
| | - Alain Bonafé
- From the Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (T.I.S.); Department of Cardiovascular Research (K.W., K.A.V., J.H.) and Department of Cardiology (D.J.C.), Saint Luke's Mid America Heart Institute, Kansas City, MO; Department of Neurology and Comprehensive Stroke Center (J.L.S.) and Division of Interventional Neuroradiology (R.J.), University of California Los Angeles; Departments of Radiology and Clinical Neurosciences, University of Calgary, Alberta, Canada (M.G.); Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada (V.M.P.); Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.); Department of Neurology, University of Heidelberg, Germany (W.H.); Department of Radiology and Neuroradiology, Christian-Albrechts-University Kiel, Germany (O.J.); Department of Neurology, University of Pittsburgh Medical Center, PA (T.G.J., V.K.R.); Department of Neurology, Inselspital, University of Bern, Switzerland (H.P.M.); Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Department of Neurology, Emory University School of Medicine, Atlanta, GA (R.G.N.); Department of Neurosurgery, Toshiba Stroke and Vascular Research Center, University at Buffalo State University of New York at Buffalo (A.H.S.); Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, FL (D.R.Y.); Division of Neurology, Erlanger Hospital at University of Tennessee, Chattanooga (T.G.D.); Department of Neurosurgery, Rush University Medical Center, Chicago, IL (D.K.L.); Institute of Neuroradiology, Klinikum der Goethe-Universität, Frankfurt, Germany (R.d.M.d.R.); Department of Neurology, Washington University in Saint Louis, MO (J.-M.L.); and Department of Medicine, University of Missouri-Kansas City School of Medicine (D.J.C.)
| | - Hans-Christoph Diener
- From the Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (T.I.S.); Department of Cardiovascular Research (K.W., K.A.V., J.H.) and Department of Cardiology (D.J.C.), Saint Luke's Mid America Heart Institute, Kansas City, MO; Department of Neurology and Comprehensive Stroke Center (J.L.S.) and Division of Interventional Neuroradiology (R.J.), University of California Los Angeles; Departments of Radiology and Clinical Neurosciences, University of Calgary, Alberta, Canada (M.G.); Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada (V.M.P.); Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.); Department of Neurology, University of Heidelberg, Germany (W.H.); Department of Radiology and Neuroradiology, Christian-Albrechts-University Kiel, Germany (O.J.); Department of Neurology, University of Pittsburgh Medical Center, PA (T.G.J., V.K.R.); Department of Neurology, Inselspital, University of Bern, Switzerland (H.P.M.); Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Department of Neurology, Emory University School of Medicine, Atlanta, GA (R.G.N.); Department of Neurosurgery, Toshiba Stroke and Vascular Research Center, University at Buffalo State University of New York at Buffalo (A.H.S.); Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, FL (D.R.Y.); Division of Neurology, Erlanger Hospital at University of Tennessee, Chattanooga (T.G.D.); Department of Neurosurgery, Rush University Medical Center, Chicago, IL (D.K.L.); Institute of Neuroradiology, Klinikum der Goethe-Universität, Frankfurt, Germany (R.d.M.d.R.); Department of Neurology, Washington University in Saint Louis, MO (J.-M.L.); and Department of Medicine, University of Missouri-Kansas City School of Medicine (D.J.C.)
| | - Elad I Levy
- From the Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (T.I.S.); Department of Cardiovascular Research (K.W., K.A.V., J.H.) and Department of Cardiology (D.J.C.), Saint Luke's Mid America Heart Institute, Kansas City, MO; Department of Neurology and Comprehensive Stroke Center (J.L.S.) and Division of Interventional Neuroradiology (R.J.), University of California Los Angeles; Departments of Radiology and Clinical Neurosciences, University of Calgary, Alberta, Canada (M.G.); Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada (V.M.P.); Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.); Department of Neurology, University of Heidelberg, Germany (W.H.); Department of Radiology and Neuroradiology, Christian-Albrechts-University Kiel, Germany (O.J.); Department of Neurology, University of Pittsburgh Medical Center, PA (T.G.J., V.K.R.); Department of Neurology, Inselspital, University of Bern, Switzerland (H.P.M.); Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Department of Neurology, Emory University School of Medicine, Atlanta, GA (R.G.N.); Department of Neurosurgery, Toshiba Stroke and Vascular Research Center, University at Buffalo State University of New York at Buffalo (A.H.S.); Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, FL (D.R.Y.); Division of Neurology, Erlanger Hospital at University of Tennessee, Chattanooga (T.G.D.); Department of Neurosurgery, Rush University Medical Center, Chicago, IL (D.K.L.); Institute of Neuroradiology, Klinikum der Goethe-Universität, Frankfurt, Germany (R.d.M.d.R.); Department of Neurology, Washington University in Saint Louis, MO (J.-M.L.); and Department of Medicine, University of Missouri-Kansas City School of Medicine (D.J.C.)
| | - Vitor M Pereira
- From the Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (T.I.S.); Department of Cardiovascular Research (K.W., K.A.V., J.H.) and Department of Cardiology (D.J.C.), Saint Luke's Mid America Heart Institute, Kansas City, MO; Department of Neurology and Comprehensive Stroke Center (J.L.S.) and Division of Interventional Neuroradiology (R.J.), University of California Los Angeles; Departments of Radiology and Clinical Neurosciences, University of Calgary, Alberta, Canada (M.G.); Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada (V.M.P.); Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.); Department of Neurology, University of Heidelberg, Germany (W.H.); Department of Radiology and Neuroradiology, Christian-Albrechts-University Kiel, Germany (O.J.); Department of Neurology, University of Pittsburgh Medical Center, PA (T.G.J., V.K.R.); Department of Neurology, Inselspital, University of Bern, Switzerland (H.P.M.); Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Department of Neurology, Emory University School of Medicine, Atlanta, GA (R.G.N.); Department of Neurosurgery, Toshiba Stroke and Vascular Research Center, University at Buffalo State University of New York at Buffalo (A.H.S.); Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, FL (D.R.Y.); Division of Neurology, Erlanger Hospital at University of Tennessee, Chattanooga (T.G.D.); Department of Neurosurgery, Rush University Medical Center, Chicago, IL (D.K.L.); Institute of Neuroradiology, Klinikum der Goethe-Universität, Frankfurt, Germany (R.d.M.d.R.); Department of Neurology, Washington University in Saint Louis, MO (J.-M.L.); and Department of Medicine, University of Missouri-Kansas City School of Medicine (D.J.C.)
| | - Gregory W Albers
- From the Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (T.I.S.); Department of Cardiovascular Research (K.W., K.A.V., J.H.) and Department of Cardiology (D.J.C.), Saint Luke's Mid America Heart Institute, Kansas City, MO; Department of Neurology and Comprehensive Stroke Center (J.L.S.) and Division of Interventional Neuroradiology (R.J.), University of California Los Angeles; Departments of Radiology and Clinical Neurosciences, University of Calgary, Alberta, Canada (M.G.); Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada (V.M.P.); Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.); Department of Neurology, University of Heidelberg, Germany (W.H.); Department of Radiology and Neuroradiology, Christian-Albrechts-University Kiel, Germany (O.J.); Department of Neurology, University of Pittsburgh Medical Center, PA (T.G.J., V.K.R.); Department of Neurology, Inselspital, University of Bern, Switzerland (H.P.M.); Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Department of Neurology, Emory University School of Medicine, Atlanta, GA (R.G.N.); Department of Neurosurgery, Toshiba Stroke and Vascular Research Center, University at Buffalo State University of New York at Buffalo (A.H.S.); Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, FL (D.R.Y.); Division of Neurology, Erlanger Hospital at University of Tennessee, Chattanooga (T.G.D.); Department of Neurosurgery, Rush University Medical Center, Chicago, IL (D.K.L.); Institute of Neuroradiology, Klinikum der Goethe-Universität, Frankfurt, Germany (R.d.M.d.R.); Department of Neurology, Washington University in Saint Louis, MO (J.-M.L.); and Department of Medicine, University of Missouri-Kansas City School of Medicine (D.J.C.)
| | - Christophe Cognard
- From the Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (T.I.S.); Department of Cardiovascular Research (K.W., K.A.V., J.H.) and Department of Cardiology (D.J.C.), Saint Luke's Mid America Heart Institute, Kansas City, MO; Department of Neurology and Comprehensive Stroke Center (J.L.S.) and Division of Interventional Neuroradiology (R.J.), University of California Los Angeles; Departments of Radiology and Clinical Neurosciences, University of Calgary, Alberta, Canada (M.G.); Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada (V.M.P.); Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.); Department of Neurology, University of Heidelberg, Germany (W.H.); Department of Radiology and Neuroradiology, Christian-Albrechts-University Kiel, Germany (O.J.); Department of Neurology, University of Pittsburgh Medical Center, PA (T.G.J., V.K.R.); Department of Neurology, Inselspital, University of Bern, Switzerland (H.P.M.); Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Department of Neurology, Emory University School of Medicine, Atlanta, GA (R.G.N.); Department of Neurosurgery, Toshiba Stroke and Vascular Research Center, University at Buffalo State University of New York at Buffalo (A.H.S.); Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, FL (D.R.Y.); Division of Neurology, Erlanger Hospital at University of Tennessee, Chattanooga (T.G.D.); Department of Neurosurgery, Rush University Medical Center, Chicago, IL (D.K.L.); Institute of Neuroradiology, Klinikum der Goethe-Universität, Frankfurt, Germany (R.d.M.d.R.); Department of Neurology, Washington University in Saint Louis, MO (J.-M.L.); and Department of Medicine, University of Missouri-Kansas City School of Medicine (D.J.C.)
| | - Werner Hacke
- From the Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (T.I.S.); Department of Cardiovascular Research (K.W., K.A.V., J.H.) and Department of Cardiology (D.J.C.), Saint Luke's Mid America Heart Institute, Kansas City, MO; Department of Neurology and Comprehensive Stroke Center (J.L.S.) and Division of Interventional Neuroradiology (R.J.), University of California Los Angeles; Departments of Radiology and Clinical Neurosciences, University of Calgary, Alberta, Canada (M.G.); Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada (V.M.P.); Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.); Department of Neurology, University of Heidelberg, Germany (W.H.); Department of Radiology and Neuroradiology, Christian-Albrechts-University Kiel, Germany (O.J.); Department of Neurology, University of Pittsburgh Medical Center, PA (T.G.J., V.K.R.); Department of Neurology, Inselspital, University of Bern, Switzerland (H.P.M.); Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Department of Neurology, Emory University School of Medicine, Atlanta, GA (R.G.N.); Department of Neurosurgery, Toshiba Stroke and Vascular Research Center, University at Buffalo State University of New York at Buffalo (A.H.S.); Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, FL (D.R.Y.); Division of Neurology, Erlanger Hospital at University of Tennessee, Chattanooga (T.G.D.); Department of Neurosurgery, Rush University Medical Center, Chicago, IL (D.K.L.); Institute of Neuroradiology, Klinikum der Goethe-Universität, Frankfurt, Germany (R.d.M.d.R.); Department of Neurology, Washington University in Saint Louis, MO (J.-M.L.); and Department of Medicine, University of Missouri-Kansas City School of Medicine (D.J.C.)
