Stroke: Effect of implementing an evaluation and treatment protocol compliant with NINDS recommendations

Addressing Disparities in Acute Stroke Management and Prognosis

There are now abundant data demonstrating disparities in acute stroke management and prognosis; however, interventions to reduce these disparities remain limited. This special report aims to provide a critical review of the current landscape of disparities in acute stroke care and highlight opportunities to use implementation science to reduce disparities throughout the early care continuum. In the prehospital setting, stroke symptom recognition campaigns that have been successful in reducing prehospital delays used a multilevel approach to education, including mass media, culturally tailored community education, and professional education. The mobile stroke unit is an organizational intervention that has the potential to provide more equitable access to timely thrombolysis and thrombectomy treatments. In the hospital setting, interventions to address implicit biases among health care providers in acute stroke care decision-making are urgently needed as part of a multifaceted approach to advance stroke equity. Implementing stroke systems of care interventions, such as evidence-based stroke care protocols at designated stroke centers, can have a broader public health impact and may help reduce geographic, racial, and ethnic disparities in stroke care, although further research is needed. The long-term impact of disparities in acute stroke care cannot be underestimated. The consistent trend of longer time to treatment for Black and Hispanic people experiencing stroke has direct implications on long-term disability and independence after stroke. A learning health system model may help expedite the translation of evidence-based interventions into clinical practice to reduce disparities in stroke care.

Influences of different referral modes on clinical outcomes after endovascular therapy for acute ischemic stroke

Background and purpose

As endovascular thrombectomy (EVT) is time-dependent, it is crucial to refer patients promptly. Current referral modes include Mothership (MS), Drip and Ship (DS) and Drive the Doctor (DD). The purpose of this study was to investigate the influences of different referral modes on the clinical outcomes of patients with acute ischemic stroke after EVT. 

Methods

A total of 349 patients from 15 hospitals between April 2017 and March 2020 were enrolled. The primary outcomes include poor outcome (modified Rankin Scale score of 3 to 6), symptomatic intracranial hemorrhage transformation (sICH), mortality and cost. Regression analysis was used to assess the association of referral modes with poor outcome, sICH, mortality and cost in acute ischemic stroke patients.

Results

Among the 349 patients, 83 were in DD group (23.78%), 85 in MS group (24.36%) and 181 in DS group (51.86%). There were statistically significant differences in intravenous thrombolysis, onset-to-door time, onset-to-puncture time, puncture-to-recanalization time, door-to-puncture time, door-to-recanalization time, and cost among the DD, MS, and DS groups (59.04% vs 35.29% vs 33.15%, P<0.001; 90 vs 166 vs 170 minutes, P<0.001; 230 vs 270 vs 270 minutes, P<0.001; 82 vs 54 vs 51 minutes, P<0.001; 110 vs 85 vs 96 minutes, P=0.004; 210 vs 146 vs 150 minutes, P<0.001; 64258 vs 80041 vs 70750 Chinese Yuan, P=0.018). In terms of sICH, mortality and poor outcome, there was no significant difference among the DD, MS, and DS groups (22.89% vs 18.82% vs 19.34%, P=0.758; 24.10% vs 24.71% vs 29.83%, P=0.521; 64.47% vs 64.71% vs 68.51%, P=0.827). The results of multiple regression analysis indicated that there was no independent correlation between different referral modes regarding sICH (OR_MS: 0.50, 95%CI: 0.18, 1.38, P=0.1830; OR_DS: 0.47, 95%CI: 0.19, 1.16, P=0.1000), mortality (OR_MS: 0.56, 95%CI: 0.19, 1.67, P=0.2993; OR_DS: 0.65, 95%CI: 0.25, 1.69, P=0.3744) and poor outcome (OR_MS: 0.61, 95%CI: 0.25, 1.47, P=0.2705; OR_DS: 0.53, 95%CI: 0.24, 1.18, P=0.1223). However, there was a correlation between MS group and cost (β=30449.73, 95%CI: 11022.18, 49877.29; P=0.0023). The multiple regression analysis on patients finally admitted in comprehensive stroke center (MS+DS) versus patients finally admitted in primary stroke center (DD) showed that DD mode was independently associated with lower costs (β=-19438.86, 95%CI: -35977.79, -2899.94; P=0.0219).

Conclusion

There was no independent correlation between three referral modes and sICH, mortality, poor outcome correspondingly. Different referral modes can be implemented in clinical practice according to the situations encountered. Compared to MS and DS modes, DD mode is more economical.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-022-02751-w.

Discrete-Event Simulation to Model the Thrombolysis Process for Acute Ischemic Stroke Patients at Urban and Rural Hospitals

Background: Effective treatment with tissue plasminogen activator (tPA) critically relies on rapid treatment. Door-to-needle time (DNT) is a key measure of hospital efficiency linked to patient outcomes. Numerous changes can reduce DNT, but they are difficult to trial and implement. Discrete-event simulation (DES) provides a way to model and determine the impact of process improvements.

Methods: A conceptual framework was developed to illustrate the thrombolysis process; allowing for treatment processes to be replicated using a DES model developed in ARENA. Activity time duration distributions from three sites (one urban and two rural) were used. Five scenarios, three process changes, and two reductions in activity durations, were simulated and tested. Scenarios were tested individually and in combinations. The primary outcome measure is median DNT. The study goal is to determine the largest improvement in DNT at each site.

Results: Administration of tPA in the imaging area resulted in the largest median DNT reduction for Site 1 and Site 2 for individual test scenarios (12.6%, 95% CI 12.4–12.8%, and 8.2%, 95% CI 7.5–9.0%, respectively). Ensuring that patients arriving via emergency medical services (EMS) remain on the EMS stretcher to imaging resulted in the largest median DNT improvement for Site 3 (9.2%, 95% CI 7.9–10.5%). Reducing both the treatment decision time and tPA preparation time by 35% resulted in a 11.0% (95% CI 10.0–12.0%) maximum reduction in median DNT. The lowest median and 90^th percentile DNTs were achieved by combining all test scenarios, with a maximum reduction of 26.7% (95% CI 24.5–28.9%) and 17.1% (95% CI 12.5–21.7%), respectively.

