1
|
Ospel JM, Diprose WK, Ganesh A, Martins S, Nguyen T, Psychogios M, Mansour O, Al-Ajlan F, Yang P, Pandian J, Gopinathan A, Sandset EC, Kennedy J, Volders D, Fahed R, Tjoumakaris S, Bhogal P, Kurz M, Yavagal D, Inoa V, Hill MD, Goyal M. Challenges to Widespread Implementation of Stroke Thrombectomy. Stroke 2024; 55:2173-2183. [PMID: 38979609 DOI: 10.1161/strokeaha.124.045889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Abstract
Endovascular treatment (EVT) for acute ischemic stroke is one of the most efficacious and effective treatments in medicine, yet globally, its implementation remains limited. Patterns of EVT underutilization exist in virtually any health care system and range from a complete lack of access to selective undertreatment of certain patient subgroups. In this review, we outline different patterns of EVT underutilization and possible causes. We discuss common challenges and bottlenecks that are encountered by physicians, patients, and other stakeholders when trying to establish and expand EVT services in different scenarios and possible pathways to overcome these challenges. Lastly, we discuss the importance of implementation research studies, strategic partnerships, and advocacy efforts to mitigate EVT underutilization.
Collapse
Affiliation(s)
- Johanna Maria Ospel
- Department of Diagnostic Imaging (J.M.O., M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Alberta, Canada
- Department of Clinical Neurosciences (J.M.O., W.K.D., A. Ganesh, M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - William K Diprose
- Department of Clinical Neurosciences (J.M.O., W.K.D., A. Ganesh, M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Aravind Ganesh
- Department of Clinical Neurosciences (J.M.O., W.K.D., A. Ganesh, M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Sheila Martins
- Neurology Department, Hospital Moinhos de Vento, Porto Alegre, Brazil (S.M.)
| | - Thanh Nguyen
- Departments of Radiology and Neurology, Boston Medical Center, MA (T.N.)
| | - Marios Psychogios
- Department of Neuroradiology, University Hospital Basel, Switzerland (M.P.)
| | - Ossama Mansour
- Alexandria Faculty of Medicine, Department of Neurology, Alexandria University, Egypt (O.M.)
| | - Fahad Al-Ajlan
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia (F.A.-A.)
| | - Pengfei Yang
- Department of Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (P.Y.)
| | - Jeyaraj Pandian
- Department of Neurology, Christian Medical College and Hospital, Vellore, India (J.P.)
| | - Anil Gopinathan
- Division of Interventional Radiology, Department of Diagnostic Imaging, National University Health System, Singapore (A. Gopinathan)
| | | | - James Kennedy
- Oxford University Hospital NHS Foundation Trust, Oxford, United Kingdom (J.K.)
| | - David Volders
- Department of Radiology, Dalhousie University, Halifax, Canada (D.V.)
| | - Robert Fahed
- Division Neurology, Department of Medicine, The Ottawa Hospital, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada (R.F.)
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA (S.T.)
| | - Pervinder Bhogal
- Department of Neuroradiology, The Royal London Hospital, Barts NHS Trust, United Kingdom (P.B.)
| | - Martin Kurz
- Department of Neurology, Stavanger University Hospital, Norway (M.K.)
| | - Dileep Yavagal
- Department of Neurology, University of Miami Miller School of Medicine, FL (D.Y.)
| | - Violiza Inoa
- Department of Neurology, University of Tennessee Health Science Center, Memphis (V.I.)
| | - Michael D Hill
- Department of Diagnostic Imaging (J.M.O., M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Alberta, Canada
- Department of Clinical Neurosciences (J.M.O., W.K.D., A. Ganesh, M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Mayank Goyal
- Department of Diagnostic Imaging (J.M.O., M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Alberta, Canada
- Department of Clinical Neurosciences (J.M.O., W.K.D., A. Ganesh, M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Alberta, Canada
| |
Collapse
|
2
|
Uchida K, Rinkel LA, Ospel JM, Diprose WK, Goyal M. A systematic review of randomized controlled trials of endovascular therapy for stroke on mortality and disability. J Neurol Sci 2024; 460:122991. [PMID: 38579415 DOI: 10.1016/j.jns.2024.122991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 03/01/2024] [Accepted: 03/31/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND Endovascular treatment (EVT) has become standard of care for patients with anterior circulation large vessel occlusion (LVO) stroke, with indications having recently expanded to late time-window and large ischemic core patients. There is conflicting evidence on whether EVT reduces mortality or only disability. We performed a meta-analysis of randomized controlled trials (RCTs) to assess the effect of EVT on mortality and severe disability. METHODS We systematically searched PubMed, Web of Science, Scopus, and Embase on November 15, 2023, to identify phase 3 RCTs comparing EVT to best medical treatment (BMT) in patients with anterior circulation LVO stroke in a common effects meta-analysis. The primary outcome was mortality at 3 months. Secondary outcomes were moderately severe or severe disability (modified Rankin Scale (mRS) score 4-5) at 3 months. RESULTS 18 studies comparing EVT to BMT were included, with a total of 4309 patients; 2159 that were treated with EVT, and 2150 treated with BMT. Mortality was significantly lower in the EVT group than in the BMT group (odds ratio (OR): 0.81, 95% CI: 0.70-0.94). Proportions of moderately severe or severe disability (OR: 0.55, 95% CI: 0.48-0.62) were also significantly lower in patients treated with EVT. CONCLUSIONS This meta-analysis suggests that EVT reduces both mortality and moderately severe or severe disability in patients with anterior circulation LVO stroke.
Collapse
Affiliation(s)
- Kazutaka Uchida
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan; Department of Diagnostic Imaging, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Leon A Rinkel
- Department of Diagnostic Imaging, Cumming School of Medicine, University of Calgary, AB, Canada; Departments of Neurology, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Johanna M Ospel
- Department of Diagnostic Imaging, Cumming School of Medicine, University of Calgary, AB, Canada; Department of Neuroradiology, University Hospital of Basel, Switzerland
| | - William K Diprose
- Department of Diagnostic Imaging, Cumming School of Medicine, University of Calgary, AB, Canada; Department of Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Mayank Goyal
- Department of Diagnostic Imaging, Cumming School of Medicine, University of Calgary, AB, Canada.
| |
Collapse
|
3
|
Pan Y, Huo X, Jin A, Nguyen TN, Ma G, Tong X, Zhang X, Gao F, Ma N, Mo D, Ren Z, Wang Y, Miao Z. Cost-effectiveness of endovascular therapy for acute ischemic stroke with large infarct in China. J Neurointerv Surg 2024; 16:453-458. [PMID: 37328189 DOI: 10.1136/jnis-2023-020466] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 05/31/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Endovascular therapy administered within 24 hours has been shown to improve outcomes for patients with acute ischemic stroke with large infarction, but the data on its cost-effectiveness are limited. OBJECTIVE To evaluate the cost-effectiveness of endovascular therapy for acute ischemic stroke with large infarction in China, the largest low- and middle-income country. METHODS A short-term decision tree model and a long-term Markov model were used to analyze the cost-effectiveness of endovascular therapy for patients with acute ischemic stroke with large infarction. Outcomes, transition probability, and cost data were obtained from a recent clinical trial and published literature. The benefit of endovascular therapy was assessed by the cost per quality-adjusted life-years (QALYs) gained in the short and long term. Deterministic one-way and probabilistic sensitivity analyses were performed to assess the robustness of the results. RESULTS Compared with medical management alone, endovascular therapy for acute ischemic stroke with large infarction was found to be cost-effective from the fourth year onward and during a lifetime. In the long term, endovascular therapy yielded a lifetime gain of 1.33 QALYs at an additional cost of ¥73 900 (US$ 11 400), resulting in an incremental cost of ¥55 500 (US$ 8530) per QALY gained. Probabilistic sensitivity analysis showed that endovascular therapy was cost-effective in 99.5% of the simulation runs at a willingness-to-pay threshold of ¥243 000 (3 × gross domestic product per capita of China in 2021) per QALY gained. CONCLUSIONS Endovascular therapy for acute ischemic stroke with large infarction could be cost-effective in China.