| | - Olav Jansen
- From the Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (T.I.S.); Department of Cardiovascular Research (K.W., K.A.V., J.H.) and Department of Cardiology (D.J.C.), Saint Luke's Mid America Heart Institute, Kansas City, MO; Department of Neurology and Comprehensive Stroke Center (J.L.S.) and Division of Interventional Neuroradiology (R.J.), University of California Los Angeles; Departments of Radiology and Clinical Neurosciences, University of Calgary, Alberta, Canada (M.G.); Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada (V.M.P.); Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.); Department of Neurology, University of Heidelberg, Germany (W.H.); Department of Radiology and Neuroradiology, Christian-Albrechts-University Kiel, Germany (O.J.); Department of Neurology, University of Pittsburgh Medical Center, PA (T.G.J., V.K.R.); Department of Neurology, Inselspital, University of Bern, Switzerland (H.P.M.); Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Department of Neurology, Emory University School of Medicine, Atlanta, GA (R.G.N.); Department of Neurosurgery, Toshiba Stroke and Vascular Research Center, University at Buffalo State University of New York at Buffalo (A.H.S.); Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, FL (D.R.Y.); Division of Neurology, Erlanger Hospital at University of Tennessee, Chattanooga (T.G.D.); Department of Neurosurgery, Rush University Medical Center, Chicago, IL (D.K.L.); Institute of Neuroradiology, Klinikum der Goethe-Universität, Frankfurt, Germany (R.d.M.d.R.); Department of Neurology, Washington University in Saint Louis, MO (J.-M.L.); and Department of Medicine, University of Missouri-Kansas City School of Medicine (D.J.C.)
| | - Tudor G Jovin
- From the Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (T.I.S.); Department of Cardiovascular Research (K.W., K.A.V., J.H.) and Department of Cardiology (D.J.C.), Saint Luke's Mid America Heart Institute, Kansas City, MO; Department of Neurology and Comprehensive Stroke Center (J.L.S.) and Division of Interventional Neuroradiology (R.J.), University of California Los Angeles; Departments of Radiology and Clinical Neurosciences, University of Calgary, Alberta, Canada (M.G.); Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada (V.M.P.); Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.); Department of Neurology, University of Heidelberg, Germany (W.H.); Department of Radiology and Neuroradiology, Christian-Albrechts-University Kiel, Germany (O.J.); Department of Neurology, University of Pittsburgh Medical Center, PA (T.G.J., V.K.R.); Department of Neurology, Inselspital, University of Bern, Switzerland (H.P.M.); Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Department of Neurology, Emory University School of Medicine, Atlanta, GA (R.G.N.); Department of Neurosurgery, Toshiba Stroke and Vascular Research Center, University at Buffalo State University of New York at Buffalo (A.H.S.); Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, FL (D.R.Y.); Division of Neurology, Erlanger Hospital at University of Tennessee, Chattanooga (T.G.D.); Department of Neurosurgery, Rush University Medical Center, Chicago, IL (D.K.L.); Institute of Neuroradiology, Klinikum der Goethe-Universität, Frankfurt, Germany (R.d.M.d.R.); Department of Neurology, Washington University in Saint Louis, MO (J.-M.L.); and Department of Medicine, University of Missouri-Kansas City School of Medicine (D.J.C.)
| | - Heinrich P Mattle
- From the Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (T.I.S.); Department of Cardiovascular Research (K.W., K.A.V., J.H.) and Department of Cardiology (D.J.C.), Saint Luke's Mid America Heart Institute, Kansas City, MO; Department of Neurology and Comprehensive Stroke Center (J.L.S.) and Division of Interventional Neuroradiology (R.J.), University of California Los Angeles; Departments of Radiology and Clinical Neurosciences, University of Calgary, Alberta, Canada (M.G.); Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada (V.M.P.); Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.); Department of Neurology, University of Heidelberg, Germany (W.H.); Department of Radiology and Neuroradiology, Christian-Albrechts-University Kiel, Germany (O.J.); Department of Neurology, University of Pittsburgh Medical Center, PA (T.G.J., V.K.R.); Department of Neurology, Inselspital, University of Bern, Switzerland (H.P.M.); Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Department of Neurology, Emory University School of Medicine, Atlanta, GA (R.G.N.); Department of Neurosurgery, Toshiba Stroke and Vascular Research Center, University at Buffalo State University of New York at Buffalo (A.H.S.); Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, FL (D.R.Y.); Division of Neurology, Erlanger Hospital at University of Tennessee, Chattanooga (T.G.D.); Department of Neurosurgery, Rush University Medical Center, Chicago, IL (D.K.L.); Institute of Neuroradiology, Klinikum der Goethe-Universität, Frankfurt, Germany (R.d.M.d.R.); Department of Neurology, Washington University in Saint Louis, MO (J.-M.L.); and Department of Medicine, University of Missouri-Kansas City School of Medicine (D.J.C.)
| | - Raul G Nogueira
- From the Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (T.I.S.); Department of Cardiovascular Research (K.W., K.A.V., J.H.) and Department of Cardiology (D.J.C.), Saint Luke's Mid America Heart Institute, Kansas City, MO; Department of Neurology and Comprehensive Stroke Center (J.L.S.) and Division of Interventional Neuroradiology (R.J.), University of California Los Angeles; Departments of Radiology and Clinical Neurosciences, University of Calgary, Alberta, Canada (M.G.); Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada (V.M.P.); Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.); Department of Neurology, University of Heidelberg, Germany (W.H.); Department of Radiology and Neuroradiology, Christian-Albrechts-University Kiel, Germany (O.J.); Department of Neurology, University of Pittsburgh Medical Center, PA (T.G.J., V.K.R.); Department of Neurology, Inselspital, University of Bern, Switzerland (H.P.M.); Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Department of Neurology, Emory University School of Medicine, Atlanta, GA (R.G.N.); Department of Neurosurgery, Toshiba Stroke and Vascular Research Center, University at Buffalo State University of New York at Buffalo (A.H.S.); Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, FL (D.R.Y.); Division of Neurology, Erlanger Hospital at University of Tennessee, Chattanooga (T.G.D.); Department of Neurosurgery, Rush University Medical Center, Chicago, IL (D.K.L.); Institute of Neuroradiology, Klinikum der Goethe-Universität, Frankfurt, Germany (R.d.M.d.R.); Department of Neurology, Washington University in Saint Louis, MO (J.-M.L.); and Department of Medicine, University of Missouri-Kansas City School of Medicine (D.J.C.)
| | - Adnan H Siddiqui
- From the Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (T.I.S.); Department of Cardiovascular Research (K.W., K.A.V., J.H.) and Department of Cardiology (D.J.C.), Saint Luke's Mid America Heart Institute, Kansas City, MO; Department of Neurology and Comprehensive Stroke Center (J.L.S.) and Division of Interventional Neuroradiology (R.J.), University of California Los Angeles; Departments of Radiology and Clinical Neurosciences, University of Calgary, Alberta, Canada (M.G.); Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada (V.M.P.); Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.); Department of Neurology, University of Heidelberg, Germany (W.H.); Department of Radiology and Neuroradiology, Christian-Albrechts-University Kiel, Germany (O.J.); Department of Neurology, University of Pittsburgh Medical Center, PA (T.G.J., V.K.R.); Department of Neurology, Inselspital, University of Bern, Switzerland (H.P.M.); Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Department of Neurology, Emory University School of Medicine, Atlanta, GA (R.G.N.); Department of Neurosurgery, Toshiba Stroke and Vascular Research Center, University at Buffalo State University of New York at Buffalo (A.H.S.); Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, FL (D.R.Y.); Division of Neurology, Erlanger Hospital at University of Tennessee, Chattanooga (T.G.D.); Department of Neurosurgery, Rush University Medical Center, Chicago, IL (D.K.L.); Institute of Neuroradiology, Klinikum der Goethe-Universität, Frankfurt, Germany (R.d.M.d.R.); Department of Neurology, Washington University in Saint Louis, MO (J.-M.L.); and Department of Medicine, University of Missouri-Kansas City School of Medicine (D.J.C.)
| | - Dileep R Yavagal
- From the Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (T.I.S.); Department of Cardiovascular Research (K.W., K.A.V., J.H.) and Department of Cardiology (D.J.C.), Saint Luke's Mid America Heart Institute, Kansas City, MO; Department of Neurology and Comprehensive Stroke Center (J.L.S.) and Division of Interventional Neuroradiology (R.J.), University of California Los Angeles; Departments of Radiology and Clinical Neurosciences, University of Calgary, Alberta, Canada (M.G.); Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada (V.M.P.); Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.); Department of Neurology, University of Heidelberg, Germany (W.H.); Department of Radiology and Neuroradiology, Christian-Albrechts-University Kiel, Germany (O.J.); Department of Neurology, University of Pittsburgh Medical Center, PA (T.G.J., V.K.R.); Department of Neurology, Inselspital, University of Bern, Switzerland (H.P.M.); Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Department of Neurology, Emory University School of Medicine, Atlanta, GA (R.G.N.); Department of Neurosurgery, Toshiba Stroke and Vascular Research Center, University at Buffalo State University of New York at Buffalo (A.H.S.); Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, FL (D.R.Y.); Division of Neurology, Erlanger Hospital at University of Tennessee, Chattanooga (T.G.D.); Department of Neurosurgery, Rush University Medical Center, Chicago, IL (D.K.L.); Institute of Neuroradiology, Klinikum der Goethe-Universität, Frankfurt, Germany (R.d.M.d.R.); Department of Neurology, Washington University in Saint Louis, MO (J.-M.L.); and Department of Medicine, University of Missouri-Kansas City School of Medicine (D.J.C.)