Conclusions: The detailed conceptual framework clarifies the intra-hospital logistics of the thrombolysis process. The most significant median DNT improvement at rural hospitals resulted from ensuring patients arriving via EMS remain on the EMS stretcher to imaging, while urban sites benefit more from administering tPA in the imaging area. Reducing the durations of activities on the critical path will provide further DNT improvements. Significant DNT improvements are achievable in urban and rural settings by combining process changes with reducing activity durations.

Cost-Effectiveness of Advanced Neuroimaging for Transient and Minor Neurological Events in the Emergency Department

Background Accurate diagnosis of patients with transient or minor neurological events can be challenging. Recent studies suggest that advanced neuroimaging can improve diagnostic accuracy in low-risk patients with transient or minor neurological symptoms, but a cost-effective emergency department diagnostic evaluation strategy remains uncertain. Methods and Results We constructed a decision-analytic model to evaluate 2 diagnostic evaluation strategies for patients with low-risk transient or minor neurological symptoms: (1) obtain advanced neuroimaging (magnetic resonance imaging brain and magnetic resonance angiography head and neck) on every patient or (2) current emergency department standard-of-care clinical evaluation with basic neuroimaging. Main probability variables were: proportion of patients with true ischemic events, strategy specificity and sensitivity, and recurrent stroke rate. Direct healthcare costs were included. We calculated incremental cost-effectiveness ratios, conducted sensitivity analyses, and evaluated various diagnostic test parameters primarily using a 1-year time horizon. Cost-effectiveness standards would be met if the incremental cost-effectiveness ratio was less than willingness to pay. We defined willingness to pay as $100 000 US dollars per quality-adjusted life year. Our primary and sensitivity analyses found that the advanced neuroimaging strategy was more cost-effective than emergency department standard of care. The incremental effectiveness of the advanced neuroimaging strategy was slightly less than the standard-of-care strategy, but the standard-of-care strategy was more costly. Potentially superior diagnostic approaches to the modeled advanced neuroimaging strategy would have to be >92% specific, >70% sensitive, and cost less than or equal to standard-of-care strategy's cost. Conclusions Obtaining advanced neuroimaging on emergency department patient with low-risk transient or minor neurological symptoms was the more cost-effective strategy in our model.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A Systematic Review of Cardiovascular Outcomes-Based Cost-Effectiveness Analyses of Lipid-Lowering Therapies

BACKGROUND

Previous reviews have evaluated economic analyses of lipid-lowering therapies using lipid levels as surrogate markers for cardiovascular disease. However, drug approval and health technology assessment agencies have stressed that surrogates should only be used in the absence of clinical endpoints.

OBJECTIVE

The aim of this systematic review was to identify and summarise the methodologies, weaknesses and strengths of economic models based on atherosclerotic cardiovascular disease event rates.

METHODS

Cost-effectiveness evaluations of lipid-lowering therapies using cardiovascular event rates in adults with hyperlipidaemia were sought in Medline, Embase, Medline In-Process, PubMed and NHS EED and conference proceedings. Search results were independently screened, extracted and quality checked by two reviewers.

RESULTS

Searches until February 2016 retrieved 3443 records, from which 26 studies (29 publications) were selected. Twenty-two studies evaluated secondary prevention (four also assessed primary prevention), two considered only primary prevention and two included mixed primary and secondary prevention populations. Most studies (18) based treatment-effect estimates on single trials, although more recent evaluations deployed meta-analyses (5/10 over the last 10 years). Markov models (14 studies) were most commonly used and only one study employed discrete event simulation. Models varied particularly in terms of health states and treatment-effect duration. No studies used a systematic review to obtain utilities. Most studies took a healthcare perspective (21/26) and sourced resource use from key trials instead of local data. Overall, reporting quality was suboptimal.

CONCLUSIONS

This review reveals methodological changes over time, but reporting weaknesses remain, particularly with respect to transparency of model reporting.

Simulation as an ethical imperative and epistemic responsibility for the implementation of medical guidelines in health care

Guidelines orient best practices in medicine, yet, in health care, many real world constraints limit their optimal realization. Since guideline implementation problems are not systematically anticipated, they will be discovered only post facto, in a learning curve period, while the already implemented guideline is tweaked, debugged and adapted. This learning process comes with costs to human health and quality of life. Despite such predictable hazard, the study and modeling of medical guideline implementation is still seldom pursued. In this article we argue that to systematically identify, predict and prevent medical guideline implementation errors is both an epistemic responsibility and an ethical imperative in health care, in order to properly provide beneficence, minimize or avoid harm, show respect for persons, and administer justice. Furthermore, we suggest that implementation knowledge is best achieved technically by providing simulation modeling studies to anticipate the realization of medical guidelines, in multiple contexts, with system and scenario analysis, in its alignment with the emerging field of implementation science and in recognition of learning health systems. It follows from both claims that it is an ethical imperative and an epistemic responsibility to simulate medical guidelines in context to minimize (avoidable) harm in health care, before guideline implementation.

Modeling the Cost Effectiveness of Neuroimaging-Based Treatment of Acute Wake-Up Stroke

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.

Different Imaging Strategies in Patients With Possible Basilar Artery Occlusion: Cost-Effectiveness Analysis

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.

An assessment of the cost-effectiveness of magnetic resonance, including diffusion-weighted imaging, in patients with transient ischaemic attack and minor stroke: a systematic review, meta-analysis and economic evaluation

BACKGROUND

Patients with transient ischaemic attack (TIA) or minor stroke need rapid treatment of risk factors to prevent recurrent stroke. ABCD2 score or magnetic resonance diffusion-weighted brain imaging (MR DWI) may help assessment and treatment.

OBJECTIVES

Is MR with DWI cost-effective in stroke prevention compared with computed tomography (CT) brain scanning in all patients, in specific subgroups or as 'one-stop' brain-carotid imaging? What is the current UK availability of services for stroke prevention?

DATA SOURCES

Published literature; stroke registries, audit and randomised clinical trials; national databases; survey of UK clinical and imaging services for stroke; expert opinion.

REVIEW METHODS

Systematic reviews and meta-analyses of published/unpublished data. Decision-analytic model of stroke prevention including on a 20-year time horizon including nine representative imaging scenarios.