Collapse
Affiliation(s)
- Yuesong Pan
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
| | - Xiaochuan Huo
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
| | - Aoming Jin
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Thanh N Nguyen
- Department of Neurology and Radiology, Boston Medical Center, Boston, Massachusetts, USA
| | - Gaoting Ma
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
| | - Xu Tong
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
| | - Xuelei Zhang
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
| | - Feng Gao
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
| | - Ning Ma
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
| | - Dapeng Mo
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
| | - Zeguang Ren
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
- Department of Neurosurgery, The Affiliated Hospital of Guizhou Medical University, Guizhou, China
| | - Yongjun Wang
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
| | - Zhongrong Miao
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
| |
Collapse
|
4
|
O’Cearbhaill RM, O’Herlihy F, Herlihy D, Alderson J, Brennan P, Power S, O’Hare A, Thornton J. Standardised aspiration first approach reduces materials used and cost of thrombectomy procedure in anterior circulation large vessel occlusion stoke. Interv Neuroradiol 2023; 29:648-654. [PMID: 36069045 PMCID: PMC10680961 DOI: 10.1177/15910199221125101] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 08/23/2022] [Indexed: 11/15/2022] Open
Abstract
PURPOSE The aim of this study is to compare the volume of equipment and equipment costs in a cohort of consecutive patients with anterior circulation large vessel occlusion treated with a standardised aspiration first approach to those treated with a stent retriever first approach. METHODS The equipment used in each case was recorded from a prospectively maintained equipment log. We then compared the volume of equipment used in each group. The cost of this equipment was calculated for each group based on local prices. Estimated equipment costs were then compared. RESULTS Our patient cohort consisted of 127 consecutive patients who were treated with a non-standardised stent retriever first technique (group A), 127 consecutive patients who underwent a new standardised aspiration first technique (group B), and 126 consecutive patients reflecting more recent practise where an aspiration first approach has been an established practise in our department (group C).Standardised aspiration first approach results in reduced equipment usage in thrombectomy procedures. The total equipment cost per case in the stent retriever first group (group A) was significantly higher at €4726.4 ($4818.3) versus €3093.1 ($3153.2) in the aspiration first group (group B), a reduction of 34.6% and €2798.5 ($2852.9) in the current practise group (group C), a reduction of 40.8%. There was no statistically significant difference in cost between groups B and C (p = 0.57). CONCLUSION The standardised aspiration first technique utilised a reduced volume of equipment and confers a 40.8% reduced cost per procedure compared to a stent retriever first approach.
Collapse
Affiliation(s)
| | | | | | - Jack Alderson
- Department of Radiology, Beaumont Hospital, Dublin, Ireland
| | - Paul Brennan
- Department of Radiology, Beaumont Hospital, Dublin, Ireland
| | - Sarah Power
- Department of Radiology, Beaumont Hospital, Dublin, Ireland
| | - Alan O’Hare
- Department of Radiology, Beaumont Hospital, Dublin, Ireland
| | - John Thornton
- Department of Radiology, Beaumont Hospital, Dublin, Ireland
| |
Collapse
|
5
|
Gao L, Tan E, Chen C, Kleinig T, Yan B, Cheung A, Levi C, Garcia-Esperon C, Cordato D, Blair C, Lin L, Parsons M, Bivard A. Cost-Effectiveness of Endovascular Thrombectomy in M2 Occlusion Stroke: Real-World Experience Versus Clinical Trials. J Endovasc Ther 2023:15266028231201098. [PMID: 37789615 DOI: 10.1177/15266028231201098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
OBJECTIVES This study sought to establish the cost-effectiveness of endovascular thrombectomy (EVT) in M2 occlusions compared with patients who did not have EVT using both real-world and clinical trial evidence. METHODS The effectiveness of EVT in M2 occlusions was informed by the International Stroke Perfusion Imaging Registry (INSPIRE, real-world data for a wide range of strokes) and HERMES collaboration, trial data. Patients who received EVT and non-EVT treatment from INSPIRE were matched according to baseline characteristics. A Markov model with 7 health states defined by the 3-month modified Rankin scale (mRS) was constructed. Endovascular thrombectomy and non-EVT-treated patients in real-world, and clinical trials were run through the Markov model separately to generate the results from a limited societal perspective. National statistics and published literature informed the long-term probability of recurrent stroke, mortality, costs of management post-stroke, non-medical care, and nursing home care. RESULTS A total of 83 (42 EVT and 41 non-EVT) patients were matched of 278 (45 EVT and 233 non-EVT) patients in INSPIRE who had M2 occlusion stroke at presentation. The long-term simulation estimated that offering EVT to M2 occlusion stroke patients was associated with greater benefits (5.48 EVT vs 5.24 non-EVT quality-adjusted life year [QALY]) and higher costs (A$133 457 EVT vs A$126 127 non-EVT) compared with non-EVT treatment in real-world from a limited societal perspective. The incremental cost-effectiveness ratio (ICER) of EVT in real-world was A$29 981 (€19 488)/QALY. The analysis using the data from HERMES collaboration yielded consistent results for the EVT patients. Comparison with real-world cost-effectiveness analyses of EVT in internal carotid artery/middle cerebral artery-M1 (ICA/MCA-M1) occlusion suggested a potential reduced QALY gains and increased ICER in M2 occlusions. CONCLUSIONS Our study suggested that the benefits gained from EVT in M2 occlusion stroke in the real-world were similar to that derived from the clinical trials. The clinical and cost benefits from EVT appeared to be reduced in M2 compared with that from the ICA/MCA-M1 occlusions. CLINICAL IMPACT Our study has provided valuable insights into the clinical significance of endovascular therapy (EVT) in the context of M2 occlusion stroke within a real-world setting. It is noteworthy that our findings indicate that the benefits obtained from EVT in M2 occlusion stroke closely align with those observed in controlled clinical trials. However, it is essential to recognize that there is a reduction in the clinical and cost-related advantages when comparing M2 occlusions to more proximal ICA/MCA-M1 occlusions.