| | - Thomas G Devlin
- From the Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (T.I.S.); Department of Cardiovascular Research (K.W., K.A.V., J.H.) and Department of Cardiology (D.J.C.), Saint Luke's Mid America Heart Institute, Kansas City, MO; Department of Neurology and Comprehensive Stroke Center (J.L.S.) and Division of Interventional Neuroradiology (R.J.), University of California Los Angeles; Departments of Radiology and Clinical Neurosciences, University of Calgary, Alberta, Canada (M.G.); Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada (V.M.P.); Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.); Department of Neurology, University of Heidelberg, Germany (W.H.); Department of Radiology and Neuroradiology, Christian-Albrechts-University Kiel, Germany (O.J.); Department of Neurology, University of Pittsburgh Medical Center, PA (T.G.J., V.K.R.); Department of Neurology, Inselspital, University of Bern, Switzerland (H.P.M.); Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Department of Neurology, Emory University School of Medicine, Atlanta, GA (R.G.N.); Department of Neurosurgery, Toshiba Stroke and Vascular Research Center, University at Buffalo State University of New York at Buffalo (A.H.S.); Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, FL (D.R.Y.); Division of Neurology, Erlanger Hospital at University of Tennessee, Chattanooga (T.G.D.); Department of Neurosurgery, Rush University Medical Center, Chicago, IL (D.K.L.); Institute of Neuroradiology, Klinikum der Goethe-Universität, Frankfurt, Germany (R.d.M.d.R.); Department of Neurology, Washington University in Saint Louis, MO (J.-M.L.); and Department of Medicine, University of Missouri-Kansas City School of Medicine (D.J.C.)
| | - Demetrius K Lopes
- From the Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (T.I.S.); Department of Cardiovascular Research (K.W., K.A.V., J.H.) and Department of Cardiology (D.J.C.), Saint Luke's Mid America Heart Institute, Kansas City, MO; Department of Neurology and Comprehensive Stroke Center (J.L.S.) and Division of Interventional Neuroradiology (R.J.), University of California Los Angeles; Departments of Radiology and Clinical Neurosciences, University of Calgary, Alberta, Canada (M.G.); Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada (V.M.P.); Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.); Department of Neurology, University of Heidelberg, Germany (W.H.); Department of Radiology and Neuroradiology, Christian-Albrechts-University Kiel, Germany (O.J.); Department of Neurology, University of Pittsburgh Medical Center, PA (T.G.J., V.K.R.); Department of Neurology, Inselspital, University of Bern, Switzerland (H.P.M.); Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Department of Neurology, Emory University School of Medicine, Atlanta, GA (R.G.N.); Department of Neurosurgery, Toshiba Stroke and Vascular Research Center, University at Buffalo State University of New York at Buffalo (A.H.S.); Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, FL (D.R.Y.); Division of Neurology, Erlanger Hospital at University of Tennessee, Chattanooga (T.G.D.); Department of Neurosurgery, Rush University Medical Center, Chicago, IL (D.K.L.); Institute of Neuroradiology, Klinikum der Goethe-Universität, Frankfurt, Germany (R.d.M.d.R.); Department of Neurology, Washington University in Saint Louis, MO (J.-M.L.); and Department of Medicine, University of Missouri-Kansas City School of Medicine (D.J.C.)
| | - Vivek K Reddy
- From the Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (T.I.S.); Department of Cardiovascular Research (K.W., K.A.V., J.H.) and Department of Cardiology (D.J.C.), Saint Luke's Mid America Heart Institute, Kansas City, MO; Department of Neurology and Comprehensive Stroke Center (J.L.S.) and Division of Interventional Neuroradiology (R.J.), University of California Los Angeles; Departments of Radiology and Clinical Neurosciences, University of Calgary, Alberta, Canada (M.G.); Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada (V.M.P.); Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.); Department of Neurology, University of Heidelberg, Germany (W.H.); Department of Radiology and Neuroradiology, Christian-Albrechts-University Kiel, Germany (O.J.); Department of Neurology, University of Pittsburgh Medical Center, PA (T.G.J., V.K.R.); Department of Neurology, Inselspital, University of Bern, Switzerland (H.P.M.); Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Department of Neurology, Emory University School of Medicine, Atlanta, GA (R.G.N.); Department of Neurosurgery, Toshiba Stroke and Vascular Research Center, University at Buffalo State University of New York at Buffalo (A.H.S.); Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, FL (D.R.Y.); Division of Neurology, Erlanger Hospital at University of Tennessee, Chattanooga (T.G.D.); Department of Neurosurgery, Rush University Medical Center, Chicago, IL (D.K.L.); Institute of Neuroradiology, Klinikum der Goethe-Universität, Frankfurt, Germany (R.d.M.d.R.); Department of Neurology, Washington University in Saint Louis, MO (J.-M.L.); and Department of Medicine, University of Missouri-Kansas City School of Medicine (D.J.C.)
| | - Richard du Mesnil de Rochemont
- From the Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (T.I.S.); Department of Cardiovascular Research (K.W., K.A.V., J.H.) and Department of Cardiology (D.J.C.), Saint Luke's Mid America Heart Institute, Kansas City, MO; Department of Neurology and Comprehensive Stroke Center (J.L.S.) and Division of Interventional Neuroradiology (R.J.), University of California Los Angeles; Departments of Radiology and Clinical Neurosciences, University of Calgary, Alberta, Canada (M.G.); Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada (V.M.P.); Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.); Department of Neurology, University of Heidelberg, Germany (W.H.); Department of Radiology and Neuroradiology, Christian-Albrechts-University Kiel, Germany (O.J.); Department of Neurology, University of Pittsburgh Medical Center, PA (T.G.J., V.K.R.); Department of Neurology, Inselspital, University of Bern, Switzerland (H.P.M.); Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Department of Neurology, Emory University School of Medicine, Atlanta, GA (R.G.N.); Department of Neurosurgery, Toshiba Stroke and Vascular Research Center, University at Buffalo State University of New York at Buffalo (A.H.S.); Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, FL (D.R.Y.); Division of Neurology, Erlanger Hospital at University of Tennessee, Chattanooga (T.G.D.); Department of Neurosurgery, Rush University Medical Center, Chicago, IL (D.K.L.); Institute of Neuroradiology, Klinikum der Goethe-Universität, Frankfurt, Germany (R.d.M.d.R.); Department of Neurology, Washington University in Saint Louis, MO (J.-M.L.); and Department of Medicine, University of Missouri-Kansas City School of Medicine (D.J.C.)
| | - Reza Jahan
- From the Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (T.I.S.); Department of Cardiovascular Research (K.W., K.A.V., J.H.) and Department of Cardiology (D.J.C.), Saint Luke's Mid America Heart Institute, Kansas City, MO; Department of Neurology and Comprehensive Stroke Center (J.L.S.) and Division of Interventional Neuroradiology (R.J.), University of California Los Angeles; Departments of Radiology and Clinical Neurosciences, University of Calgary, Alberta, Canada (M.G.); Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada (V.M.P.); Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.); Department of Neurology, University of Heidelberg, Germany (W.H.); Department of Radiology and Neuroradiology, Christian-Albrechts-University Kiel, Germany (O.J.); Department of Neurology, University of Pittsburgh Medical Center, PA (T.G.J., V.K.R.); Department of Neurology, Inselspital, University of Bern, Switzerland (H.P.M.); Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Department of Neurology, Emory University School of Medicine, Atlanta, GA (R.G.N.); Department of Neurosurgery, Toshiba Stroke and Vascular Research Center, University at Buffalo State University of New York at Buffalo (A.H.S.); Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, FL (D.R.Y.); Division of Neurology, Erlanger Hospital at University of Tennessee, Chattanooga (T.G.D.); Department of Neurosurgery, Rush University Medical Center, Chicago, IL (D.K.L.); Institute of Neuroradiology, Klinikum der Goethe-Universität, Frankfurt, Germany (R.d.M.d.R.); Department of Neurology, Washington University in Saint Louis, MO (J.-M.L.); and Department of Medicine, University of Missouri-Kansas City School of Medicine (D.J.C.)
| | - Katherine A Vilain
- From the Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (T.I.S.); Department of Cardiovascular Research (K.W., K.A.V., J.H.) and Department of Cardiology (D.J.C.), Saint Luke's Mid America Heart Institute, Kansas City, MO; Department of Neurology and Comprehensive Stroke Center (J.L.S.) and Division of Interventional Neuroradiology (R.J.), University of California Los Angeles; Departments of Radiology and Clinical Neurosciences, University of Calgary, Alberta, Canada (M.G.); Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada (V.M.P.); Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.); Department of Neurology, University of Heidelberg, Germany (W.H.); Department of Radiology and Neuroradiology, Christian-Albrechts-University Kiel, Germany (O.J.); Department of Neurology, University of Pittsburgh Medical Center, PA (T.G.J., V.K.R.); Department of Neurology, Inselspital, University of Bern, Switzerland (H.P.M.); Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Department of Neurology, Emory University School of Medicine, Atlanta, GA (R.G.N.); Department of Neurosurgery, Toshiba Stroke and Vascular Research Center, University at Buffalo State University of New York at Buffalo (A.H.S.); Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, FL (D.R.Y.); Division of Neurology, Erlanger Hospital at University of Tennessee, Chattanooga (T.G.D.); Department of Neurosurgery, Rush University Medical Center, Chicago, IL (D.K.L.); Institute of Neuroradiology, Klinikum der Goethe-Universität, Frankfurt, Germany (R.d.M.d.R.); Department of Neurology, Washington University in Saint Louis, MO (J.-M.L.); and Department of Medicine, University of Missouri-Kansas City School of Medicine (D.J.C.)
| | - John House
- From the Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (T.I.S.); Department of Cardiovascular Research (K.W., K.A.V., J.H.) and Department of Cardiology (D.J.C.), Saint Luke's Mid America Heart Institute, Kansas City, MO; Department of Neurology and Comprehensive Stroke Center (J.L.S.) and Division of Interventional Neuroradiology (R.J.), University of California Los Angeles; Departments of Radiology and Clinical Neurosciences, University of Calgary, Alberta, Canada (M.G.); Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada (V.M.P.); Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.); Department of Neurology, University of Heidelberg, Germany (W.H.); Department of Radiology and Neuroradiology, Christian-Albrechts-University Kiel, Germany (O.J.); Department of Neurology, University of Pittsburgh Medical Center, PA (T.G.J., V.K.R.); Department of Neurology, Inselspital, University of Bern, Switzerland (H.P.M.); Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Department of Neurology, Emory University School of Medicine, Atlanta, GA (R.G.N.); Department of Neurosurgery, Toshiba Stroke and Vascular Research Center, University at Buffalo State University of New York at Buffalo (A.H.S.); Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, FL (D.R.Y.); Division of Neurology, Erlanger Hospital at University of Tennessee, Chattanooga (T.G.D.); Department of Neurosurgery, Rush University Medical Center, Chicago, IL (D.K.L.); Institute of Neuroradiology, Klinikum der Goethe-Universität, Frankfurt, Germany (R.d.M.d.R.); Department of Neurology, Washington University in Saint Louis, MO (J.-M.L.); and Department of Medicine, University of Missouri-Kansas City School of Medicine (D.J.C.)
