1
|
Wechsler PM, Pandya A, Parikh NS, Razzak JA, White H, Navi BB, Kamel H, Liberman AL. Cost-Effectiveness of Increased Use of Dual Antiplatelet Therapy After High-Risk Transient Ischemic Attack or Minor Stroke. J Am Heart Assoc 2024; 13:e032808. [PMID: 38533952 PMCID: PMC11179775 DOI: 10.1161/jaha.123.032808] [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] [Received: 11/20/2023] [Accepted: 02/14/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Rates of dual antiplatelet therapy (DAPT) after high-risk transient ischemic attack or minor ischemic stroke (TIAMIS) are suboptimal. We performed a cost-effectiveness analysis to characterize the parameters of a quality improvement (QI) intervention designed to increase DAPT use after TIAMIS. METHODS AND RESULTS We constructed a decision tree model that compared current national rates of DAPT use after TIAMIS with rates after implementing a theoretical QI intervention designed to increase appropriate DAPT use. The base case assumed that a QI intervention increased the rate of DAPT use to 65% from 45%. Costs (payer and societal) and outcomes (stroke, myocardial infarction, major bleed, or death) were modeled using a lifetime horizon. An incremental cost-effectiveness ratio <$100 000 per quality-adjusted life year was considered cost-effective. Deterministic and probabilistic sensitivity analyses were performed. From the payer perspective, a QI intervention was associated with $9657 in lifetime cost savings and 0.18 more quality-adjusted life years compared with current national treatment rates. A QI intervention was cost-effective in 73% of probabilistic sensitivity analysis iterations. Results were similar from the societal perspective. The maximum acceptable, initial, 1-time payer cost of a QI intervention was $28 032 per patient. A QI intervention that increased DAPT use to at least 51% was cost-effective in the base case. CONCLUSIONS Increasing DAPT use after TIAMIS with a QI intervention is cost-effective over a wide range of costs and proportion of patients with TIAMIS treated with DAPT after implementation of a QI intervention. Our results support the development of future interventions focused on increasing DAPT use after TIAMIS.
Collapse
Affiliation(s)
- Paul M. Wechsler
- Department of Neurology, Clinical and Translational Neuroscience UnitFeil Family Brain and Mind Research Institute, Weill Cornell MedicineNew YorkNY
| | - Ankur Pandya
- Department of Health Policy and ManagementHarvard T.H. Chan School of Public HealthBostonMA
| | - Neal S. Parikh
- Department of Neurology, Clinical and Translational Neuroscience UnitFeil Family Brain and Mind Research Institute, Weill Cornell MedicineNew YorkNY
| | - Junaid A. Razzak
- Department of Emergency MedicineWeill Cornell MedicineNew YorkNY
| | - Halina White
- Department of Neurology, Clinical and Translational Neuroscience UnitFeil Family Brain and Mind Research Institute, Weill Cornell MedicineNew YorkNY
| | - Babak B. Navi
- Department of Neurology, Clinical and Translational Neuroscience UnitFeil Family Brain and Mind Research Institute, Weill Cornell MedicineNew YorkNY
| | - Hooman Kamel
- Department of Neurology, Clinical and Translational Neuroscience UnitFeil Family Brain and Mind Research Institute, Weill Cornell MedicineNew YorkNY
| | - Ava L. Liberman
- Department of Neurology, Clinical and Translational Neuroscience UnitFeil Family Brain and Mind Research Institute, Weill Cornell MedicineNew YorkNY
| |
Collapse
|
2
|
Sanmartin MX, Katz JM, Wang J, Malhotra A, Sangha K, Bastani M, Martinez G, Sanelli PC. Cost-effectiveness of endovascular thrombectomy in acute stroke patients with large ischemic core. J Neurointerv Surg 2023; 15:e166-e171. [PMID: 36175016 DOI: 10.1136/jnis-2022-019460] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 09/14/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Evidence has shown that endovascular thrombectomy (EVT) treatment improves clinical outcomes. Yet, its benefit remains uncertain in patients with large established infarcts as defined by ASPECTS (Alberta Stroke Program Early CT Score) <6. This study evaluates the cost-effectiveness of EVT, compared with standard care (SC), in acute ischemic stroke (AIS) patients with ASPECTS 3-5. METHODS An economic evaluation study was performed combining a decision tree and Markov model to estimate lifetime costs (2021 US$) and quality-adjusted life years (QALYs) of AIS patients with ASPECTS 3-5. Incremental cost-effectiveness ratios (ICERs), net monetary benefits (NMBs), and deterministic one-way and two-way sensitivity analyses were performed. Probabilistic sensitivity analyses were also performed to evaluate the robustness of our model. RESULTS Compared with SC, the cost-effectiveness analyses revealed that EVT yields higher lifetime benefits (2.20 QALYs vs 1.41 QALYs) with higher lifetime healthcare cost per patient ($285 861 vs $272 954). The difference in health benefits between EVT and SC was 0.79 QALYs, equivalent to 288 additional days of healthy life per patient. Even though EVT is more costly than SC alone, it is still cost-effective given better outcomes with ICER of $16 239/QALY. The probabilistic sensitivity analyses indicated that EVT was the most cost-effective strategy in 98.8% (9882 of 10 000) of iterations at the willingness-to-pay threshold of $100 000 per QALY. CONCLUSIONS The results of this study suggest that EVT is cost-effective in AIS patients with a large ischemic core (ASPECTS 3-5), compared with SC alone over the patient's lifetime.
Collapse
Affiliation(s)
- Maria X Sanmartin
- Siemens Healthineers USA, Malvern, Pennsylvania, USA
- Imaging Clinical Effectiveness and Outcomes Research, Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Jeffrey M Katz
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
- Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| | - Jason Wang
- Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| | - Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Kinpritma Sangha
- Siemens Healthineers USA, Malvern, Pennsylvania, USA
- Imaging Clinical Effectiveness and Outcomes Research, Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Mehrad Bastani
- Imaging Clinical Effectiveness and Outcomes Research, Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Gabriela Martinez
- Imaging Clinical Effectiveness and Outcomes Research, Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Pina C Sanelli
- Imaging Clinical Effectiveness and Outcomes Research, Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, New York, USA
- Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| |
Collapse
|
3
|
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.
Collapse
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
| |
Collapse
|
4
|
Wechsler PM, Liberman AL, Restifo D, Abramson EL, Navi BB, Kamel H, Parikh NS. Cost-Effectiveness of Smoking Cessation Interventions in Patients With Ischemic Stroke and Transient Ischemic Attack. Stroke 2023; 54:992-1000. [PMID: 36866670 PMCID: PMC10050136 DOI: 10.1161/strokeaha.122.040356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 02/17/2023] [Indexed: 03/04/2023]
Abstract
BACKGROUND Smoking cessation rates after stroke and transient ischemic attack are suboptimal, and smoking cessation interventions are underutilized. We performed a cost-effectiveness analysis of smoking cessation interventions in this population. METHODS We constructed a decision tree and used Markov models that aimed to assess the cost-effectiveness of varenicline, any pharmacotherapy with intensive counseling, and monetary incentives, compared with brief counseling alone in the secondary stroke prevention setting. Payer and societal costs of interventions and outcomes were modeled. The outcomes were recurrent stroke, myocardial infarction, and death using a lifetime horizon. Estimates and variance for the base case (35% cessation), costs and effectiveness of interventions, and outcome rates were imputed from the stroke literature. We calculated incremental cost-effectiveness ratios and incremental net monetary benefits. An intervention was considered cost-effective if the incremental cost-effectiveness ratio was less than the willingness-to-pay threshold of $100 000 per quality-adjusted life-year (QALY) or when the incremental net monetary benefit was positive. Probabilistic Monte Carlo simulations modeled the impact of parameter uncertainty. RESULTS From the payer perspective, varenicline and pharmacotherapy with intensive counseling were associated with more QALYs (0.67 and 1.00, respectively) at less total lifetime costs compared with brief counseling alone. Monetary incentives were associated with 0.71 more QALYs at an additional cost of $120 compared with brief counseling alone, yielding an incremental cost-effectiveness ratio of $168/QALY. From the societal perspective, all 3 interventions provided more QALYs at less total costs compared with brief counseling alone. In 10 000 Monte Carlo simulations, all 3 smoking cessation interventions were cost-effective in >89% of runs. CONCLUSIONS For secondary stroke prevention, it is cost-effective and potentially cost-saving to deliver smoking cessation therapy beyond brief counseling alone.