Collapse
Affiliation(s)
- Lan Gao
- Deakin Health Economics, Institute for Health Transformation, Faculty of Health, Deakin University, Burwood, VIC, Australia
| | - Elise Tan
- Deakin Health Economics, Institute for Health Transformation, Faculty of Health, Deakin University, Burwood, VIC, Australia
| | - Chushuang Chen
- Departments of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Timothy Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Bernard Yan
- Melbourne Brain Centre, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Andrew Cheung
- Department of Neurointervention, Liverpool Hospital, Liverpool, NSW, Australia
| | - Chris Levi
- Departments of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Carlos Garcia-Esperon
- Departments of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Dennis Cordato
- South Western Sydney Local Health District, Liverpool Hospital, Liverpool, Australia
| | - Chris Blair
- Department of Neurology, Gosford & Wyong Hospital, Gosford, NSW, Australia
| | - Longting Lin
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Mark Parsons
- Department of Neurology, Liverpool Hospital, South Western Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Andrew Bivard
- Melbourne Brain Centre, Royal Melbourne Hospital, Parkville, VIC, Australia
| |
Collapse
|
6
|
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
|
7
|
Thompson NR, Lapin BR, Katzan IL. Utilities Estimated from PROMIS Scales for Cost-Effectiveness Analyses in Stroke. Med Decis Making 2023; 43:704-718. [PMID: 37401739 DOI: 10.1177/0272989x231182446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2023]
Abstract
BACKGROUND The EQ-5D and Health Utilities Index Mark 3 (HUI-3) are preference-based measures used in cost-effectiveness studies. The Patient Reported Outcomes Measurement Information System (PROMIS) Preference scoring system (PROPr) is a new preference-based measure. In addition, algorithms were previously developed to map PROMIS Global Health (PROMIS-GH) items to HUI-3 using linear equating (HUILE) and 3-level EQ-5D using linear (EQ5DLE). We sought to evaluate and compare estimated utilities based on PROPr and PROMIS-GH in adult stroke survivors. METHODS We performed a retrospective cohort study of adults diagnosed with 1 of ischemic stroke, intracerebral hemorrhage, or subarachnoid hemorrhage seen in an outpatient clinic between 2015 and 2019. Patients completed PROMIS scales and other measures. We computed a modified version of PROPr (mPROPr) and compared the distributional characteristics and correlations with stroke outcomes for mPROPr, HUILE, and EQ5DLE. RESULTS T toal of 4,159 stroke survivors (average age 62.7 ± 14.7 y, 48.4% female, 77.6% ischemic stroke) were included. Mean utility estimates for mPROPr, EQ5DLE, and HUILE were 0.333 ± 0.244, 0.739 ± 0.201, and 0.544 ± 0.301, respectively. Correlations between the modified Rankin Scale and each of mPROPr and HUILE were both -0.48 and -0.43 for EQ5DLE. Regression analyses indicated that mPROPr scores may be too low for stroke patients in good health and that EQ5DLE scores may be too high for stroke patients in poor health. CONCLUSIONS All 3 PROMIS-based utilities were associated with measures of stroke disability and severity, but the distributions of utilities were very different. Our study highlights the problem cost-effectiveness researchers face of valuing health states with certainty. For researchers using utilities estimated from PROMIS scales, our study indicates that mapping PROMIS-GH item scores to HUI-3 via linear equating may be most appropriate in stroke patients. HIGHLIGHTS A new preference-based measure has been developed from the Patient Reported Outcomes Measurement Information System (PROMIS), known as the PROMIS-Preference (PROPr) scoring system, and published equations mapping PROMIS Global Health (PROMIS-GH) items to the Health Utilities Index Mark 3 (HUI-3) and EQ-5D-3L are available for use in cost-effectiveness studies.Our study provides distributional characteristics and comparisons of utilities estimated using a modified version of PROPr and equations mapping PROMIS-GH items to EQ-5D-3L and HUI-3 in a sample of stroke survivors.The results of our study show large differences in the distributions of utilities estimated using the different health state measures, and these differences highlight the ongoing difficulty researchers face in valuing health states with certainty.
Collapse
Affiliation(s)
- Nicolas R Thompson
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Brittany R Lapin
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Irene L Katzan
- Center for Outcomes Research and Evaluation, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
8
|
Parody-Rua E, Bustamante A, Montaner J, Rubio-Valera M, Serrano D, Pérez-Sánchez S, Sánchez-Viñas A, Guevara-Cuellar C, Serrano-Blanco A. Modeling the potential efficiency of a blood biomarker-based tool to guide pre-hospital thrombolytic therapy in stroke patients. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2023; 24:621-632. [PMID: 35896861 PMCID: PMC10175459 DOI: 10.1007/s10198-022-01495-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 06/21/2022] [Indexed: 05/12/2023]
Abstract
OBJECTIVES Stroke treatment with intravenous tissue-type plasminogen activator (tPA) is effective and efficient, but as its benefits are highly time dependent, it is essential to treat the patient promptly after symptom onset. This study evaluates the cost-effectiveness of a blood biomarker test to differentiate ischemic and hemorrhagic stroke to guide pre-hospital treatment with tPA in patients with suspected stroke, compared with standard hospital management. The standard care for patients suffering stroke consists mainly in diagnosis, treatment, hospitalization and monitoring. METHODS A Markov model was built with four health states according to the modified Rankin scale, in adult patients with suspected moderate to severe stroke (NIHSS 4-22) within 4.5 hours after symptom onset. A Spanish Health System perspective was used. The time horizon was 15 years. Quality-adjusted life-years (QALYs) and life-years gained (LYGs) were used as a measure of effectiveness. Short- and long-term direct health costs were included. Costs were expressed in Euros (2022). A discount rate of 3% was used. Probabilistic sensitivity analysis and several one-way sensitivity analyses were conducted. RESULTS The use of a blood-test biomarker compared with standard care was associated with more QALYs (4.87 vs. 4.77), more LYGs (7.18 vs. 7.07), and greater costs (12,807€ vs. 12,713€). The ICER was 881€/QALY. Probabilistic sensitivity analysis showed that the biomarker test was cost-effective in 82% of iterations using a threshold of 24,000€/QALY. CONCLUSIONS The use of a blood biomarker test to guide pre-hospital thrombolysis is cost-effective compared with standard hospital care in patients with ischemic stroke.
Collapse
Affiliation(s)
- Elizabeth Parody-Rua
- Teaching, Research and Innovation Unit, Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Spain
- Primary Care Prevention and Health Promotion Network (redIAPP), Barcelona, Spain
| | | | - Joan Montaner
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain
- Institute de Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville and Department of Neurology, Hospital Universitario Virgen Macarena, Seville, Spain
| | - Maria Rubio-Valera
- Head of Quality and Patient Safety, Parc Sanitari Sant Joan de Déu. Institut de Recerca Sant Joan de Déu, Sant Boi de Llobregat, Spain
- CIBER of Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | | | - Soledad Pérez-Sánchez
- Institute de Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville and Department of Neurology, Hospital Universitario Virgen Macarena, Seville, Spain
| | - Alba Sánchez-Viñas
- Teaching, Research and Innovation Unit, Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Spain
| | | | - Antoni Serrano-Blanco
- CIBER of Epidemiology and Public Health (CIBERESP), Madrid, Spain.