| | - Jin-Moo Lee
- From the Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (T.I.S.); Department of Cardiovascular Research (K.W., K.A.V., J.H.) and Department of Cardiology (D.J.C.), Saint Luke's Mid America Heart Institute, Kansas City, MO; Department of Neurology and Comprehensive Stroke Center (J.L.S.) and Division of Interventional Neuroradiology (R.J.), University of California Los Angeles; Departments of Radiology and Clinical Neurosciences, University of Calgary, Alberta, Canada (M.G.); Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada (V.M.P.); Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.); Department of Neurology, University of Heidelberg, Germany (W.H.); Department of Radiology and Neuroradiology, Christian-Albrechts-University Kiel, Germany (O.J.); Department of Neurology, University of Pittsburgh Medical Center, PA (T.G.J., V.K.R.); Department of Neurology, Inselspital, University of Bern, Switzerland (H.P.M.); Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Department of Neurology, Emory University School of Medicine, Atlanta, GA (R.G.N.); Department of Neurosurgery, Toshiba Stroke and Vascular Research Center, University at Buffalo State University of New York at Buffalo (A.H.S.); Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, FL (D.R.Y.); Division of Neurology, Erlanger Hospital at University of Tennessee, Chattanooga (T.G.D.); Department of Neurosurgery, Rush University Medical Center, Chicago, IL (D.K.L.); Institute of Neuroradiology, Klinikum der Goethe-Universität, Frankfurt, Germany (R.d.M.d.R.); Department of Neurology, Washington University in Saint Louis, MO (J.-M.L.); and Department of Medicine, University of Missouri-Kansas City School of Medicine (D.J.C.)
| | - David J Cohen
- From the Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (T.I.S.); Department of Cardiovascular Research (K.W., K.A.V., J.H.) and Department of Cardiology (D.J.C.), Saint Luke's Mid America Heart Institute, Kansas City, MO; Department of Neurology and Comprehensive Stroke Center (J.L.S.) and Division of Interventional Neuroradiology (R.J.), University of California Los Angeles; Departments of Radiology and Clinical Neurosciences, University of Calgary, Alberta, Canada (M.G.); Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada (V.M.P.); Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.); Department of Neurology, University of Heidelberg, Germany (W.H.); Department of Radiology and Neuroradiology, Christian-Albrechts-University Kiel, Germany (O.J.); Department of Neurology, University of Pittsburgh Medical Center, PA (T.G.J., V.K.R.); Department of Neurology, Inselspital, University of Bern, Switzerland (H.P.M.); Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Department of Neurology, Emory University School of Medicine, Atlanta, GA (R.G.N.); Department of Neurosurgery, Toshiba Stroke and Vascular Research Center, University at Buffalo State University of New York at Buffalo (A.H.S.); Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, FL (D.R.Y.); Division of Neurology, Erlanger Hospital at University of Tennessee, Chattanooga (T.G.D.); Department of Neurosurgery, Rush University Medical Center, Chicago, IL (D.K.L.); Institute of Neuroradiology, Klinikum der Goethe-Universität, Frankfurt, Germany (R.d.M.d.R.); Department of Neurology, Washington University in Saint Louis, MO (J.-M.L.); and Department of Medicine, University of Missouri-Kansas City School of Medicine (D.J.C.).
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Kunz WG, Hunink MM, Sommer WH, Beyer SE, Meinel FG, Dorn F, Wirth S, Reiser MF, Ertl-Wagner B, Thierfelder KM. Cost-Effectiveness of Endovascular Stroke Therapy. Stroke 2016; 47:2797-2804. [PMID: 27758942 DOI: 10.1161/strokeaha.116.014147] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 08/24/2016] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Endovascular therapy in addition to standard care (EVT+SC) has been demonstrated to be more effective than SC in acute ischemic large vessel occlusion stroke. Our aim was to determine the cost-effectiveness of EVT+SC depending on patients’ initial National Institutes of Health Stroke Scale (NIHSS) score, time from symptom onset, Alberta Stroke Program Early CT Score (ASPECTS), and occlusion location.
Methods—
A decision model based on Markov simulations estimated lifetime costs and quality-adjusted life years (QALYs) associated with both strategies applied in a US setting. Model input parameters were obtained from the literature, including recently pooled outcome data of 5 randomized controlled trials (ESCAPE [Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke], EXTEND-IA [Extending the Time for Thrombolysis in Emergency Neurological Deficits–Intra-Arterial], MR CLEAN [Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands], REVASCAT [Randomized Trial of Revascularization With Solitaire FR Device Versus Best Medical Therapy in the Treatment of Acute Stroke Due to Anterior Circulation Large Vessel Occlusion Presenting Within 8 Hours of Symptom Onset], and SWIFT PRIME [Solitaire With the Intention for Thrombectomy as Primary Endovascular Treatment]). Probabilistic sensitivity analysis was performed to estimate uncertainty of the model results. Net monetary benefits, incremental costs, incremental effectiveness, and incremental cost-effectiveness ratios were derived from the probabilistic sensitivity analysis. The willingness-to-pay was set to $50 000/QALY.
Results—
Overall, EVT+SC was cost-effective compared with SC (incremental cost: $4938, incremental effectiveness: 1.59 QALYs, and incremental cost-effectiveness ratio: $3110/QALY) in 100% of simulations. In all patient subgroups, EVT+SC led to gained QALYs (range: 0.47–2.12), and mean incremental cost-effectiveness ratios were considered cost-effective. However, subgroups with ASPECTS ≤5 or with M2 occlusions showed considerably higher incremental cost-effectiveness ratios ($14 273/QALY and $28 812/QALY, respectively) and only reached suboptimal acceptability in the probabilistic sensitivity analysis (75.5% and 59.4%, respectively). All other subgroups had acceptability rates of 90% to 100%.
Conclusions—
EVT+SC is cost-effective in most subgroups. In patients with ASPECTS ≤5 or with M2 occlusions, cost-effectiveness remains uncertain based on current data.
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Affiliation(s)
- Wolfgang G. Kunz
- From the Institute for Clinical Radiology (W.G.K., W.H.S., S.E.B., F.G.M., S.W., M.F.R., B.E.-W., K.M.T.) and Department of Neuroradiology (F.D.), LMU Munich, Munich, Germany; Departments of Radiology (M.G.M.H.) and Epidemiology (M.G.M.H.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Center for Health Decision Sciences, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA (M.G.M.H.)
| | - M.G. Myriam Hunink
- From the Institute for Clinical Radiology (W.G.K., W.H.S., S.E.B., F.G.M., S.W., M.F.R., B.E.-W., K.M.T.) and Department of Neuroradiology (F.D.), LMU Munich, Munich, Germany; Departments of Radiology (M.G.M.H.) and Epidemiology (M.G.M.H.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Center for Health Decision Sciences, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA (M.G.M.H.)
| | - Wieland H. Sommer
- From the Institute for Clinical Radiology (W.G.K., W.H.S., S.E.B., F.G.M., S.W., M.F.R., B.E.-W., K.M.T.) and Department of Neuroradiology (F.D.), LMU Munich, Munich, Germany; Departments of Radiology (M.G.M.H.) and Epidemiology (M.G.M.H.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Center for Health Decision Sciences, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA (M.G.M.H.)
| | - Sebastian E. Beyer
- From the Institute for Clinical Radiology (W.G.K., W.H.S., S.E.B., F.G.M., S.W., M.F.R., B.E.-W., K.M.T.) and Department of Neuroradiology (F.D.), LMU Munich, Munich, Germany; Departments of Radiology (M.G.M.H.) and Epidemiology (M.G.M.H.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Center for Health Decision Sciences, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA (M.G.M.H.)
| | - Felix G. Meinel
- From the Institute for Clinical Radiology (W.G.K., W.H.S., S.E.B., F.G.M., S.W., M.F.R., B.E.-W., K.M.T.) and Department of Neuroradiology (F.D.), LMU Munich, Munich, Germany; Departments of Radiology (M.G.M.H.) and Epidemiology (M.G.M.H.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Center for Health Decision Sciences, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA (M.G.M.H.)
| | - Franziska Dorn
- From the Institute for Clinical Radiology (W.G.K., W.H.S., S.E.B., F.G.M., S.W., M.F.R., B.E.-W., K.M.T.) and Department of Neuroradiology (F.D.), LMU Munich, Munich, Germany; Departments of Radiology (M.G.M.H.) and Epidemiology (M.G.M.H.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Center for Health Decision Sciences, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA (M.G.M.H.)
| | - Stefan Wirth
- From the Institute for Clinical Radiology (W.G.K., W.H.S., S.E.B., F.G.M., S.W., M.F.R., B.E.-W., K.M.T.) and Department of Neuroradiology (F.D.), LMU Munich, Munich, Germany; Departments of Radiology (M.G.M.H.) and Epidemiology (M.G.M.H.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Center for Health Decision Sciences, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA (M.G.M.H.)
| | - Maximilian F. Reiser
- From the Institute for Clinical Radiology (W.G.K., W.H.S., S.E.B., F.G.M., S.W., M.F.R., B.E.-W., K.M.T.) and Department of Neuroradiology (F.D.), LMU Munich, Munich, Germany; Departments of Radiology (M.G.M.H.) and Epidemiology (M.G.M.H.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Center for Health Decision Sciences, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA (M.G.M.H.)
| | - Birgit Ertl-Wagner
- From the Institute for Clinical Radiology (W.G.K., W.H.S., S.E.B., F.G.M., S.W., M.F.R., B.E.-W., K.M.T.) and Department of Neuroradiology (F.D.), LMU Munich, Munich, Germany; Departments of Radiology (M.G.M.H.) and Epidemiology (M.G.M.H.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Center for Health Decision Sciences, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA (M.G.M.H.)
| | - Kolja M. Thierfelder
- From the Institute for Clinical Radiology (W.G.K., W.H.S., S.E.B., F.G.M., S.W., M.F.R., B.E.-W., K.M.T.) and Department of Neuroradiology (F.D.), LMU Munich, Munich, Germany; Departments of Radiology (M.G.M.H.) and Epidemiology (M.G.M.H.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Center for Health Decision Sciences, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA (M.G.M.H.)