Collapse
Affiliation(s)
- Paul M Wechsler
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Ava L Liberman
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Daniel Restifo
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Erika L Abramson
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, 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
| | - Neal S Parikh
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| |
Collapse
|
5
|
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: 6] [Impact Index Per Article: 6.0] [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.
Collapse
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
| |
Collapse
|
6
|
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: 1] [Impact Index Per Article: 0.5] [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.
Collapse
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
| |
Collapse
|
7
|
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.
Collapse
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,
| |
Collapse
|
8
|
A systematic review of cost-effectiveness analyses on endovascular thrombectomy in ischemic stroke patients. Eur Radiol 2022; 32:3757-3766. [PMID: 35301558 DOI: 10.1007/s00330-022-08671-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 12/26/2021] [Accepted: 01/23/2022] [Indexed: 01/01/2023]
Abstract
OBJECTIVE The objective of this study was to examine the published cost-effectiveness analyses (CEAs) on endovascular thrombectomy (EVT) in acute stroke patients, with a particular focus on the practice of accounting for costs and utilities. METHODS We conducted a systematic review of published CEAs on EVT in acute stroke patients from 1/1/2009 to 10/1/2019. Published CEAs were searched in Ovid Embase, Ovid MEDLINE, and Web of Science. Cost or comparative effectiveness analyses were excluded. Risk of bias and quality assessment was based on the Consolidated Health Economic Evaluation Reporting Standard checklist. RESULTS Twenty-one studies were included in the final analysis, from the USA, Canada, Europe, Asia, and Australia. They all concluded EVT to be cost-effective, but with significant variations in methodology. Fifteen studies employed a long-term horizon (> 20 years), while only 11 incorporated risk of recurrent strokes. The willingness-to-pay (WTP) threshold varied from $10,000/quality-adjusted life year (QALY) to $120,000/QALY, with $50,000/QALY and $100,000/QALY being the most commonly used. Five studies undertook a societal perspective, but only one accounted for indirect costs. Seventeen studies based outcomes on 90-day modified Rankin Scale (mRS) scores, and 9 of these 17 studies grouped outcomes by mRS 0-2 and 3-5. Among these 9 studies, the range of QALY score reported for mRS 0-2 was 0.71-0.85 QALY, and that of mRS 3-5 was 0.21-0.40. CONCLUSIONS Our study reveals significant heterogeneity in previously published thrombectomy CEAs, highlighting need for better standardization in future CEAs. KEY POINTS • All included studies concluded thrombectomy to be cost-effective, from both long- and short-term perspectives. • Only 5 out of 22 studies undertook a societal perspective, and only 1 accounted for indirect costs. • The range of value for mRS 0-2 was 0.71-0.85 quality-adjusted life year (QALY) and 0.21-0.40 QALY for mRS 3-5.
Collapse
|
9
|
Tan E, Gao L, Collier JM, Ellery F, Dewey HM, Bernhardt J, Moodie M. The economic and health burden of stroke among younger adults in Australia from a societal perspective. BMC Public Health 2022; 22:218. [PMID: 35114974 PMCID: PMC8811989 DOI: 10.1186/s12889-021-12400-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 11/17/2021] [Indexed: 01/27/2023] Open
Abstract
Background To estimate the short term (5 years) and long term (30 years) economic burden of stroke among younger adults (18–64 years), and to calculate the loss of health-related quality of life in these individuals, in Australia. Methods A Markov microsimulation model was built to simulate incidence of stroke among younger adults in Australia. Younger adults with stroke commenced in the model via health states defined by the modified Rankin Scale at 12 months from the AVERT study (A Very Early Rehabilitation Trial), and transitioned through these health states. Costs in Australian dollars (AUD) were measured from a societal perspective for a 2018 reference year and categorised into medical, non-medical and indirect costs. Probabilistic sensitivity analyses were performed to test the robustness around the cost of illness estimates. The loss of health-related quality of life due to stroke among younger adults was calculated by determining the difference in estimated quality-adjusted life years (QALYs) between the stroke population and the general population. This was determined by multiplying the predicted remaining life years for the modelled stroke cohort and the age-matched general population, by their corresponding age-dependent utilities. Results The economic burden of stroke among younger adults was estimated to be AUD2.0 billion over 5 years, corresponding to a mean of $149,180 per stroke patient. Over 30 years, the economic impact was AUD3.4 billion, equating to a mean of $249,780 per case. Probabilistic sensitivity analyses revealed a mean cost per patient of $153,410 in the short term, and a mean cost per patient of $273,496 in the long term. Compared to the age-matched general population, younger adults with stroke experienced a loss of 4.58 life years and 9.21 QALYs. Conclusions The results of our study suggests high economic and health burden of stroke among younger adults and highlights the need for preventive interventions targeting this age group. Trial registration ACTRN12606000185561, retrospectively registered. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-12400-5.
Collapse
Affiliation(s)
- Elise Tan
- Deakin Health Economics, Institute for Health Transformation, Deakin University, Geelong, Australia.
| | - Lan Gao
- Deakin Health Economics, Institute for Health Transformation, Deakin University, Geelong, Australia
| | - Janice M Collier
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Australia
| | - Fiona Ellery
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Australia
| | - Helen M Dewey
- Eastern Health Clinical School, Monash University, Box Hill, Australia
| | - Julie Bernhardt
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Australia
| | | | - Marj Moodie
- Deakin Health Economics, Institute for Health Transformation, Deakin University, Geelong, Australia
| |
Collapse
|
10
|
Lansberg MG, Wintermark M, Kidwell CS, Albers GW. Magnetic Resonance Imaging of Cerebrovascular Diseases. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00048-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
11
|
Boltyenkov AT, Martinez G, Pandya A, Katz JM, Wang JJ, Naidich JJ, Rula E, Sanelli PC. Cost-Consequence Analysis of Advanced Imaging in Acute Ischemic Stroke Care. Front Neurol 2021; 12:774657. [PMID: 34899583 PMCID: PMC8662622 DOI: 10.3389/fneur.2021.774657] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 11/02/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction: The purpose of this study was to illustrate the potential costs and health consequences of implementing advanced CT angiography and perfusion (CTAP) as the initial imaging in patients presenting with acute ischemic stroke (AIS) symptoms at a comprehensive stroke center (CSC). Methods: A decision-simulation model based on the American Heart Association's recommendations for AIS care pathways was developed to assess imaging strategies for a 5-year period from the institutional perspective. The following strategies were compared: (1) advanced CTAP imaging: NCCT + CTA + CT perfusion at the time of presentation; (2) standard-of-care: non-contrast CT (NCCT) at the time of presentation, with CT angiography (CTA) ± CT perfusion only in select patients (initial imaging to exclude hemorrhage and extensive ischemia) for mechanical thrombectomy (MT) evaluation. Model parameters were defined with evidence-based data. Cost-consequence and sensitivity analyses were performed. The modified Rankin Scale (mRS) at 90 days was used as the outcome measure. Results: The decision-simulation modeling revealed that adoption of the advanced CTAP imaging increased per-patient imaging costs by 1.19% ($9.28/$779.72), increased per-patient treatment costs by 33.25% ($729.96/$2,195.24), and decreased other per-patient acute care costs by 0.7% (–$114.12/$16,285.85). The large increase in treatment costs was caused by higher proportion of patients being treated. However, improved outcomes lowered the other per-patient acute care costs. Over the five-year period, advanced CTAP imaging led to 1.63% (66/4,040) more patients with good outcomes (90-day mRS 0-2), 2.23% (66/2,960) fewer patients with poor outcomes (90-day mRS 3-5), and no change in mortality (90-day mRS 6). Our CT equipment utilization analysis showed that the demand for CT equipment in terms of scanner time (minutes) was 24% lower in the advanced CTAP imaging strategy compared to the standard-of-care strategy. The number of EVT procedures performed at the CSC may increase by 50%. Conclusions: Our study reveals that adoption of advanced CTAP imaging at presentation increases the demand for treatment of acute ischemic stroke patients as more patients are diagnosed within the treatment time window compared to standard-of-care imaging. Advanced imaging also leads to more patients with good functional outcomes and fewer patients with dependent functional status.