- Parc Sanitari Sant Joan de Déu. Institut de Recerca Sant Joan de Déu, Mental Health Directorate, C/Camí Vell de la Colònia, 25, 08830, Sant Boi de Llobregat, Barcelona, Spain.
- Departament de Medicina. Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain.
| |
Collapse
|
9
|
Béjot Y, Soilly AL, Bardou M, Duloquin G, Pommier T, Laurent G, Cottin Y, Vadot L, Adam H, Boulin M, Giroud M. Efficiency and effectiveness of intensive multidisciplinary follow-up of patients with stroke/TIA or myocardial infarction compared to usual monitoring: protocol of a pragmatic randomised clinical trial. DiVa (Dijon vascular) study. BMJ Open 2023; 13:e070197. [PMID: 37185649 PMCID: PMC10151851 DOI: 10.1136/bmjopen-2022-070197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/17/2023] Open
Abstract
INTRODUCTION The ongoing ageing population is associated with an increase in the number of patients suffering a stroke, transient ischaemic attack (TIA) or myocardial infarction (MI). In these patients, implementing secondary prevention is a critical challenge and new strategies need to be developed to close the gap between clinical practice and evidence-based recommendations. We describe the protocol of a randomised clinical trial that aims to evaluate the efficiency and effectiveness of an intensive multidisciplinary follow-up of patients compared with standard care. METHODS AND ANALYSIS The DiVa study is a randomised, prospective, controlled, multicentre trial including patients >18 years old with a first or recurrent stroke (ischaemic or haemorrhagic) or TIA, or a type I or II MI, managed in one of the participating hospitals of the study area, with a survival expectancy >12 months. Patients will be randomised with an allocation ratio of 1:1 in two parallel groups: one group assigned to a multidisciplinary, nurse-based and pharmacist-based 2-year follow-up in association with general practitioners, neurologists and cardiologists versus one group with usual follow-up. In each group for each disease (stroke/TIA or MI), 430 patients will be enrolled (total of 1720 patients) over 3 years. The primary outcome will be the incremental cost-utility ratio at 24 months between intensive and standard follow-up in a society perspective. Secondary outcomes will include the incremental cost-utility ratio at 6 and 12 months, the incremental cost-effectiveness ratio at 24 months, reduction at 6, 12 and 24 months of the rates of death, unscheduled rehospitalisation and iatrogenic complications, changes in quality of life, net budgetary impact at 5 years of the intensive follow-up on the national health insurance perspective and analysis of factors having positive or negative effects on the implementation of the project in the study area. ETHICS AND DISSEMINATION Ethical approval was obtained and all patients receive information about the study and give their consent to participate before randomisation. Results of the main trial and each of the secondary analyses will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Identifier: NCT04188457. Registered on 6 December 2019.
Collapse
Affiliation(s)
- Yannick Béjot
- Neurology, University Hospital Centre Dijon Bourgogne, Dijon, France
| | - Anne-Laure Soilly
- Department of Clinical Research and Innovation, Clinical Research Unit-Methodological Support Network (USMR), University Hospital Centre Dijon Bourgogne, Dijon, France
| | - Marc Bardou
- Gastroenterology, University Hospital Centre Dijon Bourgogne, Dijon, France
- CIC-Inserm 1432, University of Burgundy, Dijon, France
| | - Gauthier Duloquin
- Neurology, University Hospital Centre Dijon Bourgogne, Dijon, France
| | - Thibaut Pommier
- Cardiology, University Hospital Centre Dijon Bourgogne, Dijon, France
| | - Gabriel Laurent
- Cardiology, University Hospital Centre Dijon Bourgogne, Dijon, France
| | - Yves Cottin
- Cardiology, University Hospital Centre Dijon Bourgogne, Dijon, France
| | - Lucie Vadot
- Pharmacy, University Hospital Centre Dijon Bourgogne, Dijon, France
| | - Héloïse Adam
- Pharmacy, University Hospital Centre Dijon Bourgogne, Dijon, France
| | - Mathieu Boulin
- Pharmacy, University Hospital Centre Dijon Bourgogne, Dijon, France
| | - Maurice Giroud
- Neurology, University Hospital Centre Dijon Bourgogne, Dijon, France
| |
Collapse
|
10
|
Ospel JM, Kunz WG, McDonough RV, van Zwam W, Pinckaers F, Saver JL, Hill MD, Demchuk AM, Jovin TG, Mitchell P, Campbell BCV, White P, Muir K, Achit H, Bracard S, Brown S, Goyal M. Cost-Effectiveness of Endovascular Treatment in Large Vessel Occlusion Stroke With Mild Prestroke Disability: Results From the HERMES Collaboration. Stroke 2023; 54:226-233. [PMID: 36472199 DOI: 10.1161/strokeaha.121.038407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The clinical and economic benefit of endovascular treatment (EVT) in addition to best medical management in patients with stroke with mild preexisting symptoms/disability is not well studied. We aimed to investigate cost-effectiveness of EVT in patients with large vessel occlusion and mild prestroke symptoms/disability, defined as a modified Rankin Scale score of 1 or 2. METHODS Data are from the HERMES collaboration (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials), which pooled patient-level data from 7 large, randomized EVT trials. We used a decision model consisting of a short-run model to analyze costs and functional outcomes within 90 days after the index stroke and a long-run Markov state transition model (cycle length of 12 months) to estimate expected lifetime costs and outcomes from a health care and a societal perspective. Incremental cost-effectiveness ratio and net monetary benefits were calculated, and a probabilistic sensitivity analysis was performed. RESULTS EVT in addition to best medical management resulted in lifetime cost savings of $2821 (health care perspective) or $5378 (societal perspective) and an increment of 1.27 quality-adjusted life years compared with best medical management alone, indicating dominance of additional EVT as a treatment strategy. The net monetary benefits were higher for EVT in addition to best medical management compared with best medical management alone both at the higher (100 000$/quality-adjusted life years) and lower (50 000$/quality-adjusted life years) willingness to pay thresholds. Probabilistic sensitivity analysis showed decreased costs and an increase in quality-adjusted life years for additional EVT compared with best medical management only. CONCLUSIONS From a health-economic standpoint, EVT in addition to best medical management should be the preferred strategy in patients with acute ischemic stroke with large vessel occlusion and mild prestroke symptoms/disability.