RESULTS

The pooled recurrent stroke rate after TIA (53 studies, 30,558 patients) is 5.2% [95% confidence interval (CI) 3.9% to 5.9%] by 7 days, and 6.7% (5.2% to 8.7%) at 90 days. ABCD2 score does not identify patients with key stroke causes or identify mimics: 66% of specialist-diagnosed true TIAs and 35-41% of mimics had an ABCD2 score of ≥ 4; 20% of true TIAs with ABCD2 score of < 4 had key risk factors. MR DWI (45 studies, 9078 patients) showed an acute ischaemic lesion in 34.3% (95% CI 30.5% to 38.4%) of TIA, 69% of minor stroke patients, i.e. two-thirds of TIA patients are DWI negative. TIA mimics (16 studies, 14,542 patients) make up 40-45% of patients attending clinics. UK survey (45% response) showed most secondary prevention started prior to clinic, 85% of primary brain imaging was same-day CT; 51-54% of patients had MR, mostly additional to CT, on average 1 week later; 55% omitted blood-sensitive MR sequences. Compared with 'CT scan all patients' MR was more expensive and no more cost-effective, except for patients presenting at > 1 week after symptoms to diagnose haemorrhage; strategies that triaged patients with low ABCD2 scores for slow investigation or treated DWI-negative patients as non-TIA/minor stroke prevented fewer strokes and increased costs. 'One-stop' CT/MR angiographic-plus-brain imaging was not cost-effective.

LIMITATIONS

Data on sensitivity/specificity of MR in TIA/minor stroke, stroke costs, prognosis of TIA mimics and accuracy of ABCD2 score by non-specialists are sparse or absent; all analysis had substantial heterogeneity.

CONCLUSIONS

Magnetic resonance with DWI is not cost-effective for secondary stroke prevention. MR was most helpful in patients presenting at > 1 week after symptoms if blood-sensitive sequences were used. ABCD2 score is unlikely to facilitate patient triage by non-stroke specialists. Rapid specialist assessment, CT brain scanning and identification of serious underlying stroke causes is the most cost-effective stroke prevention strategy.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

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

Background:

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

Methods:

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

Results:

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

Conclusions:

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

Republished: Society for Neuroscience in Anesthesiology and Critical Care expert consensus statement: Anesthetic management of endovascular treatment for acute ischemic stroke

Literature on the anesthetic management of endovascular treatment of acute ischemic stroke (AIS) is limited. Anesthetic management during these procedures is still mostly dependent on individual or institutional preferences. Thus, the Society of Neuroscience in Anesthesiology and Critical Care (SNACC) created a task force to provide expert consensus recommendations on anesthetic management of endovascular treatment of AIS. The task force conducted a systematic literature review (up to August 2012). Because of the limited number of research articles relating to this subject, the task force solicited opinions from experts in this area. The task force created a draft consensus statement based on the available data. Classes of recommendations and levels of evidence were assigned to articles specifically addressing anesthetic management during endovascular treatment of stroke using the standard American Heart Association evidence rating scheme. The draft consensus statement was reviewed by the Task Force, SNACC Executive Committee and representatives of Society of NeuroInterventional Surgery (SNIS) and Neurocritical Care Society (NCS) reaching consensus on the final document. For this consensus statement the anesthetic management of endovascular treatment of AIS was subdivided into 12 topics. Each topic includes a summary of available data followed by recommendations. This consensus statement is intended for use by individuals involved in the care of patients with acute ischemic stroke, such as anesthesiologists, interventional neuroradiologists, neurologists, neurointensivists and neurosurgeons.

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

Background and Purpose—

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

Methods—

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

Results—

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

Conclusions—

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

Addressing the variation of post-surgical inpatient census with computer simulation

OBJECTIVE

This study describes the development of a Discrete Event Simulation (DES) of a large pediatric perioperative department, and its use to compare the effectiveness of increasing the number of post-surgical inpatient beds vs. implementing a new discharge strategy on the proportion of patients admitted to the surgical unit to recover.

MATERIALS AND METHODS

A DES of the system was developed and simulated data were compared with 1 year of inpatient data to establish baseline validity. Ten years of simulated data generated by the baseline simulation (control) was compared to 10 years of simulated data generated by the simulation for the experimental scenarios. Outcome and validation measures include percentage of patients recovering in post-surgical beds vs. "off floor" in medical beds, and daily census of inpatient volumes.

RESULTS

The proportion of patients admitted to the surgical inpatient unit rose from 79.0% (95% CI, 77.9-80.1%) to 89.4% (95% CI, 88.7-90.0%) in the discharge strategy scenario, and to 94.2% (95% CI, 93.5-95.0%) in the additional bed scenario. The daily mean number of patients admitted to medical beds fell from 9.3 ± 5.9 (mean ± SD) to 4.9 ± 4.5 in the discharge scenario, and to 2.4 ± 3.2 in the additional bed scenario.

DISCUSSION

Every hospital is tasked with placing the right patient in the right bed at the right time. Appropriately validated DES models can provide important insight into system dynamics. No significant variation was found between the baseline simulation and real-world data. This allows us to draw conclusions about the ramifications of changes to system capacity or discharge policy, thus meeting desired system performance measures.

Economic evaluation of using a genetic test to direct breast cancer chemoprevention in white women with a previous breast biopsy

BACKGROUND

Tamoxifen therapy reduces the risk of breast cancer but increases the risk of serious adverse events including endometrial cancer and thromboembolic events.

OBJECTIVES

The cost effectiveness of using a commercially available breast cancer risk assessment test (BREVAGen™) to inform the decision of which women should undergo chemoprevention by tamoxifen was modeled in a simulated population of women who had undergone biopsies but had no diagnosis of cancer.

METHODS

A continuous time, discrete event, mathematical model was used to simulate a population of white women aged 40-69 years, who were at elevated risk for breast cancer because of a history of benign breast biopsy. Women were assessed for clinical risk of breast cancer using the Gail model and for genetic risk using a panel of seven common single nucleotide polymorphisms. We evaluated the cost effectiveness of using genetic risk together with clinical risk, instead of clinical risk alone, to determine eligibility for 5 years of tamoxifen therapy. In addition to breast cancer, the simulation included health states of endometrial cancer, pulmonary embolism, deep-vein thrombosis, stroke, and cataract. Estimates of costs in 2012 US dollars were based on Medicare reimbursement rates reported in the literature and utilities for modeled health states were calculated as an average of utilities reported in the literature. A 50-year time horizon was used to observe lifetime effects including survival benefits.