Collapse
Affiliation(s)
- Artem T Boltyenkov
- Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, NY, United States.,Siemens Healthcare, Malvern, PA, United States.,Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Hempstead, NY, United States
| | - Gabriela Martinez
- Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, NY, United States.,Siemens Healthcare, Malvern, PA, United States.,Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Hempstead, NY, United States
| | - Ankur Pandya
- Department of Health Policy and Management, School of Public Health, Harvard University, Boston, MA, United States
| | - Jeffrey M Katz
- Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Hempstead, NY, United States.,Department of Neurology, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Hempstead, NY, United States
| | - Jason J Wang
- Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, NY, United States
| | - Jason J Naidich
- Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, NY, United States.,Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Hempstead, NY, United States
| | - Elizabeth Rula
- Harvey L. Neiman Health Policy Institute, Reston, VA, United States
| | - Pina C Sanelli
- Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, NY, United States.,Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Hempstead, NY, United States
| |
Collapse
|
12
|
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.
Collapse
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
| |
Collapse
|
13
|
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.
Collapse
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
| |
Collapse
|
14
|
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: 31] [Impact Index Per Article: 7.8] [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.
Collapse
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
| |
Collapse
|
15
|
Stevens ER, Roberts E, Kuczynski HC, Boden-Albala B. Stroke Warning Information and Faster Treatment (SWIFT): Cost-Effectiveness of a Stroke Preparedness Intervention. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2019; 22:1240-1247. [PMID: 31708060 PMCID: PMC6857539 DOI: 10.1016/j.jval.2019.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 05/09/2019] [Accepted: 06/10/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Less than 25% of stroke patients arrive to an emergency department within the 3-hour treatment window. OBJECTIVE We evaluated the cost-effectiveness of a stroke preparedness behavioral intervention study (Stroke Warning Information and Faster Treatment [SWIFT]), a stroke intervention demonstrating capacity to decrease race-ethnic disparities in ED arrival times. METHODS Using the literature and SWIFT outcomes for 2 interventions, enhanced educational (EE) materials, and interactive intervention (II), we assess the cost-effectiveness of SWIFT in 2 ways: (1) Markov model, and (2) cost-to-outcome ratio. The Markov model primary outcome was the cost per quality-adjusted life-year (QALY) gained using the cost-effectiveness threshold of $100 000/QALY. The primary cost-to-outcome endpoint was cost per additional patient with ED arrival <3 hours, stroke knowledge, and preparedness capacity. We assessed the ICER of II and EE versus standard care (SC) from a health sector and societal perspective using 2015 USD, a time horizon of 5 years, and a discount rate of 3%. RESULTS The cost-effectiveness of the II and EE programs was, respectively, $227.35 and $74.63 per additional arrival <3 hours, $440.72 and $334.09 per additional person with stroke knowledge proficiency, and $655.70 and $811.77 per additional person with preparedness capacity. Using a societal perspective, the ICER for EE versus SC was $84 643 per QALY gained and the ICER for II versus EE was $59 058 per QALY gained. Incorporating fixed costs, EE and II would need to administered to 507 and 1693 or more patients, respectively, to achieve an ICER of $100 000/QALY. CONCLUSION II was a cost-effective strategy compared with both EE and SC. Nevertheless, high initial fixed costs associated with II may limit its cost-effectiveness in settings with smaller patient populations.
Collapse
Affiliation(s)
- Elizabeth R Stevens
- Department of Epidemiology, New York University College of Global Public Health, New York, NY, USA; Department of Population Health, New York University School of Medicine, New York, NY, USA.
| | - Eric Roberts
- Department of Epidemiology, New York University College of Global Public Health, New York, NY, USA
| | - Heather Carman Kuczynski
- Department of Epidemiology, New York University College of Global Public Health, New York, NY, USA
| | - Bernadette Boden-Albala
- Department of Epidemiology, New York University College of Global Public Health, New York, NY, USA
| |
Collapse
|
16
|
Liberman AL, Choi HJ, French DD, Prabhakaran S. Is the Cost-Effectiveness of Stroke Thrombolysis Affected by Proportion of Stroke Mimics? Stroke 2019; 50:463-468. [PMID: 30572813 DOI: 10.1161/strokeaha.118.022857] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Differentiating ischemic stroke patients from stroke mimics (SM), nonvascular conditions which simulate stroke, can be challenging in the acute setting. We sought to model the cost-effectiveness of treating suspected acute ischemic stroke patients before a definitive diagnosis could be made. We hypothesized that we would identify threshold proportions of SM among suspected stroke patients arriving to an emergency department above which administration of intravenous thrombolysis was no longer cost-effective. Methods- We constructed a decision-analytic model to examine various emergency department thrombolytic treatment scenarios. The main variables were proportion of SM to true stroke patients, time from symptom onset to treatment, and complication rates. Costs, reimbursement rates, and expected clinical outcomes of ischemic stroke and SM patients were estimated from published data. We report the 90-day incremental cost-effectiveness ratio of administering intravenous thrombolysis compared with no acute treatment from a healthcare sector perspective, as well as the cost-reimbursement ratio from a hospital-level perspective. Cost-effectiveness was defined as a willingness to pay <$100 000 USD per quality adjusted life year gained and high cost-reimbursement ratio was defined as >1.5. Results- There was an increase in incremental cost-effectiveness ratios as the proportion of SM cases increased in the 3-hour time window. The threshold proportion of SM above which the decision to administer thrombolysis was no longer cost-effective was 30%. The threshold proportion of SM above which the decision to administer thrombolysis resulted in high cost-reimbursement ratio was 75%. Results were similar for patients arriving within 0 to 90 minutes of symptom onset as compared with 91 to 180 minutes but were significantly affected by cost of alteplase in sensitivity analyses. Conclusions- We identified thresholds of SM above which thrombolysis was no longer cost-effective from 2 analytic perspectives. Hospitals should monitor SM rates and establish performance metrics to prevent rising acute stroke care costs and avoid potential patient harms.