Collapse
Affiliation(s)
- Johanna M Ospel
- Department of Neuroradiology, University Hospital Basel, Switzerland (J.M.O.).,Department of Clinical Neurosciences (J.M.O., R.V.M., M.D.H., A.M.D., M.G.), University of Calgary, Canada.,Department of Diagnostic Imaging (J.M.O., R.V.M., M.D.H., A.M.D., M.G.), University of Calgary, Canada
| | - Wolfgang G Kunz
- Department of Radiology, University Hospital, LMU Munich, Germany (W.G.K.)
| | - Rosalie V McDonough
- Department of Clinical Neurosciences (J.M.O., R.V.M., M.D.H., A.M.D., M.G.), University of Calgary, Canada.,Department of Diagnostic Imaging (J.M.O., R.V.M., M.D.H., A.M.D., M.G.), University of Calgary, Canada
| | - Wim van Zwam
- Department of Radiology, Maastricht University Medical Center, the Netherlands (W.v.Z.)
| | | | - Jeffrey L Saver
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles (J.L.S.)
| | - Michael D Hill
- Department of Clinical Neurosciences (J.M.O., R.V.M., M.D.H., A.M.D., M.G.), University of Calgary, Canada.,Department of Diagnostic Imaging (J.M.O., R.V.M., M.D.H., A.M.D., M.G.), University of Calgary, Canada
| | - Andrew M Demchuk
- Department of Clinical Neurosciences (J.M.O., R.V.M., M.D.H., A.M.D., M.G.), University of Calgary, Canada.,Department of Diagnostic Imaging (J.M.O., R.V.M., M.D.H., A.M.D., M.G.), University of Calgary, Canada
| | - Tudor G Jovin
- Department of Neurology, Cooper University Health Care, Camden (T.G.J.)
| | - Peter Mitchell
- Department of Radiology (P.M.), Royal Melbourne Hospital, University of Melbourne, Australia
| | - Bruce C V Campbell
- Department of Neurology (B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Australia
| | - Phil White
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom (P.W.)
| | - Keith Muir
- Department of Neurology, University of Glasgow, Scotland (K.M.)
| | - Hamza Achit
- Department of Medicine (H.A.), Nancy University Hospital, France
| | - Serge Bracard
- Department of Neuroradiology (S.B.), Nancy University Hospital, France
| | - Scott Brown
- Altair Biostatistics, St Louis Park' MN (S.B.)
| | - Mayank Goyal
- Department of Clinical Neurosciences (J.M.O., R.V.M., M.D.H., A.M.D., M.G.), University of Calgary, Canada.,Department of Diagnostic Imaging (J.M.O., R.V.M., M.D.H., A.M.D., M.G.), University of Calgary, Canada
| | | |
Collapse
|
11
|
di Biase L, Bonura A, Caminiti ML, Pecoraro PM, Di Lazzaro V. Neurophysiology tools to lower the stroke onset to treatment time during the golden hour: microwaves, bioelectrical impedance and near infrared spectroscopy. Ann Med 2022; 54:2658-2671. [PMID: 36154386 PMCID: PMC9542520 DOI: 10.1080/07853890.2022.2124448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Reperfusion therapy administration timing in acute ischaemic stroke is the main determinant of patients' mortality and long-term disability. Indeed, the first hour from the stroke onset is defined the "golden hour", in which the treatment has the highest efficacy and lowest side effects. Delayed ambulance transport, inappropriate triage and difficulty in accessing CT scans lead to delayed onset to treatment time (OTT) in clinical practice. To date brain CT scan is needed to rule out intracranial haemorrhage, which is a major contraindication to thrombolytic therapy. The availability, dimension and portability make CT suitable mainly for intrahospital use, determining further delays in the therapies administration. This review aims at evaluating portable neurophysiology technologies developed with the scope of speeding up the diagnostic phase of acute stroke and, therefore, the initiation of intravenous thrombolysis. Medline databases were explored for studies concerning near infrared spectroscopy (NIRS), bioelectrical impedance spectroscopy (BIS) and Microwave imaging (MWI) as methods for stroke diagnosis. A total of 1368 articles were found, and 12 of these fit with our criteria and were included in the review. For each technology, the following parameters were evaluated: diagnostic accuracy, ability to differentiate ischaemic and haemorrhagic stroke, diagnosis time from stroke onset, portability and technology readiness level (TRL). All the described methods seem to be able to identify acute stroke even though the number of studies is very limited. Low cost and portability make them potentially usable during ambulance transport, possibly leading to a reduction of stroke OTT along with the related huge benefits in terms of patients outcome and health care costs. In addition, unlike standard imaging techniques, neurophysiological techniques could allow continuous monitoring of patients for timely intrahospital stroke diagnosis.KEY MESSAGESFirst hour from the stroke onset is defined the "golden hour", in which the treatment has the highest efficacy and lowest side effects.The delay for stroke onset to brain imaging time is one of the major reasons why only a minority of patients with acute ischaemic stroke are eligible to reperfusion therapies.Neurophysiology techniques (NIRS, BIS and MWI) could have a potential high impact in reducing the time to treatment in stroke patients.
Collapse
Affiliation(s)
- Lazzaro di Biase
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology and Neurobiology, Università Campus Bio-Medico di Roma, Roma, Italy.,Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy.,Brain Innovations Laboratory, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Adriano Bonura
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology and Neurobiology, Università Campus Bio-Medico di Roma, Roma, Italy.,Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
| | - Maria Letizia Caminiti
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology and Neurobiology, Università Campus Bio-Medico di Roma, Roma, Italy.,Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
| | - Pasquale Maria Pecoraro
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology and Neurobiology, Università Campus Bio-Medico di Roma, Roma, Italy.,Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
| | - Vincenzo Di Lazzaro
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology and Neurobiology, Università Campus Bio-Medico di Roma, Roma, Italy.,Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
| |
Collapse
|
12
|
Grunwald IQ, Wagner V, Podlasek A, Koduri G, Guyler P, Gerry S, Shah S, Sievert H, Sharma A, Mathur S, Fassbender K, Shariat K, Houston G, Kanodia A, Walter S. How a thrombectomy service can reduce hospital deficit: a cost-effectiveness study. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2022; 20:59. [PMID: 36333706 PMCID: PMC9636798 DOI: 10.1186/s12962-022-00395-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022] Open
Abstract
Background There is level 1 evidence for cerebral thrombectomy with thrombolysis in acute large vessel occlusion. Many hospitals are now contemplating setting up this life-saving service. For the hospital, however, the first treatment is associated with an initial high cost to cover the procedure. Whilst the health economic benefit of treating stroke is documented, this is the only study to date performing matched-pair, patient-level costing to determine treatment cost within the first hospital episode and up to 90 days post-event. Methods We conducted a retrospective coarsened exact matched-pair analysis of 50 acute stroke patients eligible for thrombectomy. Results Thrombectomy resulted in significantly more good outcomes (mRS 0–2) compared to matched controls (56% vs 8%, p = 0.001). More patients in the thrombectomy group could be discharged home (60% vs 28%), fewer were discharged to nursing homes (4% vs 16%), residential homes (0% vs 12%) or rehabilitation centres (8% vs 20%). Thrombectomy patients had fewer serious adverse events (n = 30 vs 86) and were, on average, discharged 36 days earlier. They required significantly fewer physiotherapy sessions (18.72 vs 46.49, p = 0.0009) resulting in a median reduction in total rehabilitation cost of £4982 (p = 0.0002) per patient. The total cost of additional investigations was £227 lower (p = 0.0369). Overall, the median cost without thrombectomy was £39,664 per case vs £22,444, resulting in median savings of £17,221 (p = 0.0489). Conclusions Mechanical thrombectomy improved patient outcome, reduced length of hospitalisation and, even without procedural reimbursement, significantly reduced cost to the thrombectomy providing hospital.