RESULTS

For those women at intermediate risk of developing breast cancer (1.2-1.66 % 5-year risk), the incremental cost-effectiveness ratio for the combined genetic and clinical risk assessment strategy over the clinical risk assessment-only strategy was US$47,000, US$44,000, and US$65,000 per quality-adjusted life-year gained, for women aged 40-49, 50-59, and 60-69 years, respectively (assuming a price of US$945 for genetic testing). Results were sensitive to assumptions about patient adherence, utility of life while taking tamoxifen, and cost of genetic testing.

CONCLUSIONS

From the US payer's perspective, the combined genetic and clinical risk assessment strategy may be a moderately cost-effective alternative to using clinical risk alone to guide chemoprevention recommendations for women at intermediate risk of developing breast cancer.

A systematic review and critical appraisal of quality measures for the emergency care of acute ischemic stroke

Acute stroke is an important focus of quality improvement efforts. There are many organizations involved in quality measurement for acute stroke, and a complex landscape of quality measures exists. Our objective is to describe and evaluate existing US quality measures for the emergency care of acute ischemic stroke patients in the emergency department (ED) setting. We performed a systematic review of the literature to identify the existing quality measures for the emergency care of acute ischemic stroke. We then convened a panel of experts to appraise how well the measures satisfy the American College of Cardiology/American Heart Association (ACC/AHA) criteria for performance measure development (strength of the underlying evidence, clinical importance, magnitude of the relationship between performance and outcome, and cost-effectiveness). We identified 7 quality measures relevant to the emergency care of acute ischemic stroke that fall into 4 main categories: brain imaging, thrombolytic administration, dysphagia screening, and mortality. Three of the 7 measures met all 4 of the ACC/AHA evaluation criteria: brain imaging within 24 hours, thrombolytic therapy within 3 hours of symptom onset, and thrombolytic therapy within 60 minutes of hospital arrival. Measures not satisfying all evaluation criteria were brain imaging report within 45 minutes, consideration for thrombolytic therapy, dysphagia screening, and mortality rate. There remains room for improvement in the development and use of measures that reflect high-quality emergency care of acute ischemic stroke patients in the United States.

Transcatheter aortic valve replacement in nonsurgical candidates with severe, symptomatic aortic stenosis: a cost-effectiveness analysis

BACKGROUND

Transcatheter aortic valve replacement (TAVR) seems to improve the survival and quality of life of patients with aortic stenosis ineligible for surgical aortic valve replacement.

METHODS AND RESULTS

We used a decision analytic Markov model to estimate lifetime costs and benefits in a hypothetical cohort of patients with severe, symptomatic aortic stenosis who were ineligible for surgical aortic valve replacement. The model compared transfemoral TAVR with medical management and was calibrated to the Placement of Aortic Transcatheter Valves (PARTNER) trial. TAVR increased life expectancy from 2.08 to 2.93 years and quality-adjusted life expectancy from 1.19 to 1.93 years. TAVR also reduced subsequent hospitalizations by 1.40 but increased complications, particularly stroke (from 1% to 11% lifetime risk), and also increased lifetime costs from $83,600 to $169,100. The incremental cost-effectiveness of TAVR was $116,500 per quality-adjusted life-year gained ($99,900 per life-year gained). Results were robust to reasonable changes in individual variables but were sensitive to the level of annual healthcare costs caused by noncardiac diseases and to the projected life expectancy of medically treated patients.

CONCLUSIONS

TAVR seems to be an effective but somewhat expensive alternative to medical management among patients with symptomatic aortic stenosis ineligible for surgery. TAVR is more cost-effective for patients with a lower burden of noncardiac disease.

The cost of materials for intra-arterial thrombectomy

This paper reports the cost of endovascular materials used for the treatment of large-vessel ischemic stroke in the anterior circulation according to the angiographic score and clinical results at three months. From November 2009 to July 2011, 57 ischemic patients (mean age, 64.6 ±13.8 years) with anterior large vessel occlusion were included. Mean National Institutes of Health Stroke Scale (NIHSS) on admission was 18.4 ± 4.9. Mean duration of symptoms until the arterial puncture was 207±67 minutes. Recanalization was assessed using the Thrombolysis In Myocardial Infarction (TIMI) score. Patient selection was performed on a non-enhanced CT scanner. According to the TIMI final angiographic score and the modified Rankin score (mRS) at three months, we determined the cost of the material used. Complete (n=12, TIMI grade 3) or partial perfusion (n=35, TIMI grade 2) was achieved in 47 (82.5%) lesions. At three months, 33.3% (n=19) had a mRS score ≤ 2. The mean cost of the material used in the operative room was 5018±2402 euro. Intra-arterial thrombolysis presents a substantial initial cost and the long-term economic impact has to be evaluated. Our health system has to take the price of these new technologies into account for future medical choices and urgently evaluate them in randomized controlled trials.

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

STUDY OBJECTIVE

The European Cooperative Acute Stroke Study III (ECASS III) showed that recombinant tissue plasminogen activator (rtPA) administered 3 to 4.5 hours after acute ischemic stroke led to improvement in patient disability versus placebo. We evaluate the long-term incremental cost-effectiveness of rtPA administered 3 to 4.5 hours after acute ischemic stroke onset versus no treatment according to patient clinical and demographic factors.

METHODS

We developed a disease-based decision analytic model to project lifetime outcomes of patients post-acute ischemic stroke from the payer perspective. Clinical data were derived from the ECASS III trial, longitudinal cohort studies, and health state preference studies. Cost data were based on Medicare reimbursement and other published sources. We performed probabilistic sensitivity analyses to evaluate uncertainty in the analysis.

RESULTS

rtPA in a hypothetical cohort resulted in a gain of 0.07 years of life (95% credible range 0.0005 to 0.17) and 0.24 quality-adjusted life-years (95% credible range 0.01 to 0.60) and a difference in cost of $1,495 (95% credible range -$4,637 to $6,100) compared with placebo. The incremental cost-effectiveness ratio for all patients was $6,255 per quality-adjusted life-year gained; for patients younger than 65 years, cost saving; for patients aged 65 years or older, $35,813 per quality-adjusted life-year; for patients with baseline National Institutes of Health Stroke Scale (NIHSS) score 0 to 9, $16,322 per quality-adjusted life-year; for patients with NIHSS score 10 to 19, $37,462 per quality-adjusted life-year; and for patients with NIHSS score greater than or equal to 20, $2,432 per quality-adjusted life-year. The majority of other subgroups such as sex, history of stroke, and history of hypertension were either cost saving or cost-effective, with the exceptions of diabetes and atrial fibrillation.