Collapse
Affiliation(s)
- Ava L Liberman
- From the Department of Neurology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY (A.L.L.)
| | - Ho-Jun Choi
- McCormick School of Engineering and Applied Science, Northwestern University. Evanston, IL (H.-J.C.)
| | - Dustin D French
- Department of Ophthalmology and Center for Healthcare Studies (D.D.F.), Feinberg School of Medicine, Northwestern University, Chicago, IL.,Veterans Affairs Health Services Research and Development Service, Chicago, Illinois (D.D.F.)
| | - Shyam Prabhakaran
- Department of Neurology (S.P.), Feinberg School of Medicine, Northwestern University, Chicago, IL
| |
Collapse
|
17
|
Whetten J, van der Goes DN, Tran H, Moffett M, Semper C, Yonas H. Cost-effectiveness of Access to Critical Cerebral Emergency Support Services (ACCESS): a neuro-emergent telemedicine consultation program. J Med Econ 2018; 21:398-405. [PMID: 29316820 DOI: 10.1080/13696998.2018.1426591] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
AIMS Access to Critical Cerebral Emergency Support Services (ACCESS) was developed as a low-cost solution to providing neuro-emergent consultations to rural hospitals in New Mexico that do not offer comprehensive stroke care. ACCESS is a two-way audio-visual program linking remote emergency department physicians and their patients to stroke specialists. ACCESS also has an education component in which hospitals receive training from stroke specialists on the triage and treatment of patients. This study assessed the clinical and economic outcomes of the ACCESS program in providing services to rural New Mexico from a healthcare payer perspective. METHODS A decision tree model was constructed using findings from the ACCESS program and existing literature, the likelihood that a patient will receive a tissue plasminogen activator (tPA), cost of care, and resulting quality adjusted life years (QALYs). Data from the ACCESS program includes emergency room patients in rural New Mexico from May 2015 to August 2016. Outcomes and costs have been estimated for patients who were taken to a hospital providing neurological telecare and patients who were not. RESULTS The use of ACCESS decreased neuro-emergent stroke patient transfers from rural hospitals to urban settings from 85% to 5% (no tPA) and 90% to 23% (tPA), while stroke specialist reading of patient CT/MRI imaging within 3 h of onset of stroke symptoms increased from 2% to 22%. Results indicate that use of ACCESS has the potential to save $4,241 ($3,952-$4,438) per patient and increase QALYs by 0.20 (0.14-0.22). This increase in QALYs equates to ∼73 more days of life at full health. The cost savings and QALYs are expected to increase when moving from a 90-day model to a lifetime model. CONCLUSION The analysis demonstrates potential savings and improved quality-of-life associated with the use of ACCESS for patients presenting to rural hospitals with acute ischemic stroke (AIS).
Collapse
Affiliation(s)
- Justin Whetten
- a Department of Economics , University of New Mexico , Albuquerque , NM , USA
| | | | - Huy Tran
- b Department of Neurosurgery , University of New Mexico , Albuquerque , NM , USA
| | - Maurice Moffett
- a Department of Economics , University of New Mexico , Albuquerque , NM , USA
| | - Colin Semper
- b Department of Neurosurgery , University of New Mexico , Albuquerque , NM , USA
| | - Howard Yonas
- b Department of Neurosurgery , University of New Mexico , Albuquerque , NM , USA
| |
Collapse
|
18
|
Lahiry S, Levi C, Kim J, Cadilhac DA, Searles A. Economic Evaluation of a Pre-Hospital Protocol for Patients with Suspected Acute Stroke. Front Public Health 2018; 6:43. [PMID: 29552550 PMCID: PMC5840434 DOI: 10.3389/fpubh.2018.00043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 02/07/2018] [Indexed: 11/13/2022] Open
Abstract
Background In regional and rural Australia, patients experiencing ischemic stroke do not have equitable access to an intravenous recombinant tissue plasminogen activator (tPA). Although thrombolysis with tPA is a clinically proven and cost-effective treatment for eligible stroke patients, there are few economic evaluations on pre-hospital triage interventions to improve access to tPA. Aim To describe the potential cost-effectiveness of the pre-hospital acute stroke triage (PAST) protocol implemented to provide priority transfer of appropriate patients from smaller hospitals to a primary stroke center (PSC) in regional New South Wales, Australia. Materials and methods The PAST protocol was evaluated using a prospective and historical control design. Using aggregated administrative data, a decision analytic model was used to simulate costs and patient outcomes. During the implementation of the PAST protocol (intervention), patient data were collected prospectively at the PSC. Control patients included two groups (i) patients arriving at the PSC in the 12 months before the implementation of the PAST protocol and, (ii) patients from the geographical catchment area of the smaller regional hospitals that were previously not bypassed during the control period. Control data were collected retrospectively. The primary outcome of the economic evaluation was the additional cost per disability adjusted life years (DALYs) averted in the intervention period compared to the control period. Results The intervention was associated with a 17 times greater odds of eligible patients receiving tPA (adjusted odds ratio, 95% CI 9.42-31.2, p < 0.05) and the majority of the associated costs were incurred during acute care and rehabilitation. Overall, the intervention was associated with an estimated net avoidance of 93.3 DALYs. The estimated average cost per DALY averted per patient in the intervention group compared to the control group was $10,921. Conclusion Based on our simulation modeling, the pre-hospital triage intervention was a potentially cost-effective strategy for improving access to tPA therapy for patients with ischemic stroke in regional Australia.
Collapse
Affiliation(s)
- Suman Lahiry
- Centre for Clinical Epidemiology and Biostatistics (CCEB), Community Medicine and Clinical Epidemiology, School of Medicine and Public Health (SMPH), Hunter Medical Research Institute (HMRI), University of Newcastle, Callaghan, NSW, Australia
| | - Christopher Levi
- Sydney Partnership for Health Education Research and Enterprise (SPHERE), Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Joosup Kim
- Translational Public Health and Evaluation Division, Stroke and Ageing Research, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia.,Public Health, Stroke Division, the Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, VIC, Australia
| | - Dominique A Cadilhac
- Translational Public Health and Evaluation Division, Stroke and Ageing Research, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia.,Public Health, Stroke Division, the Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, VIC, Australia
| | - Andrew Searles
- Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia.,Health Research Economics, Hunter Medical Research Institute (HMRI), New Lambton, NSW, Australia
| |
Collapse
|
19
|
Joo H, Wang G, George MG. Age-specific Cost Effectiveness of Using Intravenous Recombinant Tissue Plasminogen Activator for Treating Acute Ischemic Stroke. Am J Prev Med 2017; 53:S205-S212. [PMID: 29153122 PMCID: PMC5819005 DOI: 10.1016/j.amepre.2017.06.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 05/09/2017] [Accepted: 06/05/2017] [Indexed: 01/12/2023]
Abstract
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.
Collapse
Affiliation(s)
- Heesoo Joo
- IHRC Inc., Atlanta, Georgia; Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia.
| | - Guijing Wang
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Mary G George
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| |
Collapse
|
20
|
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.
Collapse
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.)
| |
Collapse
|
21
|
Leng X, Lan L, Liu L, Leung TW, Wong KS. Good collateral circulation predicts favorable outcomes in intravenous thrombolysis: a systematic review and meta-analysis. Eur J Neurol 2016; 23:1738-1749. [PMID: 27478977 DOI: 10.1111/ene.13111] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 06/27/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE Baseline collateral status has been correlated with outcomes of acute ischaemic stroke patients receiving intravenous thrombolysis (IVT) in previous studies. We carried out the current systematic review and meta-analysis to synthesize currently available evidence regarding such correlations. METHODS Full-text articles published since 2000 were retrieved and screened. The overall effect sizes of good versus poor collateral status over a series of outcomes and certain baseline features were estimated by random-effects models and presented in risk ratios (RRs) or mean differences. RESULTS Overall, 28 (3057 patients) and 14 (1584 patients) studies were included in qualitative and quantitative synthesis, respectively. Compared with poor pre-treatment collateral status, good collaterals showed a beneficial effect over the primary outcome of a favorable functional outcome at 3 or 6 months [RR, 2.45; 95% confidence interval, 1.94-3.09; P < 0.001] in acute ischaemic stroke patients receiving IVT treatment. However, such an effect tended to be different between studies with prescribed time windows of 3, 4.5 and > 4.5 h (up to 7 h), with the RRs being 2.21, 2.48 and 5.00, respectively (I2 = 53%). Good pre-treatment collaterals were also associated with a smaller infarct size at baseline, and a lower rate of symptomatic intracranial hemorrhage and a higher rate of neurological improvement early after IVT treatment. CONCLUSIONS The present study has demonstrated the prognostic value of baseline collateral circulation for outcomes of acute ischaemic stroke patients receiving intravenous reperfusion therapies, studied with different time windows of up to 7 h after ictus for IVT therapy.