Collapse
|
13
|
Moving from traditional to more advanced treatments in stroke care is cost-effective: A case study from Greece. J Stroke Cerebrovasc Dis 2022; 31:106764. [PMID: 36095859 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 09/04/2022] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES Stroke is the most common cause of disability in high-income countries. Several countries offer a limited range of advanced treatments with implications for outcomes, disability and costs. This study estimates the burden of disability that could have been avoided through the transition from traditional (no intravenous thrombolytic therapy (IVT), or endovascular thrombectomy (EVT)) to modern stroke treatments (treatment in stroke units, IVT and EVT). We perform a cost-effectiveness analysis comparing best practice with traditional stroke care, using Greece as a case study. MATERIALS AND METHODS A Markov model was used to calculate costs and Quality Adjusted Life Years (QALYs) for each treatment strategy, using a lifetime horizon. Data for model inputs were derived from meta-analyses of trials, and national and international cost databases. Sensitivity analyses were also performed to address potential uncertainty and test the robustness of the findings. RESULTS Incremental effectiveness comprised 0.22 QALYs per patient and year. Best practice was cost-effective for more than 90% of all iterations (ICER for the baseline scenario: €2,109.25/QALY). Sensitivity analysis demonstrated that the findings remain robust. Considering the stroke incidence in Greece, the annual additional cost to implement best practice was calculated to be between 0.07%-0.15% of the total health expenditure. CONCLUSION Best practice stroke treatment was cost-effective and affordable in a case study based on Greece. The results could be leveraged by including effects of preventive policies and rehabilitation. They also highlight the importance of adopting modern treatment strategies from a cost-effectiveness perspective, apart from the improved clinical outcomes.
Collapse
|
14
|
Zhang L, Lopes S, Lavelle T, Jones KO, Chen L, Jindal M, Zinzow H, Shi L. Economic Evaluations of Mindfulness-Based Interventions: a Systematic Review. Mindfulness (N Y) 2022; 13:2359-2378. [PMID: 36061089 PMCID: PMC9425809 DOI: 10.1007/s12671-022-01960-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/06/2022] [Indexed: 11/16/2022]
Abstract
Objectives This study includes a systematic review of cost-effectiveness analyses (CEAs) and cost–benefit analyses (CBAs) of mindfulness-based interventions (MBIs). Methods A literature search was conducted using PubMed, Web of Science, JSTOR, and CINAHL for studies published between January 1985 and September 2021, including an original cost-related evaluation of an MBI. A qualitative assessment of bias was performed using the Drummond checklist. Results Twenty-eight mindfulness-based intervention studies (18 CEAs and 10 CBAs) were included in this review. Mindfulness-based stress reduction (MBSR) was less costly and more effective when compared with the usual care of cognitive behavioral therapy among patients with chronic lower back pain, fibromyalgia, and breast cancer. MBSR among patients with various physical/mental conditions was associated with reductions in healthcare costs. Mindfulness-based cognitive therapy (MBCT) was also less costly and more effective than the comparison group among patients with depression, medically unexplained symptoms, and multiple sclerosis. MBCT’s cost-effectiveness advantage was also identified among breast cancer patients with persistent pain, non-depressed adults with a history of major depressive disorder episodes, adults diagnosed with ADHD, and all cancer patients. From a societal perspective, the cost-saving property of mindfulness training was evident when used as the treatment of aggressive behaviors among persons with intellectual/developmental disabilities in mental health facilities. Conclusions Based on this review, more standardized MBI protocols such as MBSR and MBCT compare favorably with usual care in terms of health outcomes and cost-effectiveness. Other MBIs may result in cost savings from both healthcare and societal perspectives among high-risk patient populations.
Collapse
|
15
|
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
|
16
|
Ni W, Kunz WG, Goyal M, Chen L, Jiang Y. Quality of life and cost consequence of delays in endovascular treatment for acute ischemic stroke in China. HEALTH ECONOMICS REVIEW 2022; 12:4. [PMID: 34993675 PMCID: PMC8740348 DOI: 10.1186/s13561-021-00352-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 12/22/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Although endovascular therapy (EVT) improves clinical outcomes in patients with acute ischemic stroke, the time of EVT initiation significantly influences clinical outcomes and healthcare costs. This study evaluated the impact of EVT treatment delay on cost-effectiveness in China. METHODS A model combining a short-term decision tree and long-term Markov health state transition matrix was constructed. For each time window of symptom onset to EVT, the probability of receiving EVT or non-EVT treatment was varied, thereby varying clinical outcomes and healthcare costs. Clinical outcomes and cost data were derived from clinical trials and literature. Incremental cost-effectiveness ratio and incremental net monetary benefits were simulated. Deterministic and probabilistic sensitivity analyses were performed to assess the robustness of the model. The willingness-to-pay threshold per quality-adjusted life-year (QALY) was set to ¥71,000 ($10,281). RESULTS EVT performed between 61 and 120 min after the stroke onset was most cost-effective comparing to other time windows to perform EVT among AIS patients in China, with an ICER of ¥16,409/QALY ($2376) for performing EVT at 61-120 min versus the time window of 301-360 min. Each hour delay in EVT resulted in an average loss of 0.45 QALYs and 165.02 healthy days, with an average net monetary loss of ¥15,105 ($2187). CONCLUSIONS Earlier treatment of acute ischemic stroke patients with EVT in China increases lifetime QALYs and the economic value of care without any net increase in lifetime costs. Thus, healthcare policies should aim to improve efficiency of pre-hospital and in-hospital workflow processes to reduce the onset-to-puncture duration in China.
Collapse
Affiliation(s)
- Weiyi Ni
- Department of Pharmaceutical and Health Economics, University of Southern California, Los Angeles, California, USA
| | - Wolfgang G Kunz
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Mayank Goyal
- Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Lijin Chen
- Chronic Disease Research Institute, School of Public Health, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yawen Jiang
- School of Public Health (Shenzhen), Sun Yat-sen University, Room 215, Mingde Garden #6, Sun Yat-sen University, 132 East Outer Ring Road, Panyu District, Guangzhou, Guangdong, China.
| |
Collapse
|
17
|
Ribera A, Giménez E, Oristrell G, Osorio D, Marsal JR, García-Pérez L, Ballesteros M, Ródenas E, Belahnech Y, Escalona R, Rivas N, Roca-Luque I, Ferreira-González I, Espallargues M. Coste-efectividad del desfibrilador automático implantable para la prevención primaria de la muerte súbita cardiaca. Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2021.02.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
|
18
|
Mao N, Xue F, Cai W, Li J. Effects of nurse-led home-based telephone support or home visits on cognitive function. Clin Transl Sci 2021; 15:741-748. [PMID: 34786853 PMCID: PMC8932695 DOI: 10.1111/cts.13195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 10/09/2021] [Accepted: 10/21/2021] [Indexed: 11/30/2022] Open
Abstract
Patients who have undergone carotid revascularization surgery have a high risk of postoperative cognitive decline, and home‐based care is the major form of postoperative management. Here, we aimed to compare the nurse‐led home‐based telephone support (NLHBTS) and home visits as additional postoperative care for patients who have undergone carotid revascularization surgery. The study recruited 172 patients, and 131 patients were randomly assigned to receive combined telephone support and home visits (intervention group) or home visits alone (control group) during the study period of 12 weeks. At baseline, 1 month, and 3 months, cognitive function was assessed using the Trail Making Test, Processing Speed Index, Boston Naming Test, Working Memory Index, Controlled Oral Word Association Test, and Hopkins Verbal Test. Sixty‐five patients in the intervention group and 66 in the control group completed the 1‐month treatment, and 49 in the intervention group and 48 in the control group completed the 3‐month treatment. The intervention group showed significant improvement in four of the six cognitive tests after the 3‐month treatment, whereas the control group only showed significant improvement in the Controlled Oral Word Association Test. Compared to the control group, significantly higher scores were achieved by the intervention group at 3 months in the Trail Making Tests (113 ± 23 vs. 128 ± 18, p = 0.001), Processing Speed Index (115 ± 15 vs. 108 ± 14, p = 0.020), Controlled Oral Word Association Test (51 ± 11 vs. 45 ± 9, p = 0.004), and Hopkins Verbal Learning Test (9.0 ± 1.6 vs. 8.3 ± 1.8, p = 0.046). NLHBTS, in combination with home visits, could facilitate the improvement of cognitive function in patients with carotid artery stenosis after surgery.