CONCLUSION

The results indicate that rtPA in the 3- to 4.5-hour therapeutic window provides improvement in long-term patient outcomes in most patient subgroups and is a good economic value versus no treatment.

The chain of care enabling tPA treatment in acute ischemic stroke: a comprehensive review of organisational models

Protracted and partial implementation of treatment with intravenous tissue plasminogen activator (tPA) within 4.5 h after acute stroke onset results in potentially eligible patients not receiving optimal treatment. The goal of this study was to review the performance of various organisational models of acute stroke care delivery, and subsequent attempts to improve implementation of tPA treatment. Publications comprehensively reporting on organisational models to improve implementation of i.v. tPA treatment of acute ischemic stroke patients were selected. The efficacy of organisational models was assessed using process outcome measures: thrombolysis rates, time-dependent operational endpoints (time delays), functional outcomes: safety (rate of symptomatic intracranial hemorrhage, mortality rates) and clinical outcome at 90 days (modified Rankin Scale). Fifty-eight published studies assessing organisational models were identified. Four dominant models of acute stroke care delivery were discerned, i.e., primary and comprehensive stroke centres, telemedicine, and the mobile stroke unit. Performance reported for these models suggest a large variation in administration of thrombolytic therapy (0.7-30 %). Time delays and functional outcomes found varied considerably, just like safety and mortality (0.0-11.5 %, and 3.4-31.9 %, respectively). These findings suggest that improving organisational models for tPA treatment may improve acute stroke care. However, implementation may be hampered by regional variation in acute stroke care capacity, expertise, and a fragmented approach towards organising stroke care.

Proportion of patients treated with thrombolysis in a centralized versus a decentralized acute stroke care setting

BACKGROUND AND PURPOSE

Today, treatment of acute stroke consists of tissue-type plasminogen activator (tPA), admission to a stroke unit, and aspirin. Although tPA treatment is the most effective, there is substantial undertreatment. Centralized care may affect rate, timing, and outcome of thrombolysis compared to decentralized treatment in community hospitals. The present study aimed to assess the impact of organizational models on the proportion of patients undergoing tPA treatment.

METHODS

A prospective, multicenter, observational study among 13 hospitals in the North of the Netherlands was conducted. In the centralized model, tPA treatment for 4 hospitals was administered in 1 stroke center. The decentralized model comprised 9 community hospitals. Primary outcome was the proportion of patients treated with tPA. Secondary outcome measures were proportion of patients arriving within 4.5 hours, safety, 90-day functional outcome, and onset-to-door, door-to-needle, and onset-to-needle times. Potential confounders were adjusted using logistic regression analysis.

RESULTS

Two hundred eighty-three and 801 ischemic stroke patients were enrolled in the centralized and decentralized settings. Numbers of patients treated with tPA were 62 (21.9%) and 113 (14.1%) (OR, 1.72; 95% CI, 1.22-2.43). Adjusting for potential confounders did not alter results (OR, 2.03; 95% CI, 1.39-2.96). In the centralized setting, significantly more patients arrived at the hospital within the 4.5-hour time window (P<0.01), and shorter door-to-needle times were reached (35 versus 47 minutes). Other secondary outcome measures did not differ across setting.

CONCLUSIONS

In a centralized setting, the results demonstrate a 50% increased likelihood of treatment. Prehospital factors seem to contribute to this result.

Decreased length of stay after addition of healthcare provider in emergency department triage: a comparison between computer-simulated and real-world interventions

OBJECTIVE

(1) To determine the effects of adding a provider in triage on average length of stay (LOS) and proportion of patients with >6 h LOS. (2) To assess the accuracy of computer simulation in predicting the magnitude of such effects on these metrics.

METHODS

A group-level quasi-experimental trial comparing the St. Louis Veterans Affairs Medical Center emergency department (1) before intervention, (2) after institution of provider in triage, and discrete event simulation (DES) models of similar (3) 'before' and (4) 'after' conditions. The outcome measures were daily mean LOS and percentage of patients with LOS >6 h.

RESULTS

The DES-modelled intervention predicted a decrease in the %6-hour LOS from 19.0% to 13.1%, and a drop in the daily mean LOS from 249 to 200 min (p<0.0001). Following (actual) intervention, the number of patients with LOS >6 h decreased from 19.9% to 14.3% (p<0.0001), with the daily mean LOS decreasing from 247 to 210 min (p<0.0001).

CONCLUSION

Physician and mid-level provider coverage at triage significantly reduced emergency department LOS in this setting. DES accurately predicted the magnitude of this effect. These results suggest further work in the generalisability of triage providers and in the utility of DES for predicting quantitative effects of process changes.

Cost-effectiveness of recombinant tissue plasminogen activator in the management of acute ischemic stroke: a systematic review

BACKGROUND AND PURPOSE

This work was undertaken to review the current cost-effectiveness analysis data on thrombolysis by intravenous (IV) therapy with recombinant tissue plasminogen activator (rtPA) for acute ischemic stroke.

METHODS

PubMed was searched for articles published between 1995 and 2008. The cost-effectiveness analysis data from eight eligible studies were reviewed, paying particular attention to their modeling assumptions and the quality of the source data.

RESULTS

THE REVIEWED STUDIES WERE FROM SIX COUNTRIES: USA (n=2), UK (n=2), Canada (n=1), Australia (n=1), Spain (n=1), and Denmark (n=1); most were performed from the healthcare-system and/or societal perspectives. IV rtPA was associated with an acceptable increase in short-term cost [range: US$ 36-236/patient; US$ 29,148-55,591/quality-adjusted life-years (QALYs)], and a net long-term cost saving that was higher from a societal perspective (range: -US$ 12,043 to -US$ 630/patient; -US$ 207,253 to -US$ 21,938/QALYs) than from a healthcare-system perspective (range: -US$ 5,811 to -US$ 5,415/patient; -US$ 41,137 to -US$ 4,662/QALYs).