Collapse
Affiliation(s)
- X Leng
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - L Lan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - L Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - T W Leung
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - K S Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| |
Collapse
|
22
|
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.
Collapse
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
| |
Collapse
|
23
|
Magnetic Resonance Imaging of Cerebrovascular Diseases. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00048-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|
24
|
McMeekin P, Flynn D, Ford GA, Rodgers H, Gray J, Thomson RG. Development of a decision analytic model to support decision making and risk communication about thrombolytic treatment. BMC Med Inform Decis Mak 2015; 15:90. [PMID: 26560132 PMCID: PMC4642673 DOI: 10.1186/s12911-015-0213-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 10/27/2015] [Indexed: 01/18/2023] Open
Abstract
Background Individualised prediction of outcomes can support clinical and shared decision making. This paper describes the building of such a model to predict outcomes with and without intravenous thrombolysis treatment following ischaemic stroke. Methods A decision analytic model (DAM) was constructed to establish the likely balance of benefits and risks of treating acute ischaemic stroke with thrombolysis. Probability of independence, (modified Rankin score mRS ≤ 2), dependence (mRS 3 to 5) and death at three months post-stroke was based on a calibrated version of the Stroke-Thrombolytic Predictive Instrument using data from routinely treated stroke patients in the Safe Implementation of Treatments in Stroke (SITS-UK) registry. Predictions in untreated patients were validated using data from the Virtual International Stroke Trials Archive (VISTA). The probability of symptomatic intracerebral haemorrhage in treated patients was incorporated using a scoring model from Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST) data. Results The model predicts probabilities of haemorrhage, death, independence and dependence at 3-months, with and without thrombolysis, as a function of 13 patient characteristics. Calibration (and inclusion of additional predictors) of the Stroke-Thrombolytic Predictive Instrument (S-TPI) addressed issues of under and over prediction. Validation with VISTA data confirmed that assumptions about treatment effect were just. The C-statistics for independence and death in treated patients in the DAM were 0.793 and 0.771 respectively, and 0.776 for independence in untreated patients from VISTA. Conclusions We have produced a DAM that provides an estimation of the likely benefits and risks of thrombolysis for individual patients, which has subsequently been embedded in a computerised decision aid to support better decision-making and informed consent.
Collapse
Affiliation(s)
- Peter McMeekin
- Institute of Health and Society, Newcastle University, Newcastle Upon Tyne, UK. .,School of Health, Community and Education Studies, Northumbria University, Newcastle upon Tyne, UK. .,Department of Healthcare, Northumbria University, Newcastle Upon Tyne, UK.
| | - Darren Flynn
- Institute of Health and Society, Newcastle University, Newcastle Upon Tyne, UK
| | - Gary A Ford
- Institute for Ageing and Health (Stroke Research Group), Newcastle University, Newcastle Upon Tyne, UK
| | - Helen Rodgers
- Institute for Ageing and Health (Stroke Research Group), Newcastle University, Newcastle Upon Tyne, UK
| | - Jo Gray
- Department of Healthcare, Northumbria University, Newcastle Upon Tyne, UK
| | - Richard G Thomson
- Institute of Health and Society, Newcastle University, Newcastle Upon Tyne, UK
| |
Collapse
|
25
|
Moretti A, Ferrari F, Villa RF. Pharmacological therapy of acute ischaemic stroke: Achievements and problems. Pharmacol Ther 2015; 153:79-89. [DOI: 10.1016/j.pharmthera.2015.06.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 06/03/2015] [Indexed: 01/04/2023]
|
26
|
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.
Collapse
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.).
| |
Collapse
|
27
|
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: 65] [Impact Index Per Article: 7.2] [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.
Collapse
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.)
| |
Collapse
|
28
|
Parody E, Pedraza S, García-Gil MM, Crespo C, Serena J, Dávalos A. Cost-Utility Analysis of Magnetic Resonance Imaging Management of Patients with Acute Ischemic Stroke in a Spanish Hospital. Neurol Ther 2015; 4:25-37. [PMID: 26847673 PMCID: PMC4470974 DOI: 10.1007/s40120-015-0029-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Stroke has a high rate of long-term disability and mortality and therefore has a significant economic impact. The objective of this study was to determine from a social perspective, the cost-utility of magnetic resonance imaging (MRI) compared to computed tomography (CT) as the first imaging test in acute ischemic stroke (AIS). METHODS A cost-utility analysis of MRI compared to CT as the first imaging test in AIS was performed. Economic evaluation data were obtained from a prospective study of patients with AIS ≤12 h from onset in one Spanish hospital. The measure of effectiveness was quality-adjusted life-years (QALYs) calculated from utilities of the modified Rankin Scale. Both hospital and post-discharge expenses were included in the costs. The incremental cost-effectiveness ratio (ICER) was calculated and sensitivity analysis was carried out. The costs were expressed in Euros at the 2004 exchange rate. RESULTS A total of 130 patients were analyzed. The first imaging test was CT in 87 patients and MRI in 43 patients. Baseline variables were similar in the two groups. The mean direct cost was €5830.63 for the CT group and €5692.95 for the MRI group (P = not significant). The ICER was €11,868.97/QALY. The results were sensitive when the indirect costs were included in the analysis. CONCLUSION Total direct costs and QALYs were lower in the MRI group; however, this difference was not statistically significant. MRI was shown to be a cost-effective strategy for the first imaging test in AIS in 22% of the iterations according to the efficiency threshold in Spain.
Collapse
Affiliation(s)
| | - Salvador Pedraza
- Department of Radiology-IDI, IDIBGI, Hospital Doctor Josep Trueta, UDG, Girona, Spain
| | - María M García-Gil
- Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Catalunya, Spain
| | - Carlos Crespo
- Health Economics and Pricing, Boehringer Ingelheim, Sant Cugat del Valles (Barcelona), Spain
| | - Joaquín Serena
- Department of Neurology, Hospital Doctor Josep Trueta, Girona, Spain
| | - Antoni Dávalos
- Department of Neurology, Germans Trias i Pujol Hospital, Badalona, Spain
| |
Collapse
|
29
|
Wardlaw J, Brazzelli M, Miranda H, Chappell F, McNamee P, Scotland G, Quayyum Z, Martin D, Shuler K, Sandercock P, Dennis M. 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. Health Technol Assess 2014; 18:1-368, v-vi. [PMID: 24791949 DOI: 10.3310/hta18270] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Joanna Wardlaw
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Miriam Brazzelli
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Hector Miranda
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Francesca Chappell
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Paul McNamee
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Graham Scotland
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Zahid Quayyum
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Duncan Martin
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Kirsten Shuler
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Peter Sandercock
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Martin Dennis
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| |
Collapse
|
30
|
Abstract
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.