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Johnson-Masotti AP, Laud PW, Hoffmann RG, Hayat MJ, Pinkerton SD. A Bayesian Approach to Net Health Benefits: An Illustration and Application to Modeling HIV Prevention. Med Decis Making 2016; 24:634-53. [PMID: 15534344 DOI: 10.1177/0272989x04271040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose. To conduct a cost-effectiveness analysis of HIV prevention when costs and effects cannot be measured directly. To quantify the total estimation of uncertainty due to sampling variability as well as inexact knowledge of HIV transmission parameters. Methods. The authors focus on estimating the incremental net health benefit (INHB) in a randomized trial of HIV prevention with intervention and control conditions. Using a Bernoulli model of HIV transmission, changes in the participants’ risk behaviors are converted into the number of HIV infections averted. A sampling model is used to account for variation in the behavior measurements. Bayes’s theorem and Monte Carlo methods are used to attain the stated objectives. Results. The authors obtained a positive mean INHB of 0.0008, indicating that advocacy training is just slightly favored over the control condition for men, assuming a $50,000 per quality-adjusted life year (QALY) threshold. To be confident of a positive INHB, the decision maker would need to spend more than $100,000 per QALY.
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Affiliation(s)
- Ana P Johnson-Masotti
- Clinical Epidemiology and Biostatistics Department, McMaster University, Hamilton, Ontario, Canada.
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Martikainen JA, Ottelin AM, Kiviniemi V, Gylling H. Plant stanol esters are potentially cost-effective in the prevention of coronary heart disease in men: Bayesian modelling approach. ACTA ACUST UNITED AC 2016; 14:265-72. [PMID: 17446806 DOI: 10.1097/01.hjr.0000216550.74258.12] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Plant stanol esters in spreads have demonstrated efficacy in reducing serum cholesterol. The cost-effectiveness of plant stanol esters in the prevention of coronary heart disease, however, has remained unevaluated. DESIGN A Bayesian modelling approach was applied to synthesize clinical evidence and evaluate the cost-effectiveness (Euro/quality-adjusted life years) of plant stanol esters in spread in the prevention of coronary heart disease based on published FINRISK and 4S risk functions. RESULTS The regular use of plant stanol esters reduced total serum cholesterol by -0.362 mmol/l [95% credibility interval (CrI) -0.31 to -0.41]. The corresponding placebo-adjusted reduction attributable to stanol esters when combined with statin was -0.385 mmol/l (95% CrI -0.18 to -0.61). The cost-effectiveness estimations were assessed for men and women separately at four different initial ages at which the regular use of stanol esters was assumed to be started. The base case cost per quality-adjusted life years gained by using stanol esters regularly ranged from 7436 to 20,999 Euro in men and from 34,327 to 112,151 Euro in women based on the initial starting age. According to uncertainty analysis, there is over a 90% probability that the use of plant stanol esters is cost-effective for men inclusively and for 60-year-old and older women assuming that decision-makers' maximum willingness to pay per quality-adjusted life year is 50,000 Euro. CONCLUSIONS A recommendation that plant stanol ester-containing spreads be used as a part of daily diet replacing regular spread could be viewed as potentially cost-effective public health policy in the prevention of CHD in all adult men and in older age-groups of women with total serum cholesterol levels of 5 mmol/l or greater.
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Affiliation(s)
- Janne A Martikainen
- Department of Social Pharmacy, Centre for Pharmaceutical Policy and Economics, University of Kuopio, Kuopio University Hospital, Kuopio, Finland.
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Lobotesis K, Veltkamp R, Carpenter IH, Claxton LM, Saver JL, Hodgson R. Cost-effectiveness of stent-retriever thrombectomy in combination with IV t-PA compared with IV t-PA alone for acute ischemic stroke in the UK. J Med Econ 2016; 19:785-94. [PMID: 27046347 DOI: 10.1080/13696998.2016.1174868] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To evaluate the cost-effectiveness of neurothrombectomy with a stent retriever (Solitaire * Revascularization Device) in treating acute ischemic stroke patients from the UK healthcare provider perspective. METHODS A Markov model was developed to simulate health outcomes and costs of two therapies over a lifetime time horizon: stent-retriever thrombectomy in combination with intravenous tissue-type plasminogen activator (IV t-PA), and IV t-PA alone. The model incorporated an acute phase (0-90 days) and a rest of life phase (90+ days). Health states were defined by the modified Rankin Scale score. During the rest of life phase, patients remained in the same health state until a recurrent stroke or death. Clinical effectiveness and safety data were taken from the SWIFT PRIME study. Resource use and health state utilities were informed by published data. RESULTS Combined stent-retriever thrombectomy and IV t-PA led to improved quality-of-life and increased life expectancy compared to IV t-PA alone. The higher treatment costs associated with the use of stent-retriever thrombectomy were offset by long-term cost savings due to improved patient health status, leading to overall cost savings of £33 190 per patient and a net benefit of £79 402. Deterministic and probabilistic sensitivity analyses demonstrated that the results were robust to a wide range of parameter inputs. LIMITATIONS The acute and long-term costs resource use data were taken from a study based on a patient population that was older and may have had additional comorbidities than the SWIFT PRIME population, resulting in costs that may not be representative of the cohort within this model. In addition, the estimates may not reflect stroke care today as no current evidence is available; however, the cost estimates were deemed reasonable by clinical opinion. CONCLUSIONS Combined stent-retriever neurothrombectomy and IV t-PA is a cost-effective treatment for acute ischemic stroke compared with IV t-PA alone.
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Affiliation(s)
| | - Roland Veltkamp
- b Division of Brain Sciences , Imperial College , London , UK
| | | | | | - Jeffrey L Saver
- d Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine , University of California, Los Angeles (UCLA) , Los Angeles , CA , USA
| | - Robert Hodgson
- c York Health Economics Consortium, University of York , York , UK
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Meenan RT, Saha S, Chou R, Swarztrauber K, Pyle Krages K, O'Keeffe-Rosetti MC, McDonagh M, Chan BKS, Hornbrook MC, Helfand M. Cost-Effectiveness of Echocardiography to Identify Intracardiac Thrombus among Patients with First Stroke or Transient Ischemic Attack. Med Decis Making 2016; 27:161-77. [PMID: 17409366 DOI: 10.1177/0272989x06297388] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background and Purpose . Echocardiography to select stroke patients for targeted treatments, such as anticoagulation (AC), to reduce recurrent stroke risk is controversial. The authors' objective was to evaluate the cost-effectiveness of imaging strategies that use transthoracic (TTE) and transesophageal (TEE) echocardiography for identifying intracardiac thrombus in new stroke patients. Methods . Model-based cost-effectiveness analysis of 7 echocardiographic imaging strategies and 2 nontesting strategies with model parameters based on systematic evidence review related to effectiveness of echocardiography in newly diagnosed ischemic stroke patients (white males aged 65 years in base case). Primary outcome was cost per quality-adjusted life year (QALY). Results . All strategies containing TTE were dominated by others and were eliminated from the analysis. Assuming that AC reduces recurrent stroke risk from intracardiac thrombus by 43% over 1 year, TEE generated a cost per QALY of $137,000 (relative to standard treatment) among patients with 5% thrombus prevalence. Cost per QALY dropped to $50,000 in patients with at least 15% intracardiac thrombus prevalence, or, if an 86% relative risk reduction with AC is assumed, in patients with thrombus prevalence of at least 6%. Probabilistic analyses indicate considerable uncertainty around the cost-effectiveness of echocardiography across a wide range of intracardiac thrombus prevalence (pretest probability). Conclusions . Current evidence on cost-effectiveness is insufficient to justify widespread use of echocardiography in stroke patients. Additional research on recurrent stroke risk in patients with intracardiac thrombus and on the efficacy of AC in reducing that risk may contribute to a better understanding of the circumstances under which echocardiography will be cost-effective. Key words: cost-effectiveness; decision analysis; stroke; transesophageal echocardiography; transthoracic echocardiography; diagnostic imaging. (Med Decis Making 2007;27:161—177)
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Affiliation(s)
- Richard T Meenan
- Oregon Health & Science University Evidence-based Practice Center, Portland, USA.
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Pandian JD, Padma V, Vijaya P, Sylaja PN, Murthy JMK. Stroke and Thrombolysis in Developing Countries. Int J Stroke 2016; 2:17-26. [DOI: 10.1111/j.1747-4949.2007.00089.x] [Citation(s) in RCA: 110] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background Over the past few decades, the burden of stroke in developing countries has grown to epidemic proportions. Two-thirds of global stroke occurs in low- and middle-income countries. We have found that little information is obtainable concerning the availability of thrombolysis therapy in developing countries. Summary of review The epidemiology of stroke is well investigated in the developed world; however, in the developing world stroke is less well documented. Most of the available stroke data from these countries are hospital-based. Stroke thrombolysis is currently used in few developing countries like Brazil, Argentina, Senegal, Iran, Pakistan, China, Thailand, and India. The two main barriers for implementation of thrombolysis therapy in developing countries are the high cost of tissue plasminogen activator and lack of proper infrastructure. Most of the centers with the infrastructure to deliver thrombolysis for stroke are predominantly private sector, and only available in urban areas. Conclusion Until a more cost-effective thrombolytic agent and the proper infrastructure for widespread use of thrombolysis therapy are available, developing nations should focus on primary and secondary stroke prevention strategies and the establishment of stroke units wherever possible. Such multi-faceted approaches will be more cost-effective for developing countries than the use of thrombolysis.