CONCLUSIONS

IV rtPA seems to be a cost-effective strategy for the management of acute ischemic stroke, and might reduce the associated healthcare costs as well as patients' disabilities. Further cost-effectiveness research and the development of a public health strategy are warranted to optimize the use of rtPA in Korea.

Budget impact analysis of thrombolysis for stroke in Spain: a discrete event simulation model

OBJECTIVE

Thrombolysis within the first 3 hours after the onset of symptoms of a stroke has been shown to be a cost-effective treatment because treated patients are 30% more likely than nontreated patients to have no residual disability. The objective of this study was to calculate by means of a discrete event simulation model the budget impact of thrombolysis in Spain.

METHODS

The budget impact analysis was based on stroke incidence rates and the estimation of the prevalence of stroke-related disability in Spain and its translation to hospital and social costs. A discrete event simulation model was constructed to represent the flow of patients with stroke in Spain.

RESULTS

If 10% of patients with stroke from 2000 to 2015 would receive thrombolytic treatment, the prevalence of dependent patients in 2015 would decrease from 149,953 to 145,922. For the first 6 years, the cost of intervention would surpass the savings. Nevertheless, the number of cases in which patient dependency was avoided would steadily increase, and after 2006 the cost savings would be greater, with a widening difference between the cost of intervention and the cost of nonintervention, until 2015.

CONCLUSION

The impact of thrombolysis on society's health and social budget indicates a net benefit after 6 years, and the improvement in health grows continuously. The validation of the model demonstrates the adequacy of the discrete event simulation approach in representing the epidemiology of stroke to calculate the budget impact.

Economic evaluation of atorvastatin for prevention of recurrent stroke based on the SPARCL trial

OBJECTIVES

This study evaluated the economic implications of results obtained by the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) trial.

METHODS

To enable long-term projection of the trial results, a discrete event simulation of the course of clinical care after a recent stroke or transient ischemic attack (TIA) was developed. It generates pairs of identical patients; both receive usual care, one receives atorvastatin in addition. Their clinical course is simulated based on their risk of stroke, cardiovascular events, and case fatality rates taken from SPARCL, life expectancy from Saskatchewan Health data, and utility weights from literature. Costs, from a US health-care payer perspective in 2005 US dollars, were estimated for a within-trial 5-year period; survival and quality-adjusted life-years (QALYs) were extrapolated over a patient's lifetime; all discounted at 3%/year.

RESULTS

The prevention of stroke, coronary, and other cardiovascular events expected with atorvastatin translates to mean gains of 0.155 life-years gained and 0.172 QALYs per patient over their lifetime. Reducing associated medical costs ($8405 vs. $11,237) but increasing drug costs ($13,984 vs. $8752) results in net $2400/patient, or $13,916/QALY gained. Probabilistic sensitivity analysis indicates no simulations yield ratios above $50,000/QALY.

CONCLUSION

Prescribing atorvastatin for patients with prior stroke or TIA is expected to provide health benefits at an acceptable cost in the United States.

Model-based cost-effectiveness analyses for the treatment of acute stroke events: a review and summary of challenges

OBJECTIVE

To summarize the methodological approaches used in published decision-analytic models evaluating interventions for acute stroke treatment, to highlight key components of decision-analytic models of stroke treatment, and to discuss challenges for developing stroke decision models.

METHODS

A review of the published literature was performed using Medline, to identify studies involving mathematical decision models to evaluate interventions for acute stroke treatment. Articles were analyzed to determine key components of a stroke model and to note areas in which data are lacking.

RESULTS

We identified 13 published models of acute stroke treatment. These models typically possessed a short-term treatment module and a long-term post-treatment module. The following aspects of economic modeling were found to be relevant for developing a stroke model: modeling approach and health state; health state transition probabilities; estimation of short-term, long-term, and indirect costs; health state utilities; poststroke mortality; time horizon; model validation; and estimation of parameter uncertainty.

CONCLUSIONS

Data gaps have limited the development of economic models in stroke to date. In order to more accurately assess the long-term incremental impact of a new treatment of stroke, future research is needed to address these data gaps. We recommend that the complexity of models for examining the cost-effectiveness of an acute stroke treatment be kept to a minimum such that it can incorporate the currently available data without making a large number of assumptions around the data.

Cost-effectiveness of patient selection using penumbral-based MRI for intravenous thrombolysis

BACKGROUND AND PURPOSE

Better selection of patients for intravenous recombinant tissue plasminogen activator (IV tPA) treatment may improve clinical outcomes. We examined the cost-effectiveness of adding penumbral-based MRI to usual computed tomography (CT)-based methods to identify patients for IV tPA treatment.

METHODS

A decision-analytic model estimated the lifetime costs and outcomes associated with penumbral-based MRI selection in a patient population similar to that enrolled in the IV tPA clinical trials. Inputs were obtained from published literature, clinical trial data, claims databases, and expert opinion. Outcomes included cost per life-year saved and cost per quality-adjusted life-year (QALY) gained. Costs and outcomes were discounted at 3% annually. Sensitivity analyses were conducted.

RESULTS

The addition of penumbral-based MRI selection increased total cost by $103 over the patient's remaining lifetime. Penumbral-based MRI selection resulted in favorable outcomes (modified Rankin Scale <or=1) more often than CT-based selection (36.66% versus 35.06%) with an incremental cost per life year of $1840 and an incremental cost per QALY of $1004. Multivariate sensitivity analysis predicted cost-effectiveness (<or=$50,000 per QALY) in 99.7% of simulation runs.

CONCLUSIONS

Selecting ischemic stroke patients for IV tPA treatment using penumbral-based MRI after routine CT may increase overall acute care costs, but the benefit is large enough to make this highly cost-effective. This economic analysis lends further support to the consideration of a paradigm shift in acute stroke evaluation.

Delay to Diagnosis in Acute Pediatric Arterial Ischemic Stroke

Background and Purpose— For the clinician, the diagnosis of arterial ischemic stroke (AIS) in children is a challenge. Prompt diagnosis of pediatric AIS within 6 hours enables stroke-specific thrombolytic and neuroprotective strategies.

Methods— We conducted a retrospective study of prospectively enrolled consecutive cohort of children with AIS, admitted to The Hospital for Sick Children, Toronto, from January 1992 to December 2004. The data on clinical presentation, symptom onset, emergency department arrival, neuroimaging and stroke diagnosis were recorded. The putative predictors of delayed diagnosis were selected a priori for analysis.