Collapse
|
31
|
Boudreau DM, Guzauskas GF, Chen E, Lalla D, Tayama D, Fagan SC, Veenstra DL. Cost-Effectiveness of Recombinant Tissue-Type Plasminogen Activator Within 3 Hours of Acute Ischemic Stroke. Stroke 2014; 45:3032-9. [DOI: 10.1161/strokeaha.114.005852] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
Collapse
Affiliation(s)
- Denise M. Boudreau
- From the University of Washington, Seattle (D.M.B., G.F.G., D.L.V.); Genentech, Inc South San Francisco, CA (E.C., D.T.); Palo Alto Outcomes Research, CA (D.L.); and University of Georgia College of Pharmacy, Athens (S.C.F.)
| | - Gregory F. Guzauskas
- From the University of Washington, Seattle (D.M.B., G.F.G., D.L.V.); Genentech, Inc South San Francisco, CA (E.C., D.T.); Palo Alto Outcomes Research, CA (D.L.); and University of Georgia College of Pharmacy, Athens (S.C.F.)
| | - Er Chen
- From the University of Washington, Seattle (D.M.B., G.F.G., D.L.V.); Genentech, Inc South San Francisco, CA (E.C., D.T.); Palo Alto Outcomes Research, CA (D.L.); and University of Georgia College of Pharmacy, Athens (S.C.F.)
| | - Deepa Lalla
- From the University of Washington, Seattle (D.M.B., G.F.G., D.L.V.); Genentech, Inc South San Francisco, CA (E.C., D.T.); Palo Alto Outcomes Research, CA (D.L.); and University of Georgia College of Pharmacy, Athens (S.C.F.)
| | - Darren Tayama
- From the University of Washington, Seattle (D.M.B., G.F.G., D.L.V.); Genentech, Inc South San Francisco, CA (E.C., D.T.); Palo Alto Outcomes Research, CA (D.L.); and University of Georgia College of Pharmacy, Athens (S.C.F.)
| | - Susan C. Fagan
- From the University of Washington, Seattle (D.M.B., G.F.G., D.L.V.); Genentech, Inc South San Francisco, CA (E.C., D.T.); Palo Alto Outcomes Research, CA (D.L.); and University of Georgia College of Pharmacy, Athens (S.C.F.)
| | - David L. Veenstra
- From the University of Washington, Seattle (D.M.B., G.F.G., D.L.V.); Genentech, Inc South San Francisco, CA (E.C., D.T.); Palo Alto Outcomes Research, CA (D.L.); and University of Georgia College of Pharmacy, Athens (S.C.F.)
| |
Collapse
|
32
|
Pan Y, Wang A, Liu G, Zhao X, Meng X, Zhao K, Liu L, Wang C, Johnston SC, Wang Y, Wang Y. Cost-effectiveness of clopidogrel-aspirin versus aspirin alone for acute transient ischemic attack and minor stroke. J Am Heart Assoc 2014; 3:e000912. [PMID: 24904018 PMCID: PMC4309076 DOI: 10.1161/jaha.114.000912] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Background Treatment with the combination of clopidogrel and aspirin taken soon after a transient ischemic attack (TIA) or minor stroke was shown to reduce the 90‐day risk of stroke in a large trial in China, but the cost‐effectiveness is unknown. This study sought to estimate the cost‐effectiveness of the clopidogrel‐aspirin regimen for acute TIA or minor stroke. Methods and Results A Markov model was created to determine the cost‐effectiveness of treatment of acute TIA or minor stroke patients with clopidogrel‐aspirin compared with aspirin alone. Inputs for the model were obtained from clinical trial data, claims databases, and the published literature. The main outcome measure was cost per quality‐adjusted life‐years (QALYs) gained. One‐way and multivariable probabilistic sensitivity analyses were performed to test the robustness of the findings. Compared with aspirin alone, clopidogrel‐aspirin resulted in a lifetime gain of 0.037 QALYs at an additional cost of CNY 1250 (US$ 192), yielding an incremental cost‐effectiveness ratio of CNY 33 800 (US$ 5200) per QALY gained. Probabilistic sensitivity analysis showed that clopidogrel‐aspirin therapy was more cost‐effective in 95.7% of the simulations at a willingness‐to‐pay threshold recommended by the World Health Organization of CNY 105 000 (US$ 16 200) per QALY. Conclusions Early 90‐day clopidogrel‐aspirin regimen for acute TIA or minor stroke is highly cost‐effective in China. Although clopidogrel is generic, Plavix is brand in China. If Plavix were generic, treatment with clopidogrel‐aspirin would have been cost saving.
Collapse
Affiliation(s)
- Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Y.P., A.W., G.L., X.Z., X.M., L.L., C.W., Y.W., Y.W.)
| | - Anxin Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Y.P., A.W., G.L., X.Z., X.M., L.L., C.W., Y.W., Y.W.)
| | - Gaifen Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Y.P., A.W., G.L., X.Z., X.M., L.L., C.W., Y.W., Y.W.)
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Y.P., A.W., G.L., X.Z., X.M., L.L., C.W., Y.W., Y.W.)
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Y.P., A.W., G.L., X.Z., X.M., L.L., C.W., Y.W., Y.W.)
| | - Kun Zhao
- China National Health Development Research Center, Beijing, China (K.Z.)
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Y.P., A.W., G.L., X.Z., X.M., L.L., C.W., Y.W., Y.W.)
| | - Chunxue Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Y.P., A.W., G.L., X.Z., X.M., L.L., C.W., Y.W., Y.W.)
| | - S Claiborne Johnston
- Departments of Neurology and Epidemiology, University of California, San Francisco, CA (C.J.)
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Y.P., A.W., G.L., X.Z., X.M., L.L., C.W., Y.W., Y.W.)
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Y.P., A.W., G.L., X.Z., X.M., L.L., C.W., Y.W., Y.W.)
| | | |
Collapse
|
33
|
Burton KR, Perlis N, Aviv RI, Moody AR, Kapral MK, Krahn MD, Laupacis A. Systematic review, critical appraisal, and analysis of the quality of economic evaluations in stroke imaging. Stroke 2014; 45:807-14. [PMID: 24519409 DOI: 10.1161/strokeaha.113.004027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE This study reviews the quality of economic evaluations of imaging after acute stroke and identifies areas for improvement. METHODS We performed full-text searches of electronic databases that included Medline, Econlit, the National Health Service Economic Evaluation Database, and the Tufts Cost Effectiveness Analysis Registry through July 2012. Search strategy terms included the following: stroke*; cost*; or cost-benefit analysis*; and imag*. Inclusion criteria were empirical studies published in any language that reported the results of economic evaluations of imaging interventions for patients with stroke symptoms. Study quality was assessed by a commonly used checklist (with a score range of 0% to 100%). RESULTS Of 568 unique potential articles identified, 5 were included in the review. Four of 5 articles were explicit in their analysis perspectives, which included healthcare system payers, hospitals, and stroke services. Two studies reported results during a 5-year time horizon, and 3 studies reported lifetime results. All included the modified Rankin Scale score as an outcome measure. The median quality score was 84.4% (range=71.9%-93.5%). Most studies did not consider the possibility that patients could not tolerate contrast media or could incur contrast-induced nephropathy. Three studies compared perfusion computed tomography with unenhanced computed tomography but assumed that outcomes guided by the results of perfusion computed tomography were equivalent to outcomes guided by the results of magnetic resonance imaging or noncontrast computed tomography. CONCLUSIONS Economic evaluations of imaging modalities after acute ischemic stroke were generally of high methodological quality. However, important radiology-specific clinical components were missing from all of these analyses.