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Affiliation(s)
| | - Vasantha Padma
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Pamidimukkala Vijaya
- Ankineedu Stroke Unit, Heart and Brain Center, Lalitha Super Specialty Hospital, Kothapet, Guntur, Andhra Pradesh, India
| | - P. N. Sylaja
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
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Aronsson M, Persson J, Blomstrand C, Wester P, Levin LÅ. Cost-effectiveness of endovascular thrombectomy in patients with acute ischemic stroke. Neurology 2016; 86:1053-9. [PMID: 26873954 DOI: 10.1212/wnl.0000000000002439] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 11/04/2015] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate the cost-effectiveness of adding endovascular thrombectomy to standard care in patients with acute ischemic stroke. METHODS The cost-effectiveness analysis of endovascular thrombectomy in patients with acute ischemic stroke was based on a decision-analytic Markov model. Primary outcomes from ESCAPE, Extending the Time for Thrombolysis in Emergency Neurological Deficits-Intra-Arterial (EXTEND-IA), Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN), Endovascular Revascularization With Solitaire Device Versus Best Medical Therapy in Anterior Circulation Stroke Within 8 Hours (REVASCAT), and Solitaire with the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke (SWIFT PRIME) along with data from published studies and registries were used in this analysis. We used a health care payer perspective and a lifelong time horizon to estimate costs and effects. RESULTS The model showed that adding thrombectomy with stent retrievers to guideline-based care (including IV thrombolysis) resulted in a gain of 0.40 life-years and 0.99 quality-adjusted life-years along with a cost savings of approximately $221 per patient. The sensitivity analysis showed that the results were not sensitive to changes in uncertain parameters or assumptions. CONCLUSIONS Adding endovascular treatment to standard care resulted in substantial clinical benefits at low costs. The results were consistent throughout irrespective of whether data from ESCAPE, EXTEND-IA, MR CLEAN, REVASCAT, or SWIFT PRIME were used in this model.
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Affiliation(s)
- Mattias Aronsson
- From the Department of Medical and Health Sciences (M.A., L.-Å.L.), Linkoping University; Department of Clinical Neuroscience and Rehabilitation at the Sahlgrenska Academy (J.P., C.B.), University of Gothenburg; Department of Public Health and Clinical Science (P.W.), University of Umea; and Department of Clinical Sciences (P.W.), Danderyd Hospital, Karolinska Institutet, Sweden.
| | - Josefine Persson
- From the Department of Medical and Health Sciences (M.A., L.-Å.L.), Linkoping University; Department of Clinical Neuroscience and Rehabilitation at the Sahlgrenska Academy (J.P., C.B.), University of Gothenburg; Department of Public Health and Clinical Science (P.W.), University of Umea; and Department of Clinical Sciences (P.W.), Danderyd Hospital, Karolinska Institutet, Sweden
| | - Christian Blomstrand
- From the Department of Medical and Health Sciences (M.A., L.-Å.L.), Linkoping University; Department of Clinical Neuroscience and Rehabilitation at the Sahlgrenska Academy (J.P., C.B.), University of Gothenburg; Department of Public Health and Clinical Science (P.W.), University of Umea; and Department of Clinical Sciences (P.W.), Danderyd Hospital, Karolinska Institutet, Sweden
| | - Per Wester
- From the Department of Medical and Health Sciences (M.A., L.-Å.L.), Linkoping University; Department of Clinical Neuroscience and Rehabilitation at the Sahlgrenska Academy (J.P., C.B.), University of Gothenburg; Department of Public Health and Clinical Science (P.W.), University of Umea; and Department of Clinical Sciences (P.W.), Danderyd Hospital, Karolinska Institutet, Sweden
| | - Lars-Åke Levin
- From the Department of Medical and Health Sciences (M.A., L.-Å.L.), Linkoping University; Department of Clinical Neuroscience and Rehabilitation at the Sahlgrenska Academy (J.P., C.B.), University of Gothenburg; Department of Public Health and Clinical Science (P.W.), University of Umea; and Department of Clinical Sciences (P.W.), Danderyd Hospital, Karolinska Institutet, Sweden
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Pandya A, Eggman AA, Kamel H, Gupta A, Schackman BR, Sanelli PC. Modeling the Cost Effectiveness of Neuroimaging-Based Treatment of Acute Wake-Up Stroke. PLoS One 2016; 11:e0148106. [PMID: 26840397 PMCID: PMC4740488 DOI: 10.1371/journal.pone.0148106] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 01/13/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Thrombolytic treatment (tissue-type plasminogen activator [tPA]) is only recommended for acute ischemic stroke patients with stroke onset time <4.5 hours. tPA is not recommended when stroke onset time is unknown. Diffusion-weighted MRI (DWI) and fluid attenuated inversion recovery (FLAIR) MRI mismatch information has been found to approximate stroke onset time with some accuracy. Therefore, we developed a micro-simulation model to project health outcomes and costs of MRI-based treatment decisions versus no treatment for acute wake-up stroke patients. METHODS AND FINDINGS The model assigned simulated patients a true stroke onset time from a specified probability distribution. DWI-FLAIR mismatch estimated stroke onset <4.5 hours with sensitivity and specificity of 0.62 and 0.78, respectively. Modified Rankin Scale (mRS) scores reflected tPA treatment effectiveness accounting for patients' true stroke onset time. Discounted lifetime costs and benefits (quality-adjusted life years [QALYs]) were projected for each strategy. Incremental cost-effectiveness ratios (ICERs) were calculated for the MRI-based strategy in base-case and sensitivity analyses. With no treatment, 45.1% of simulated patients experienced a good stroke outcome (mRS score 0-1). Under the MRI-based strategy, in which 17.0% of all patients received tPA despite stroke onset times >4.5 hours, 46.3% experienced a good stroke outcome. Lifetime discounted QALYs and costs were 5.312 and $88,247 for the no treatment strategy and 5.342 and $90,869 for the MRI-based strategy, resulting in an ICER of $88,000/QALY. Results were sensitive to variations in patient- and provider-specific factors such as sleep duration, hospital travel and door-to-needle times, as well as onset probability distribution, MRI specificity, and mRS utility values. CONCLUSIONS Our model-based findings suggest that an MRI-based treatment strategy for this population could be cost-effective and quantifies the impact that patient- and provider-specific factors, such as sleep duration, hospital travel and door-to-needle times, could have on the optimal decision for wake-up stroke patients.
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Affiliation(s)
- Ankur Pandya
- Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, United States of America
- * E-mail:
| | - Ashley A. Eggman
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, United States of America
| | - Hooman Kamel
- Department of Neurology, New York-Presbyterian/Weill Cornell Medical College, New York, NY, United States of America
| | - Ajay Gupta
- Department of Radiology, New York-Presbyterian/Weill Cornell Medical College, New York, NY, United States of America
| | - Bruce R. Schackman
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, United States of America
| | - Pina C. Sanelli
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, United States of America
- Department of Radiology, New York-Presbyterian/Weill Cornell Medical College, New York, NY, United States of America
- Department of Radiology, North Shore–LIJ Health System, Manhasset, NY, United States of America
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Jethwa PR, Patel TD, Hajart AF, Eloy JA, Couldwell WT, Liu JK. Cost-Effectiveness Analysis of Microscopic and Endoscopic Transsphenoidal Surgery Versus Medical Therapy in the Management of Microprolactinoma in the United States. World Neurosurg 2015; 87:65-76. [PMID: 26548828 DOI: 10.1016/j.wneu.2015.10.090] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 10/22/2015] [Accepted: 10/24/2015] [Indexed: 01/20/2023]
Abstract
BACKGROUND Although prolactinomas are treated effectively with dopamine agonists, some have proposed curative surgical resection for select cases of microprolactinomas to avoid life-long medical therapy. We performed a cost-effectiveness analysis comparing transsphenoidal surgery (either microsurgical or endoscopic) and medical therapy (either bromocriptine or cabergoline) with decision analysis modeling. METHODS A 2-armed decision tree was created with TreeAge Pro Suite 2012 to compare upfront transsphenoidal surgery versus medical therapy. The economic perspective was that of the health care third-party payer. On the basis of a literature review, we assigned plausible distributions for costs and utilities to each potential outcome, taking into account medical and surgical costs and complications. Base-case analysis, sensitivity analysis, and Monte Carlo simulations were performed to determine the cost-effectiveness of each strategy at 5-year and 10-year time horizons. RESULTS In the base-case scenario, microscopic transsphenoidal surgery was the most cost-effective option at 5 years from the time of diagnosis; however, by the 10-year time horizon, endoscopic transsphenoidal surgery became the most cost-effective option. At both time horizons, medical therapy (both bromocriptine and cabergoline) were found to be more costly and less effective than transsphenoidal surgery (i.e., the medical arm was dominated by the surgical arm in this model). Two-way sensitivity analysis demonstrated that endoscopic resection would be the most cost-effective strategy if the cure rate from endoscopic surgery was greater than 90% and the complication rate was less than 1%. Monte Carlo simulation was performed for endoscopic surgery versus microscopic surgery at both time horizons. This analysis produced an incremental cost-effectiveness ratio of $80,235 per quality-adjusted life years at 5 years and $40,737 per quality-adjusted life years at 10 years, implying that with increasing time intervals, endoscopic transsphenoidal surgery is the more cost-effective treatment strategy. CONCLUSIONS On the basis of the results of our model, transsphenoidal surgical resection of microprolactinomas, either microsurgical or endoscopic, appears to be more cost-effective than life-long medical therapy in young patients with life expectancy greater than 10 years. We caution that surgical resection for microprolactinomas be performed only in select cases by experienced pituitary surgeons at high-volume centers with high biochemical cure rates and low complication rates.
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Affiliation(s)
- Pinakin R Jethwa
- Department of Neurological Surgery, Rutgers University, New Jersey Medical School, Newark, New Jersey, USA
| | - Tapan D Patel
- Department of Neurological Surgery, Rutgers University, New Jersey Medical School, Newark, New Jersey, USA
| | - Aaron F Hajart
- Department of Neurological Surgery, Rutgers University, New Jersey Medical School, Newark, New Jersey, USA; Department of Otolaryngology-Head and Neck Surgery, Rutgers University, New Jersey Medical School, Newark, New Jersey, USA
| | - Jean Anderson Eloy
- Department of Neurological Surgery, Rutgers University, New Jersey Medical School, Newark, New Jersey, USA; Department of Otolaryngology-Head and Neck Surgery, Rutgers University, New Jersey Medical School, Newark, New Jersey, USA; Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Newark, New Jersey, USA
| | - William T Couldwell
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - James K Liu
- Department of Neurological Surgery, Rutgers University, New Jersey Medical School, Newark, New Jersey, USA; Department of Otolaryngology-Head and Neck Surgery, Rutgers University, New Jersey Medical School, Newark, New Jersey, USA; Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Newark, New Jersey, USA.