Results— A total of 209 children with AIS were studied. The median interval from symptom onset to AIS diagnosis was 22.7 hours (interquartile range: 7.1 to 57.7 hours), prehospital delay (symptom onset to hospital arrival) was 1.7 hours (interquartile range: 49 minutes to 8.1 hours), and the in-hospital delay (presentation to diagnosis) was 12.7 hours (interquartile range: 4.5 to 33.5 hours). The initial assessment was completed in 16 minutes and initial neuroimaging in 8.8 hours. The diagnosis of AIS was suspected on initial assessment in 79 (38%) children and the initial neuroimaging diagnosed AIS in 47%. The parent’s help seeking action, nonabrupt onset of symptoms, altered consciousness, milder stroke severity, posterior circulation infarction and lack of initial neuroimaging at a tertiary hospital were predictive delayed AIS diagnosis.

Conclusion— In the diagnosis of AIS, significant prehospital and in-hospital delays exist in children. Several predictors of the delayed AIS diagnosis were identified in the present study. Efforts to target these predictors can reduce diagnostic delays and optimize the management of AIS in children.

Impact of Recombinant Activated Factor VII on Health-Related Quality of Life after Intracerebral Hemorrhage

BACKGROUND

We recently demonstrated that recombinant activated factor VII (rFVIIa) given to patients presenting within 3 h of acute spontaneous intracerebral hemorrhage (ICH) reduces mortality (18% vs. 29%) and poor outcome (modified Rankin Scale, mRS, 4-6, 53 vs. 69%). This analysis was performed to determine the impact of rFVIIa on health-related quality of life (HRQoL) in those patients.

METHODS

In a prospective, randomized controlled trial, 399 patients (mean age, 66 years) received placebo, 40, 80 or 160 microg/kg of rFVIIa within 4 h of acute ICH. At 90 days, HRQoL was assessed with the EuroQoL (EQ-5D), a 5-dimensional measure of health which also includes the Visual Analogue Scale. Additionally, each level of the 90-day mRS was adjusted, using 4 different previously published utility values, to obtain a clearer picture of perceived HRQoL.

RESULTS

Among the 5 dimensions of EQ-5D, only mobility rating was significantly better for rFVIIa-treated patients (serious problems, 34 vs. 54%; p = 0.01). Yet, the utility value (scaled 1.0 = perfect health and 0.0 = dead) associated with the composite EQ-5D demonstrated significantly better HRQoL (0.48 vs. 0.36; p = 0.01). This was also true for the EQ-5D Visual Analogue Scale score (44 vs. 36; p = 0.04). Finally, all 4 algorithms for applying utility scores to the mRS indicated that rFVIIa was associated with significantly better perceived HRQoL (all p < 0.006).

CONCLUSIONS

Treatment with rFVIIa within 4 h of acute spontaneous ICH improves HRQoL.

Emerging methods in economic modeling of imaging costs and outcomes a short report on discrete event simulation

RATIONALE AND OBJECTIVES

This short report provides a non-technical overview of one emerging modeling technique, discrete event simulation (DES).

METHODS

A selective review of the literature that has applied DES methods to evaluate imaging technologies.

RESULTS

Mathematical models to evaluate the likely costs and outcomes of health technologies have become increasingly accepted. Increasing experience has also brought a mounting awareness of the limitations of conventional modeling techniques such as decision trees and Markov processes. Patient-level simulation, including DES, may provide a more flexible approach to modeling for economic evaluation of health technologies.

CONCLUSIONS

The strengths of DES suggest that it may have an increasingly important role in the future modeling of annual screening programs, diagnosis, and treatment of chronic recurrent disease and modeling the utilization of imaging equipment.

Cost-effectiveness of recombinant activated factor VII in the treatment of intracerebral hemorrhage

BACKGROUND AND PURPOSE

Intracerebral hemorrhage (ICH) is among the most costly and debilitating forms of stroke. Results from a recent Phase IIb clinical trial demonstrate that administration of recombinant activated factor VII (rFVIIa) reduces ICH mortality and improves functional outcome. In the current analysis, we examine the cost-effectiveness of early treatment with rFVIIa for ICH in the United States.

METHODS

A decision-analytic model was developed to estimate the lifetime costs and outcomes associated with rFVIIa treatment at doses of 40, 80 and 160 microg/kg compared with current standard of care in treating ICH, from a US third-party payer perspective. The patient population was similar to that of the Phase IIb clinical trial. Model structure and inputs were obtained from published literature, clinical trial data, claims databases, and expert opinion. All costs are presented in 2005 US dollars. Outcomes included incremental cost per life-year (LY) saved and incremental cost per quality-adjusted life-year (QALY) gained. Costs and outcomes were discounted at 3% annually. Univariate and multivariate sensitivity analyses were conducted to assess model robustness.

RESULTS

Compared with standard care, treatment with rFVIIa 40 microg/kg, and 160 microg/kg results in total lifetime cost-effectiveness ratios of 6308 dollars/QALY and 3152 dollars/QALY, respectively. Treatment with rFVIIa 80 microg/kg was found to be cost saving and a gain of 1.67 QALYs is achieved over a patient's lifetime. These results are robust to changes in input parameters.

CONCLUSIONS

Treatment of ICH with rFVIIa 40 microg/kg and 160 microg/kg appears to be cost-effective (<or=50,000 dollars/QALY). At the 80 microg/kg dose, rFVIIa was not only cost-effective, but also cost saving.

A clinic investigation into prehospital and emergency department delays in acute stroke care

OBJECTIVE

The aim of our study was to investigate the factors which cause prehospital and emergency department (ED) delays in acute stroke care.

SUBJECTS AND METHODS

We prospectively studied 229 acute stroke patients (median age: 71 +/- 19 years, 90 female and 139 male) who presented to the ED of the Gulhane Military Teaching Hospital, Istanbul, Turkey. Prehospital delay was defined as time from symptom onset to arrival at the ED. Emergency delay was defined as time from initial examination in the ED to arrival at the Neurology Intensive Care Unit.

RESULTS

The median interval of prehospital and emergency delays were 92.66 and 53 min, respectively. The major cause of the prehospital delay was the time from symptom onset to first call for medical help (68.21 min, 73.93%, beta coefficients: 0.99; p < 0.001), and the major cause of the ED delay was waiting for the neurological consultation (21.28 min, 39.6%), beta coefficients: 0.03; p < 0.001).