Collapse
Affiliation(s)
- Kirsteen R Burton
- From the Institute of Health Policy, Management and Evaluation (K.R.B., N.P., M.K.K., M.D.K., A.L.), Departments of Medical Imaging (K.R.B., R.I.A., A.R.M.), Surgery, Division of Urology (N.P.), Institute of Medical Science (R.I.A., A.R.M.), Medicine (M.K.K., M.D.K., A.L.), and Toronto Health Economics and Technology Assessment Collaborative (M.D.K.), University of Toronto, Toronto, ON, Canada; Institute for Clinical and Evaluative Sciences, Toronto, ON, Canada (M.K.K.); and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada (A.L.)
| | | | | | | | | | | | | |
Collapse
|
34
|
Quinn TJ, Dawson J. Acute ‘strokenomics’: efficacy and economic analyses of alteplase for acute ischemic stroke. Expert Rev Pharmacoecon Outcomes Res 2014; 9:513-22. [DOI: 10.1586/erp.09.63] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
35
|
Te Ao B, Brown P, Fink J, Vivian M, Feigin V. Potential gains and costs from increasing access to thrombolysis for acute ischemic stroke patients in New Zealand hospitals. Int J Stroke 2013; 10:903-10. [PMID: 24206567 DOI: 10.1111/ijs.12152] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND AIM Treatment of ischemic stroke patients with tissue-type plasminogen activator (tPA) is known to be effective and cost-effective, yet the percentage of patients treated with thrombolysis in hospitals remains low. The purpose of this study is to examine whether providing thrombolysis in New Zealand hospitals is currently cost-effective and to estimate the amount that might be spent on campaigns aimed at increasing thrombolysis receipt rates. METHODS A decision-analytic model was developed and populated using health services data from the literature and the Auckland Regional Community Stroke Outcome Study. The cost-utilities of providing thrombolysis over one-year and patient lifetime were estimated. Using a threshold of NZ$20 000 (US$15 337) per quality-adjusted life year, the analysis identified the maximum amount that might be spent on campaigns aiming to increase rates of receipt of thrombolysis above their current levels. Monte Carlo simulations and probabilistic sensitivity analysis explored the robustness of the findings. RESULTS Providing thrombolysis was cost-effective, especially when long-term costs and effects were considered (NZ$6641 or US$5093 per quality-adjusted life year). The results suggest that better management within hospitals would be more effective in increasing thrombolysis receipt rates (up to 17%) than campaigns aiming at higher awareness of stroke symptoms in the community. The amount that might be spent on a national campaign to increase rate of receipt of thrombolysis from its current level (3% of eligible patients) depended upon the effectiveness of the campaign, ranging from under NZ$6 million for New Zealand for an increase in rate to 30% to over $9 million for an increase in rate to 50%. CONCLUSION While thrombolysis is a cost-effective treatment in New Zealand, resources should be devoted to campaigns, both within hospitals and in the community, to increase coverage.
Collapse
Affiliation(s)
- Braden Te Ao
- National Institute for Stroke and Applied Neurosciences, Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Paul Brown
- National Institute for Stroke and Applied Neurosciences, Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand.,School of Social Science, Humanities and Arts, University of California, Merced, CA, USA
| | - John Fink
- Department of Neurology, Canterbury District Health Board, Christchurch, New Zealand
| | - Mark Vivian
- New Zealand Stroke Foundation, Wellington, New Zealand
| | - Valery Feigin
- National Institute for Stroke and Applied Neurosciences, Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand
| |
Collapse
|
36
|
Boudreau DM, Guzauskas G, Villa KF, Fagan SC, Veenstra DL. A model of cost-effectiveness of tissue plasminogen activator in patient subgroups 3 to 4.5 hours after onset of acute ischemic stroke. Ann Emerg Med 2013; 61:46-55. [PMID: 22633340 PMCID: PMC3598015 DOI: 10.1016/j.annemergmed.2012.04.020] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2011] [Revised: 02/09/2012] [Accepted: 04/06/2012] [Indexed: 11/21/2022]
Abstract
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.
Collapse
|
37
|
Earnshaw SR, McDade C, Chapman AM, Jackson D, Schwamm L. Economic Impact of Using Additional Diagnostic Tests to Better Select Patients With Stroke for Intravenous Thrombolysis in the United Kingdom. Clin Ther 2012; 34:1544-58. [DOI: 10.1016/j.clinthera.2012.05.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2012] [Revised: 05/10/2012] [Accepted: 05/14/2012] [Indexed: 10/28/2022]
|
38
|
Burke JF, Sussman JB, Morgenstern LB, Kerber KA. Time to stroke magnetic resonance imaging. J Stroke Cerebrovasc Dis 2012; 22:784-91. [PMID: 22541605 DOI: 10.1016/j.jstrokecerebrovasdis.2012.03.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Revised: 03/20/2012] [Accepted: 03/25/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Recent guidelines on stroke neuroimaging from the American Academy of Neurology (AAN) recommend magnetic resonance imaging (MRI) over computed tomography (CT) for stroke diagnosis when patients present within 12 hours of onset. We sought to estimate the proportion of stroke MRI that is performed within 12 hours. METHODS Using the best available data, we estimated total time from symptom onset to MRI with a Monte Carlo simulation. We modeled 3 times to MRI: time to presentation, time to emergency department (ED) MRI, and time to inpatient MRI. Total time to MRI was estimated by summing these time components while varying model parameters around our base model. Sensitivity analyses assessed the relative importance of model parameters to overall MRI timing. RESULTS In 2009, we estimate that 66% of stroke patients underwent MRI, 14% received an MRI in the ED, and 68% of all MRIs were obtained on hospital day 0 or 1. We estimate that 29% (95% confidence interval 24-33%) of stroke MRIs are obtained within 12 hours of onset. Sensitivity analyses revealed that even large clinical changes (eg, decreasing time to presentation) would only moderately influence this proportion. For example, if mean time to presentation were reduced to 30 minutes (from the base case estimate of 16 hours), the proportion of stroke MRI performed within 12 hours would only increase to 55.3%. CONCLUSIONS Stroke guidelines favor the use of MRI over CT only during the first 12 hours from symptom onset, yet less than one-third of stroke MRIs are actually performed within this timeframe.
Collapse
Affiliation(s)
- James F Burke
- Department of Veterans Affairs, Veterans Affairs Center for Clinical Management and Research, Ann Arbor Veterans Affairs Healthcare System, Ann Arbor, Michigan 48109, USA.
| | | | | | | |
Collapse
|
39
|
Grunwald IQ, Kühn AL. Current pediatric stroke treatment. World Neurosurg 2012; 76:S80-4. [PMID: 22182276 DOI: 10.1016/j.wneu.2011.06.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2011] [Revised: 05/17/2011] [Accepted: 06/22/2011] [Indexed: 11/30/2022]
Abstract
BACKGROUND The treatment of stroke in children and infants is essential, but unfortunately is not supported by factual and substantiated data. METHODS This is a comprehensive review of the currently published data on acute ischemic stroke treatment in children and highlights recent advances and possibilities with mechanical devices in the treatment of stroke in this vulnerable age population. RESULTS The current treatment for most children with acute ischemic stroke is limited to the management of the symptoms. Mechanical recanalization may improve recanalization rates and clinical outcomes. CONCLUSIONS Although clinical trials will be difficult to establish in children, continued research and additional experience are imperative to treat this often devastating condition.