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Wu X, Kalra VB, Durand D, Malhotra A. Utility analysis of management strategies for suspected subarachnoid haemorrhage in patients with thunderclap headache with negative CT result. Emerg Med J 2015; 33:30-6. [DOI: 10.1136/emermed-2015-204634] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 05/04/2015] [Indexed: 11/03/2022]
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Beyer SE, Hunink MG, Schöberl F, von Baumgarten L, Petersen SE, Dichgans M, Janssen H, Ertl-Wagner B, Reiser MF, Sommer WH. Different Imaging Strategies in Patients With Possible Basilar Artery Occlusion: Cost-Effectiveness Analysis. Stroke 2015; 46:1840-9. [PMID: 26022634 PMCID: PMC4476845 DOI: 10.1161/strokeaha.115.008841] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 04/02/2015] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND PURPOSE This study evaluated the cost-effectiveness of different noninvasive imaging strategies in patients with possible basilar artery occlusion. METHODS A Markov decision analytic model was used to evaluate long-term outcomes resulting from strategies using computed tomographic angiography (CTA), magnetic resonance imaging, nonenhanced CT, or duplex ultrasound with intravenous (IV) thrombolysis being administered after positive findings. The analysis was performed from the societal perspective based on US recommendations. Input parameters were derived from the literature. Costs were obtained from United States costing sources and published literature. Outcomes were lifetime costs, quality-adjusted life-years (QALYs), incremental cost-effectiveness ratios, and net monetary benefits, with a willingness-to-pay threshold of $80,000 per QALY. The strategy with the highest net monetary benefit was considered the most cost-effective. Extensive deterministic and probabilistic sensitivity analyses were performed to explore the effect of varying parameter values. RESULTS In the reference case analysis, CTA dominated all other imaging strategies. CTA yielded 0.02 QALYs more than magnetic resonance imaging and 0.04 QALYs more than duplex ultrasound followed by CTA. At a willingness-to-pay threshold of $80,000 per QALY, CTA yielded the highest net monetary benefits. The probability that CTA is cost-effective was 96% at a willingness-to-pay threshold of $80,000/QALY. Sensitivity analyses showed that duplex ultrasound was cost-effective only for a prior probability of ≤0.02 and that these results were only minimally influenced by duplex ultrasound sensitivity and specificity. Nonenhanced CT and magnetic resonance imaging never became the most cost-effective strategy. CONCLUSIONS Our results suggest that CTA in patients with possible basilar artery occlusion is cost-effective.
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Affiliation(s)
- Sebastian E Beyer
- From the Institute of Clinical Radiology (S.E.B., B.E.-W., M.F.R., W.H.S.), Department of Neurology (F.S., L.B.), Institute for Stroke and Dementia Research (M.D.), and Department of Neuroradiology (H.J.), Ludwig-Maximilian University of Munich Hospitals, Munich, Germany; Advanced Cardiovascular Imaging, William Harvey Research Institute, National Institute for Health Research, Cardiovascular Biomedical Research Unit at Barts, The London Chest Hospital, London, United Kingdom (S.E.P.); Department of Radiology (M.G.H.) and Department of Epidemiology (M.G.H.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Department of Health Policy and Management, Harvard School of Public Health, Harvard University, Boston, MA (M.G.H.)
| | - Myriam G Hunink
- From the Institute of Clinical Radiology (S.E.B., B.E.-W., M.F.R., W.H.S.), Department of Neurology (F.S., L.B.), Institute for Stroke and Dementia Research (M.D.), and Department of Neuroradiology (H.J.), Ludwig-Maximilian University of Munich Hospitals, Munich, Germany; Advanced Cardiovascular Imaging, William Harvey Research Institute, National Institute for Health Research, Cardiovascular Biomedical Research Unit at Barts, The London Chest Hospital, London, United Kingdom (S.E.P.); Department of Radiology (M.G.H.) and Department of Epidemiology (M.G.H.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Department of Health Policy and Management, Harvard School of Public Health, Harvard University, Boston, MA (M.G.H.)
| | - Florian Schöberl
- From the Institute of Clinical Radiology (S.E.B., B.E.-W., M.F.R., W.H.S.), Department of Neurology (F.S., L.B.), Institute for Stroke and Dementia Research (M.D.), and Department of Neuroradiology (H.J.), Ludwig-Maximilian University of Munich Hospitals, Munich, Germany; Advanced Cardiovascular Imaging, William Harvey Research Institute, National Institute for Health Research, Cardiovascular Biomedical Research Unit at Barts, The London Chest Hospital, London, United Kingdom (S.E.P.); Department of Radiology (M.G.H.) and Department of Epidemiology (M.G.H.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Department of Health Policy and Management, Harvard School of Public Health, Harvard University, Boston, MA (M.G.H.)
| | - Louisa von Baumgarten
- From the Institute of Clinical Radiology (S.E.B., B.E.-W., M.F.R., W.H.S.), Department of Neurology (F.S., L.B.), Institute for Stroke and Dementia Research (M.D.), and Department of Neuroradiology (H.J.), Ludwig-Maximilian University of Munich Hospitals, Munich, Germany; Advanced Cardiovascular Imaging, William Harvey Research Institute, National Institute for Health Research, Cardiovascular Biomedical Research Unit at Barts, The London Chest Hospital, London, United Kingdom (S.E.P.); Department of Radiology (M.G.H.) and Department of Epidemiology (M.G.H.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Department of Health Policy and Management, Harvard School of Public Health, Harvard University, Boston, MA (M.G.H.)
| | - Steffen E Petersen
- From the Institute of Clinical Radiology (S.E.B., B.E.-W., M.F.R., W.H.S.), Department of Neurology (F.S., L.B.), Institute for Stroke and Dementia Research (M.D.), and Department of Neuroradiology (H.J.), Ludwig-Maximilian University of Munich Hospitals, Munich, Germany; Advanced Cardiovascular Imaging, William Harvey Research Institute, National Institute for Health Research, Cardiovascular Biomedical Research Unit at Barts, The London Chest Hospital, London, United Kingdom (S.E.P.); Department of Radiology (M.G.H.) and Department of Epidemiology (M.G.H.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Department of Health Policy and Management, Harvard School of Public Health, Harvard University, Boston, MA (M.G.H.)
| | - Martin Dichgans
- From the Institute of Clinical Radiology (S.E.B., B.E.-W., M.F.R., W.H.S.), Department of Neurology (F.S., L.B.), Institute for Stroke and Dementia Research (M.D.), and Department of Neuroradiology (H.J.), Ludwig-Maximilian University of Munich Hospitals, Munich, Germany; Advanced Cardiovascular Imaging, William Harvey Research Institute, National Institute for Health Research, Cardiovascular Biomedical Research Unit at Barts, The London Chest Hospital, London, United Kingdom (S.E.P.); Department of Radiology (M.G.H.) and Department of Epidemiology (M.G.H.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Department of Health Policy and Management, Harvard School of Public Health, Harvard University, Boston, MA (M.G.H.)
| | - Hendrik Janssen
- From the Institute of Clinical Radiology (S.E.B., B.E.-W., M.F.R., W.H.S.), Department of Neurology (F.S., L.B.), Institute for Stroke and Dementia Research (M.D.), and Department of Neuroradiology (H.J.), Ludwig-Maximilian University of Munich Hospitals, Munich, Germany; Advanced Cardiovascular Imaging, William Harvey Research Institute, National Institute for Health Research, Cardiovascular Biomedical Research Unit at Barts, The London Chest Hospital, London, United Kingdom (S.E.P.); Department of Radiology (M.G.H.) and Department of Epidemiology (M.G.H.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Department of Health Policy and Management, Harvard School of Public Health, Harvard University, Boston, MA (M.G.H.)
| | - Birgit Ertl-Wagner
- From the Institute of Clinical Radiology (S.E.B., B.E.-W., M.F.R., W.H.S.), Department of Neurology (F.S., L.B.), Institute for Stroke and Dementia Research (M.D.), and Department of Neuroradiology (H.J.), Ludwig-Maximilian University of Munich Hospitals, Munich, Germany; Advanced Cardiovascular Imaging, William Harvey Research Institute, National Institute for Health Research, Cardiovascular Biomedical Research Unit at Barts, The London Chest Hospital, London, United Kingdom (S.E.P.); Department of Radiology (M.G.H.) and Department of Epidemiology (M.G.H.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Department of Health Policy and Management, Harvard School of Public Health, Harvard University, Boston, MA (M.G.H.)
| | - Maximilian F Reiser
- From the Institute of Clinical Radiology (S.E.B., B.E.-W., M.F.R., W.H.S.), Department of Neurology (F.S., L.B.), Institute for Stroke and Dementia Research (M.D.), and Department of Neuroradiology (H.J.), Ludwig-Maximilian University of Munich Hospitals, Munich, Germany; Advanced Cardiovascular Imaging, William Harvey Research Institute, National Institute for Health Research, Cardiovascular Biomedical Research Unit at Barts, The London Chest Hospital, London, United Kingdom (S.E.P.); Department of Radiology (M.G.H.) and Department of Epidemiology (M.G.H.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Department of Health Policy and Management, Harvard School of Public Health, Harvard University, Boston, MA (M.G.H.)
| | - Wieland H Sommer
- From the Institute of Clinical Radiology (S.E.B., B.E.-W., M.F.R., W.H.S.), Department of Neurology (F.S., L.B.), Institute for Stroke and Dementia Research (M.D.), and Department of Neuroradiology (H.J.), Ludwig-Maximilian University of Munich Hospitals, Munich, Germany; Advanced Cardiovascular Imaging, William Harvey Research Institute, National Institute for Health Research, Cardiovascular Biomedical Research Unit at Barts, The London Chest Hospital, London, United Kingdom (S.E.P.); Department of Radiology (M.G.H.) and Department of Epidemiology (M.G.H.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Department of Health Policy and Management, Harvard School of Public Health, Harvard University, Boston, MA (M.G.H.).
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Leppert MH, Campbell JD, Simpson JR, Burke JF. Cost-Effectiveness of Intra-Arterial Treatment as an Adjunct to Intravenous Tissue-Type Plasminogen Activator for Acute Ischemic Stroke. Stroke 2015; 46:1870-6. [PMID: 26012639 DOI: 10.1161/strokeaha.115.009779] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 04/24/2015] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND PURPOSE The objective of this study was to determine the cost-effectiveness of intra-arterial treatment within the 0- to 6-hour window after intravenous tissue-type plasminogen activator within 0- to 4.5-hour compared with intravenous tissue-type plasminogen activator alone, in the US setting and from a social perspective. METHODS A decision analytic model estimated the lifetime costs and outcomes associated with the additional benefit of intra-arterial therapy compared with standard treatment with intravenous tissue-type plasminogen activator alone. Model inputs were obtained from published literature, the Multicenter Randomized Clinical Trial of Endovascular Therapy for Acute Ischemic Stroke in the Netherlands (MR CLEAN) study, and claims databases in the United States. Health outcomes were measured in quality-adjusted life years (QALYs). Treatment benefit was assessed by calculating the cost per QALY gained. One-way and probabilistic sensitivity analyses were performed to estimate the overall uncertainty of model results. RESULTS The addition of intra-arterial therapy compared with standard treatment alone yielded a lifetime gain of 0.7 QALY for an additional cost of $9911, which resulted in a cost of $14 137 per QALY. Multivariable sensitivity analysis predicted cost-effectiveness (≤$50 000 per QALY) in 97.6% of simulation runs. CONCLUSIONS Intra-arterial treatment after intravenous tissue-type plasminogen activator for patients with anterior circulation strokes within the 6-hour window is likely cost-effective. From a societal perspective, increased investment in access to intra-arterial treatment for acute stroke may be justified.