CONCLUSION

The results indicate that prehospital and ED delays are due to late decision to seek medical care and delayed neurological consultation. Hence, educational campaigns are needed to increase public awareness of stroke signs and the necessity of calling emergency services immediately when persons are suffering a possible stroke. Equally, ED physicians need to be trained in the recognition of symptoms and signs of acute stroke and the necessity for rapid neurological evaluation.

Houston Paramedic and Emergency Stroke Treatment and Outcomes Study (HoPSTO)

Background and Purpose— Establishment of stroke centers, combined with accurate paramedic diagnosis and rapid transport, is essential to deliver acute stroke therapy. We wanted to measure and improve paramedic and hospital performance through implementation of the Brain Attack Coalition and American Stroke Association guidelines.

Methods— Pre-intervention and active-intervention phases with parallel data measurement points were used. The study involved six hospitals comprising the majority of acute-stroke admissions in Houston, Tex. Hospital, paramedic, and patient data were collected prospectively pre-intervention and during the active-intervention phase on all suspected acute-stroke patients admitted by Houston Fire Department-Emergency Medical Services. A multilevel educational intervention included paramedic, hospital, and community education. Paramedic diagnostic accuracy, hospital-performance efficiency, and thrombolytic treatment rates were the main outcome measures of the study.

Results— Four hundred forty-six patients (74 per month) were transported in the pre-intervention phase to participating hospitals (59.8% of all suspected stroke patients transported city wide by Houston Fire Department—Emergency Medical Services), compared with 1072 patients (89 per month, or 68.7%) transported in the active-intervention phase ( P <0.001). Accuracy of paramedic diagnosis of stroke increased from 61% to 79%. Admission within 2 hours of symptom onset increased from 58% to 62% ( P =0.002). Thrombolysis rates increased in 4 of 6 centers, with 1 post- tissue plasminogen activator hemorrhage (3.7%) reported.

Conclusions— A multilevel educational program improves rapid hospitalization and paramedic diagnostic accuracy and increases the number of patients presenting for evaluation within the 3-hour tissue plasminogen activator window. Stroke center development supports safe thrombolytic practice in community settings.

Hourly Blood Pressure Monitoring After Intravenous Tissue Plasminogen Activator for Ischemic Stroke

BACKGROUND AND PURPOSE

Blood pressure (BP) control is considered essential in patients treated with tissue plasminogen activator (tPA) for ischemic stroke, and it is recommended that BP be monitored every 15 minutes to 1 hour for 24 hours in these patients. We postulated that patients whose BP is not initially elevated are unlikely to have elevated BP later and, therefore, may not need prolonged BP monitoring.

METHODS

We performed a retrospective chart review of patients treated with intravenous tPA for ischemic stroke over a 3-year period. Patients with incomplete records were excluded.

RESULTS

Seventy-nine patients (35 male, age 68.8+/-14.3 years) were studied. Before tPA treatment, 16 patients (20%) had hypertension (systolic BP > or =185 or diastolic BP > or =110 mm Hg). All 16 patients had subsequent hypertension over the next 24 hours. Of the remaining 63, 27 patients (43%) had hypertension (systolic BP > or =180 or diastolic BP > or =105 mm Hg) within the first 6 hours. An additional 4 had minor transient systolic elevations (< or =182 mm Hg) after 6 hours that normalized without treatment. Neurological worsening, seen in 13 patients (17%), was not associated with the presence of hypertension (initial or subsequent).

CONCLUSIONS

In patients receiving tPA for stroke, absence of hypertension at presentation does not preclude subsequent increase in blood pressure. However, if blood pressure is not elevated during the first 6 hours, subsequent hypertension over the next 18 hours is unlikely. This study is small and retrospective, and needs to be repeated in a larger prospective cohort. However, our results provide preliminary evidence to suggest that where resources are scarce, these patients may be discharged from the intensive care unit earlier than the recommended 24 hours, provided that they are not at high risk for neurological deterioration.

Economic benefit from clinical practice guideline compliance in stroke patient management

BACKGROUND AND PURPOSE

In a previous study we showed that compliance with evidence-based guidelines improves the health outcome of stroke patients in terms of both survival and residual disability. In this analysis, we shall investigate the impact of such guidelines on healthcare costs during the acute/sub-acute hospitalisation phase.

METHOD

we considered the direct costs from the hospital's point of view, where funding is provided by the National Healthcare System. We did not consider production loss or intangible costs related to the decreased quality of life. Data was collected on both costs and guideline compliance prospectively, and the relationship between them was studied through a multivariate statistical model.

RESULTS

Patients treated according to guidelines result in lower costs; on average they have a shorter length of stay in hospital (10.8 versus 12.9 days), leading to a significant difference in the consumption of hospital resources. On a level of statistical analysis, guideline compliance is a significant independent indicator of cost, together with the patient's initial disability and neurological deficit.

Management of Ischemic Stroke in the Next Decade: Stroke Centers of Excellence

Stroke has been increasingly recognized as an important and expensive medical and societal problem during the past 10 years. Currently, organized stroke care is delivered to the American population in only a few cities and hospitals that provide an efficient system for rapid transportation, diagnosis, treatment, and rehabilitation. The Brain Attack Coalition (BAC) has recently proposed the concepts of stroke centers of excellence (akin to trauma level I centers), primary stroke centers, and comprehensive stroke center. The U.S. government, with the Paul Coverdell National Acute Stroke Registry and the Stroke Treatment and Ongoing Prevention Act of 2003, further supports these concepts. Herein, a discussion of the influence that the BAC, the Paul Coverdell National Acute Stroke Registry, and the Stroke Treatment and Ongoing Prevention Acts of 2001 and 2003 will have on the future of stroke therapy in this country during the next 10 years is presented. Also discussed are the elements that are crucial to organized stroke care and the formation of stroke centers of excellence. These include triage and diagnosis in the field, transportation, triage and imaging in the emergency department, prompt transfer to a dedicated stroke unit with focused care, rehabilitation, manpower, prevention and research, reimbursement issues, and politics. The importance of multidisciplinary collaboration on the professional and societal levels and, finally, government- and private sector-sponsored research are also presented.