Collapse
Affiliation(s)
- Iris Quasar Grunwald
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Trust, Oxford, United Kingdom.
| | | |
Collapse
|
40
|
Nelson RE, Saltzman GM, Skalabrin EJ, Demaerschalk BM, Majersik JJ. The cost-effectiveness of telestroke in the treatment of acute ischemic stroke. Neurology 2011; 77:1590-8. [PMID: 21917781 DOI: 10.1212/wnl.0b013e318234332d] [Citation(s) in RCA: 126] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE To conduct a cost-effectiveness analysis of telestroke--a 2-way, audiovisual technology that links stroke specialists to remote emergency department physicians and their stroke patients--compared to usual care (i.e., remote emergency departments without telestroke consultation or stroke experts). METHODS A decision-analytic model was developed for both 90-day and lifetime horizons. Model inputs were taken from published literature where available and supplemented with western states' telestroke experiences. Costs were gathered using a societal perspective and converted to 2008 US dollars. Quality-adjusted life-years (QALYs) gained were combined with costs to generate incremental cost-effectiveness ratios (ICERs). In the lifetime horizon model, both costs and QALYs were discounted at 3% annually. Both one-way sensitivity analyses and Monte Carlo simulations were performed. RESULTS In the base case analysis, compared to usual care, telestroke results in an ICER of $108,363/QALY in the 90-day horizon and $2,449/QALY in the lifetime horizon. For the 90-day and lifetime horizons, 37.5% and 99.7% of 10,000 Monte Carlo simulations yielded ICERs <$50,000/QALY, a ratio commonly considered acceptable in the United States. CONCLUSION When a lifetime perspective is taken, telestroke appears cost-effective compared to usual care, since telestroke costs are upfront but benefits of improved stroke care are lifelong. If barriers to use such as low reimbursement rates and high equipment costs are reduced, telestroke has the potential to diminish the striking geographic disparities of acute stroke care in the United States.
Collapse
Affiliation(s)
- R E Nelson
- VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | | | | | | | | |
Collapse
|
41
|
Pearce T, Ngan-Soo E, Bradley M. Radiological investigation of acute stroke 1: non-enhanced computed tomography. Br J Hosp Med (Lond) 2011; 72:379-82. [PMID: 21841609 DOI: 10.12968/hmed.2011.72.7.379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Radiology plays a central part in the acute stroke management pathway, with its role now widened beyond establishing the diagnosis. This article reviews the role of the non-enhanced computed tomography brain scan, particularly focusing on the hyper-acute presentation of stroke from a radiological perspective.
Collapse
Affiliation(s)
- Tim Pearce
- Frenchay Hospital, North Bristol NHS Trust, Bristol BS16 1LE
| | | | | |
Collapse
|
42
|
Tung CE, Win SS, Lansberg MG. Cost-effectiveness of tissue-type plasminogen activator in the 3- to 4.5-hour time window for acute ischemic stroke. Stroke 2011; 42:2257-62. [PMID: 21719767 DOI: 10.1161/strokeaha.111.615682] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The aim of this study was to determine the cost-effectiveness of tissue-type plasminogen activator (tPA) treatment in the 3- to 4.5-hour time window after ischemic stroke. METHODS Decision-analytic and Markov state-transition models were created to determine the cost-effectiveness of treatment of ischemic stroke patients with intravenous tPA administered in the 3- to 4.5-hour time window compared with medical therapy without tPA. Health benefits were measured in quality-adjusted life-years (QALYs). The economic outcome measure of the model was the difference in estimated healthcare costs between the 2 treatment alternatives. The incremental cost-effectiveness ratio was calculated by dividing the cost difference by the difference in QALYs. One-way sensitivity and probabilistic analyses were performed to test the robustness of the model. RESULTS The administration of tPA compared with standard medical therapy resulted in a lifetime gain of 0.28 QALYs for an additional cost of $6050, yielding an incremental cost-effectiveness ratio of $21 978 per QALY. One-way sensitivity analyses demonstrated that the incremental cost-effectiveness ratio was most sensitive to the cost of hospitalization for patients who received tPA. Based on probabilistic analysis, there is an 88% probability that tPA is the preferred treatment at a willingness-to-pay threshold of $50 000 per QALY. CONCLUSIONS The balance of costs and benefits favors treatment with intravenous tPA in the 3- to 4.5-hour time window. This supports, from a societal perspective, the use of tPA therapy in this treatment time window for acute ischemic stroke.
Collapse
Affiliation(s)
- Christie E Tung
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, California 94305-5235, USA.
| | | | | |
Collapse
|
43
|
Warach S, Baird AE, Dani KA, Wintermark M, Kidwell CS. Magnetic Resonance Imaging of Cerebrovascular Diseases. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10046-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
44
|
Jackson D, Earnshaw SR, Farkouh R, Schwamm L. Cost-effectiveness of CT perfusion for selecting patients for intravenous thrombolysis: a US hospital perspective. AJNR Am J Neuroradiol 2010; 31:1669-74. [PMID: 20538823 PMCID: PMC7965001 DOI: 10.3174/ajnr.a2138] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2010] [Accepted: 03/23/2010] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Improved selection of patients with stroke for IV tPA treatment may enhance clinical outcomes. Given the limited availability of MR imaging in hospitals, we examined the cost-effectiveness of adding CTP to the usual CT-based methods for selecting patients on the basis of the presence and extent of penumbra. MATERIALS AND METHODS A decision-analytic model estimated the costs and outcomes associated with penumbra-based CTP selection in a patient population similar to that enrolled in the IV tPA clinical trials. Model inputs were obtained from published literature, clinical trial data, standard US costing sources, and expert opinion. Cost per life-year saved and cost per QALY gained were estimated from a hospital perspective. RESULTS Addition of penumbra-based CTP to standard unenhanced CT improved favorable outcome (mRS, ≤1) by 0.59% and reduced cost by $42 compared with selection based on unenhanced CT alone. Life-years and QALYs improved. Multivariate sensitivity analysis predicted cost-effectiveness (≤$50,000 per QALY) in 89.2% of simulation runs. CONCLUSIONS Using penumbra-based CTP after routine CT to select patients with ischemic stroke for IV tPA is cost-effective compared with the usual CT-based methods for hospitals. With the ease of access of CTP, penumbra-based selection methods may be readily available to hospitals. Thus, this economic analysis may lend further support to the consideration of a paradigm shift in acute stroke evaluation.
Collapse
Affiliation(s)
- D Jackson
- GE Healthcare, Chalfont St. Giles, Buckinghamshire, United Kingdom.
| | | | | | | |
Collapse
|
45
|
|
46
|
Bogousslavsky J, Paciaroni M. The economics of treating stroke as an acute brain attack. BMC Med 2009; 7:51. [PMID: 19775424 PMCID: PMC2761940 DOI: 10.1186/1741-7015-7-51] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2009] [Accepted: 09/23/2009] [Indexed: 11/25/2022] Open
Abstract
Currently, treatments for ischemic stroke focus on restoring or improving perfusion to the ischemic area using thrombolytics. The increased hospitalization costs related to thrombolysis are offset by a decrease in rehabilitation costs, for a net cost savings to the healthcare system. However, early treatment is essential. The benefit of thrombolysis is time-dependent but only a very small proportion of patients, 2%, are presently being treated with tPA. In the United States, if the proportion of all ischemic stroke patients that receive tPA were increased to 4, 6, 8, 10, 15, or 20%, the realized cost saving would be approximately $ 15, 22, 30, 37, 55, and 74 million, respectively. Being so, efforts should be made to educate the public and paramedics regarding early stroke signs. Furthermore, additional acute stroke therapy training programs need to be established for emergency departments. Finally, hospital systems need to be re-engineered to treat patients as quickly as possible in order to optimize thrombolytic benefit as well as maximize cost-effectiveness.
Collapse
Affiliation(s)
- Julien Bogousslavsky
- Center for Brain and Nervous System Disorders, Genolier Swiss Medical Network, Clinique Valmont, Glion/Montreux, Switzerland.
| | | |
Collapse
|