Collapse
Affiliation(s)
- Nanqi Mao
- Department of Vascular Surgery, the First Hospital of Quanzhou Affiliated to Fujian Medical University, Quanzhou, Fujian, China
| | - Fangyuan Xue
- Department of Vascular Surgery, the First Hospital of Quanzhou Affiliated to Fujian Medical University, Quanzhou, Fujian, China
| | - Wanyu Cai
- Department of Vascular Surgery, the First Hospital of Quanzhou Affiliated to Fujian Medical University, Quanzhou, Fujian, China
| | - Jiahong Li
- Department of Vascular Surgery, the First Hospital of Quanzhou Affiliated to Fujian Medical University, Quanzhou, Fujian, China
| |
Collapse
|
19
|
Bulwa Z, Chen M. Stroke Center Designations, Neurointerventionalist Demand, and the Finances of Stroke Thrombectomy in the United States. Neurology 2021; 97:S17-S24. [PMID: 34785600 DOI: 10.1212/wnl.0000000000012780] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 11/24/2020] [Indexed: 11/15/2022] Open
Abstract
PURPOSE OF THE REVIEW This article aims to provide an update on the designation of stroke centers, neurointerventionalist demand, and cost-effectiveness of stroke thrombectomy in the United States. RECENT FINDINGS There are now more than 1,660 stroke centers certified by national accrediting bodies in the United States, 306 of which are designated as thrombectomy-capable or comprehensive stroke centers. Considering the amount of nationally certified centers and the number of patients with acute stroke eligible for thrombectomy, each center would be responsible for 64 to 104 thrombectomies per year. As a result, there is a growing demand placed on neurointerventionalists, who have the ability to alter the trajectory of large vessel occlusive strokes. Numbers needed to achieve functional independence after stroke thrombectomy at 90 days range from 3.2 to 7.4 patients in the early time window and 2.8 to 3.6 patients in the extended time window in appropriately selected candidates. With the low number needed to treat, in a variety of valued-based calculations and cost-effectiveness analyses, stroke thrombectomy has proved to be both clinically effective and cost-effective. SUMMARY Advancements in the early recognition and treatment of stroke have been paralleled by a remodeling of health care systems to ensure best practices in a timely manner. Stroke center-accrediting bodies provide oversight to safeguard these standards. As successful trial data from high volume centers transform into real-world experience, we must continue to re-evaluate cost-effectiveness, strike a balance between sufficient case volumes to maintain clinical excellence vs the burden and burnout associated with call responsibilities, and improve access to care for all.
Collapse
Affiliation(s)
- Zachary Bulwa
- From the Departments of Neurology (Z.B.) and Neurosurgery (M.C.), Rush University Medical Center, Chicago, IL.
| | - Michael Chen
- From the Departments of Neurology (Z.B.) and Neurosurgery (M.C.), Rush University Medical Center, Chicago, IL
| |
Collapse
|
20
|
de Souza AC, Martins SO, Polanczyk CA, Araújo DV, Etges APB, Zanotto BS, Neyeloff JL, Carbonera LA, Chaves MLF, de Carvalho JJF, Rebello LC, Abud DG, Cabral LS, Lima FO, Mont'Alverne F, Sc Magalhães P, Diegoli H, Safanelli J, André Silveira Salvetti T, de Sousa Mendes Parente B, Eli Frudit M, Silva GS, Pontes-Neto OM, Nogueira RG. Cost-effectiveness of mechanical thrombectomy for acute ischemic stroke in Brazil: Results from the RESILIENT trial. Int J Stroke 2021; 17:17474930211055932. [PMID: 34730045 DOI: 10.1177/17474930211055932] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The RESILIENT trial demonstrated the clinical benefit of mechanical thrombectomy in patients presenting acute ischemic stroke secondary to anterior circulation large vessel occlusion in Brazil. AIMS This economic evaluation aims to assess the cost-utility of mechanical thrombectomy in the RESILIENT trial from a public healthcare perspective. METHODS A cost-utility analysis was applied to compare mechanical thrombectomy plus standard medical care (n = 78) vs. standard medical care alone (n = 73), from a subset sample of the RESILIENT trial (151 of 221 patients). Real-world direct costs were considered, and utilities were imputed according to the Utility-Weighted modified Rankin Score. A Markov model was structured, and probabilistic and deterministic sensitivity analyses were performed to evaluate the robustness of results. RESULTS The incremental costs and quality-adjusted life years gained with mechanical thrombectomy plus standard medical care were estimated at Int$ 7440 and 1.04, respectively, compared to standard medical care alone, yielding an incremental cost-effectiveness ratio of Int$ 7153 per quality-adjusted life year. The deterministic sensitivity analysis demonstrated that mRS-6 costs of the first year most affected the incremental cost-effectiveness ratio. After 1000 simulations, most of results were below the cost-effective threshold. CONCLUSIONS The intervention's clear long-term benefits offset the initially higher costs of mechanical thrombectomy in the Brazilian public healthcare system. Such therapy is likely to be cost-effective and these results were crucial to incorporate mechanical thrombectomy in the Brazilian public stroke centers.