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Affiliation(s)
- Michelle H Leppert
- From the Departments of Neurology (M.H.L., J.R.S.) and Pharmacy (J.D.C.), University of Colorado, Aurora; and Stroke Program, University of Michigan, Ann Arbor (J.F.B.).
| | - Jonathan D Campbell
- From the Departments of Neurology (M.H.L., J.R.S.) and Pharmacy (J.D.C.), University of Colorado, Aurora; and Stroke Program, University of Michigan, Ann Arbor (J.F.B.)
| | - Jennifer R Simpson
- From the Departments of Neurology (M.H.L., J.R.S.) and Pharmacy (J.D.C.), University of Colorado, Aurora; and Stroke Program, University of Michigan, Ann Arbor (J.F.B.)
| | - James F Burke
- From the Departments of Neurology (M.H.L., J.R.S.) and Pharmacy (J.D.C.), University of Colorado, Aurora; and Stroke Program, University of Michigan, Ann Arbor (J.F.B.)
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Matchar DB, Nguyen HV, Tian Y. Bundled Payment and Care of Acute Stroke. Stroke 2015; 46:1414-21. [DOI: 10.1161/strokeaha.115.009089] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 03/13/2015] [Indexed: 12/20/2022]
Affiliation(s)
- David Bruce Matchar
- From the Department of Medicine, Duke University Medical Center, Durham, NC (D.B.M.); and Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore (D.B.M., H.V.N., Y.T.)
| | - Hai V. Nguyen
- From the Department of Medicine, Duke University Medical Center, Durham, NC (D.B.M.); and Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore (D.B.M., H.V.N., Y.T.)
| | - Yuan Tian
- From the Department of Medicine, Duke University Medical Center, Durham, NC (D.B.M.); and Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore (D.B.M., H.V.N., Y.T.)
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Fletcher JJ, Kotagal V, Mammoser A, Peterson M, Morgenstern LB, Burke JF. Cost-effectiveness of transfers to centers with neurological intensive care units after intracerebral hemorrhage. Stroke 2014; 46:58-64. [PMID: 25477220 DOI: 10.1161/strokeaha.114.006653] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND PURPOSE Our aim was to estimate the cost-effectiveness of transferring patients with intracerebral hemorrhage from centers without specialized neurological intensive care units (neuro-ICUs) to centers with neuro-ICUs. METHODS Decision analytic models were developed for the lifetime horizons. Model inputs were derived from the best available data, informed by a variety of previous cost-effectiveness models of stroke. The effect of neuro-ICU care on functional outcomes was modeled in 3 scenarios. A favorable outcomes scenario was modeled based on the best observational data and compared with moderately favorable and least-favorable outcomes scenarios. Health benefits were measured in quality-adjusted life years (QALYs), and costs were estimated from a societal perspective. Costs were combined with QALYs gained to generate incremental cost-effectiveness ratios. One-way sensitivity analysis and Monte Carlo simulations were performed to test robustness of the model assumptions. RESULTS Transferring patients to centers with neuro-ICUs yielded an incremental cost-effectiveness ratio for the lifetime horizon of $47,431 per QALY, $91,674 per QALY, and $380,358 per QALY for favorable, moderately favorable, and least-favorable scenarios, respectively. Models were robust at a willingness-to-pay threshold of $100,000 per QALY, with 95.5%, 75.0%, and 2.1% of simulations below the threshold for favorable, moderately favorable, and least-favorable scenarios, respectively. CONCLUSIONS Transferring patients with intracerebral hemorrhage to centers with specialized neuro-ICUs is cost-effective if observational estimates of the neuro-ICU-based functional outcome distribution are accurate. If future work confirms these functional outcome distributions, then a strong societal rationale exists to build systems of care designed to transfer intracerebral hemorrhage patients to specialized neuro-ICUs.
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Affiliation(s)
- Jeffrey J Fletcher
- From the Departments of Neurosurgery (J.J.F., L.B.M.), Neurology (V.K., A.M.), Biostatistics (L.B.M.), Physical Medicine and Rehabilitation (M.P.), and the Stroke Program (L.B.M., J.F.B.), University of Michigan, Ann Arbor; and Department of Neurology, Bronson Methodist Hospital, Kalamazoo, MI (J.J.F.).
| | - Vikas Kotagal
- From the Departments of Neurosurgery (J.J.F., L.B.M.), Neurology (V.K., A.M.), Biostatistics (L.B.M.), Physical Medicine and Rehabilitation (M.P.), and the Stroke Program (L.B.M., J.F.B.), University of Michigan, Ann Arbor; and Department of Neurology, Bronson Methodist Hospital, Kalamazoo, MI (J.J.F.)
| | - Aaron Mammoser
- From the Departments of Neurosurgery (J.J.F., L.B.M.), Neurology (V.K., A.M.), Biostatistics (L.B.M.), Physical Medicine and Rehabilitation (M.P.), and the Stroke Program (L.B.M., J.F.B.), University of Michigan, Ann Arbor; and Department of Neurology, Bronson Methodist Hospital, Kalamazoo, MI (J.J.F.)
| | - Mark Peterson
- From the Departments of Neurosurgery (J.J.F., L.B.M.), Neurology (V.K., A.M.), Biostatistics (L.B.M.), Physical Medicine and Rehabilitation (M.P.), and the Stroke Program (L.B.M., J.F.B.), University of Michigan, Ann Arbor; and Department of Neurology, Bronson Methodist Hospital, Kalamazoo, MI (J.J.F.)
| | - Lewis B Morgenstern
- From the Departments of Neurosurgery (J.J.F., L.B.M.), Neurology (V.K., A.M.), Biostatistics (L.B.M.), Physical Medicine and Rehabilitation (M.P.), and the Stroke Program (L.B.M., J.F.B.), University of Michigan, Ann Arbor; and Department of Neurology, Bronson Methodist Hospital, Kalamazoo, MI (J.J.F.)
| | - James F Burke
- From the Departments of Neurosurgery (J.J.F., L.B.M.), Neurology (V.K., A.M.), Biostatistics (L.B.M.), Physical Medicine and Rehabilitation (M.P.), and the Stroke Program (L.B.M., J.F.B.), University of Michigan, Ann Arbor; and Department of Neurology, Bronson Methodist Hospital, Kalamazoo, MI (J.J.F.)
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Vagal AS, Khatri P, Broderick JP, Tomsick TA, Yeatts SD, Eckman MH. Time to Angiographic Reperfusion in Acute Ischemic Stroke. Stroke 2014; 45:3625-30. [DOI: 10.1161/strokeaha.114.007188] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Our objective was to use decision analytic modeling to compare 2 treatment strategies of intravenous recombinant tissue-type plasminogen activator (r-tPA) alone versus combined intravenous r-tPA/endovascular therapy in a subgroup of patients with large vessel (internal carotid artery terminus, M1, and M2) occlusion based on varying times to angiographic reperfusion and varying rates of reperfusion.
Methods—
We developed a decision model using Interventional Management of Stroke (IMS) III trial data and comprehensive literature review. We performed 1-way sensitivity analyses for time to reperfusion and 2-way sensitivity for time to reperfusion and rate of reperfusion success. We also performed probabilistic sensitivity analyses to address uncertainty in total time to reperfusion for the endovascular approach.
Results—
In the base case, endovascular approach yielded a higher expected utility (6.38 quality-adjusted life years) than the intravenous-only arm (5.42 quality-adjusted life years). One-way sensitivity analyses demonstrated superiority of endovascular treatment to intravenous-only arm unless time to reperfusion exceeded 347 minutes. Two-way sensitivity analysis demonstrated that endovascular treatment was preferred when probability of reperfusion is high and time to reperfusion is small. Probabilistic sensitivity results demonstrated an average gain for endovascular therapy of 0.76 quality-adjusted life years (SD 0.82) compared with the intravenous-only approach.
Conclusions—
In our post hoc model with its underlying limitations, endovascular therapy after intravenous r-tPA is the preferred treatment as compared with intravenous r-tPA alone. However, if time to reperfusion exceeds 347 minutes, intravenous r-tPA alone is the recommended strategy. This warrants validation in a randomized, prospective trial among patients with large vessel occlusions.
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Affiliation(s)
- Achala S. Vagal
- From the Department of Radiology (A.S.V., T.A.T.), Department of Neurology (P.K., J.P.B.), and Department of Internal Medicine (M.H.E.), University of Cincinnati Medical Center, OH; and Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y.)
| | - Pooja Khatri
- From the Department of Radiology (A.S.V., T.A.T.), Department of Neurology (P.K., J.P.B.), and Department of Internal Medicine (M.H.E.), University of Cincinnati Medical Center, OH; and Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y.)
| | - Joseph P. Broderick
- From the Department of Radiology (A.S.V., T.A.T.), Department of Neurology (P.K., J.P.B.), and Department of Internal Medicine (M.H.E.), University of Cincinnati Medical Center, OH; and Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y.)
| | - Thomas A. Tomsick
- From the Department of Radiology (A.S.V., T.A.T.), Department of Neurology (P.K., J.P.B.), and Department of Internal Medicine (M.H.E.), University of Cincinnati Medical Center, OH; and Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y.)
| | - Sharon D. Yeatts
- From the Department of Radiology (A.S.V., T.A.T.), Department of Neurology (P.K., J.P.B.), and Department of Internal Medicine (M.H.E.), University of Cincinnati Medical Center, OH; and Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y.)
| | - Mark H. Eckman
- From the Department of Radiology (A.S.V., T.A.T.), Department of Neurology (P.K., J.P.B.), and Department of Internal Medicine (M.H.E.), University of Cincinnati Medical Center, OH; and Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y.)
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