Collapse
Affiliation(s)
- Ana Claudia de Souza
- Department of Neurology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Sheila O Martins
- Department of Neurology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Carisi Anne Polanczyk
- National Institute of Science and Technology for Health Technology Assessment (IATS), Porto Alegre, Brazil
| | | | - Ana Paula Bs Etges
- National Institute of Science and Technology for Health Technology Assessment (IATS), Porto Alegre, Brazil
| | - Bruna Stella Zanotto
- National Institute of Science and Technology for Health Technology Assessment (IATS), Porto Alegre, Brazil
| | - Jeruza Lavanholi Neyeloff
- National Institute of Science and Technology for Health Technology Assessment (IATS), Porto Alegre, Brazil
| | | | | | - João José Freitas de Carvalho
- Department of Neurology, Hospital Geral de Fortaleza, Fortaleza, Brazil
- Department of Neurology, University of Fortaleza, Fortaleza, Brazil
| | - Letícia Costa Rebello
- Department of Neurology, 283325Hospital de Base do Distrito Federal, Brasilia, Brazil
| | - Daniel Giansante Abud
- Department of Interventional Neuroradiology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Lucas Scotta Cabral
- Department of Interventional Neuroradiology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Fabrício O Lima
- Department of Neurology, Hospital Geral de Fortaleza, Fortaleza, Brazil
| | - Francisco Mont'Alverne
- Department of Neurology, Hospital Geral de Fortaleza, Fortaleza, Brazil
- Department of Interventional Neuroradiology, Hospital Geral de Fortaleza, Fortaleza, Brazil
- Department of Post-Graduation Medical Sciences, University of Fortaleza, Fortaleza, Brazil
| | - Pedro Sc Magalhães
- Stroke Neurology Division, Hospital Municipal de Joinville, Joinville, Brazil
| | - Henrique Diegoli
- Stroke Neurology Division, Hospital Municipal de Joinville, Joinville, Brazil
| | - Juliana Safanelli
- Stroke Neurology Division, Hospital Municipal de Joinville, Joinville, Brazil
| | | | | | - Michel Eli Frudit
- Department of Interventional Neuroradiology, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Gisele Sampaio Silva
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Octávio M Pontes-Neto
- Stroke Service Neurology Division, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Raul G Nogueira
- Department of Neurology, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA, USA
| |
Collapse
|
21
|
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
|
22
|
Ospel JM, McDonough R, Kunz WG, Goyal M. Is concurrent intravenous alteplase in patients undergoing endovascular treatment for large vessel occlusion stroke cost-effective even if the cost of alteplase is only US$1? J Neurointerv Surg 2021; 14:568-572. [PMID: 34187871 DOI: 10.1136/neurintsurg-2021-017817] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 06/08/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND The added value of intravenous (IV) alteplase in large vessel occlusion (LVO) stroke over and beyond endovascular treatment (EVT) is controversial. We compared the long-term costs and cost-effectiveness of a direct-to-EVT paradigm in LVO stroke patients presenting directly to the mothership hospital to concurrent EVT and IV alteplase. METHODS We used a decision model consisting of a short-run model to analyze costs and functional outcomes within 90 days after the index stroke and a long-run Markov state transition model (cycle length of 12 months) to estimate expected lifetime costs and outcomes. Outcome data were from the DIRECT-MT trial (NCT03469206). Incremental cost-effectiveness ratios and net monetary benefits were calculated and probabilistic sensitivity analysis was performed. Analysis was performed from a healthcare perspective and a societal perspective using both a minimal assumed alteplase cost of US$1 and true alteplase cost. RESULTS When assuming a minimal cost of alteplase of $1, EVT with concurrent IV alteplase resulted in incremental lifetime cost of $5664 (healthcare perspective)/$4804 (societal perspective) and a decrement of 0.25 quality-adjusted life years (QALYs) compared with EVT only, indicating dominance of the EVT only approach. Net monetary benefits were consistently higher for EVT only compared with EVT with concurrent alteplase. Probabilistic sensitivity analysis showed increased costs without an increase in QALYs for EVT and concurrent IV alteplase compared with EVT only. Results were even more in favor of EVT when the true cost of alteplase was used for analysis. CONCLUSION EVT without concurrent alteplase is the preferred strategy from a health economic standpoint.
Collapse
Affiliation(s)
- Johanna Maria Ospel
- Radiology, Universitatsspital Basel, Basel, Switzerland.,Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Rosalie McDonough
- Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.,Diagnostic and Interventional Neuroradiology, Department of Diagnostic and Interventional Neuroradiology, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | | | - Mayank Goyal
- Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada .,Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
23
|
Vardanyan R, Hagana A, Iqbal H, Arjomandi Rad A, Mahmud M, Ruparell K, Rabee N, Khan J, Poole W, Shakir RA. A Cost Utility Analysis of Minimally Invasive Surgery with Thrombolysis Compared to Standard Medical Treatment in Spontaneous Intracerebral Haemorrhagic Stroke. J Stroke Cerebrovasc Dis 2021; 30:105934. [PMID: 34167871 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105934] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 05/29/2021] [Accepted: 05/31/2021] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVES Standard medical management of spontaneous intracerebral haemorrhage (ICH) and surgical hematoma evacuation starkly differ, and whilst landmark randomised control trials report no clinical benefit of early surgical evacuation compared with medical treatment in supratentorial ICH, minimally invasive surgery (MIS) with thrombolysis has been neglected within these studies. However, recent technological advancements in MIS have renewed interest in the surgical treatment of ICH. Several economic evaluations have focused on the benefits of MIS in ischaemic stroke management, but no economic evaluations have yet been performed comparing MIS to standard medical treatment for ICH. MATERIALS AND METHOD All costs were sourced from the UK in GBP. Where possible, the 2019/2020 NHS reference costs were used. The MISTIE III study was used to analyse the outcomes of patients undergoing either MIS or standard medical treatment in this economic evaluation. RESULTS The incremental cost-effectiveness ratio (ICER) for MIS was £485,240.26 for every quality-adjusted life year (QALY) gained. Although MIS resulted in a higher QALY compared to medical treatment, the gain was insignificant at 0.011 QALY. Four sensitivity analyses based on combinations of alternative EQ-5D values and categorisation of MIS outcomes, alongside alterations to the cost of significant adverse events, were performed to check the robustness of the ICER calculation. The most realistic sensitivity analysis showed a potential increase in cost effectiveness when clot size is reduced to <15ml, with the ICER falling to £74,335.57. DISCUSSION From the perspective of the NHS, MIS with thrombolysis is not cost-effective compared to optimal medical treatment. ICER shows that intention-to-treat MIS would require a cost of £485,240.26 to gain one extra QALY, which is significantly above the NHS threshold of £30,000. Further UK studies with ICH survivor utilities, more replicable surgical technique, and the reporting of clot size reduction are indicated as the present sensitivity analysis suggests that MIS is promising. Greater detail about outcomes and complications would ensure improved cost-benefit analyses and support valid and efficient allocation of resources by the NHS.
Collapse
Affiliation(s)
- Robert Vardanyan
- Faculty of Medicine, Department of Medicine, Imperial College London, London, United Kingdom.
| | - Arwa Hagana
- Faculty of Medicine, Department of Medicine, Imperial College London, London, United Kingdom
| | - Haseeb Iqbal
- Faculty of Medicine, Department of Medicine, Imperial College London, London, United Kingdom
| | - Arian Arjomandi Rad
- Faculty of Medicine, Department of Medicine, Imperial College London, London, United Kingdom
| | - Mohammad Mahmud
- Faculty of Medicine, Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Kajal Ruparell
- Faculty of Medicine, Department of Medicine, Imperial College London, London, United Kingdom
| | - Nuha Rabee
- School of Medicine and Dentistry, Barts and The London, Queen Mary, University of London, London, United Kingdom
| | - Javad Khan
- Faculty of Medicine, King's College London, London, United Kingdom
| | - William Poole
- Faculty of Medicine, Department of Medicine, Imperial College London, London, United Kingdom
| | - Raad A Shakir
- Faculty of Medicine, Department of Brain Sciences, Imperial College London, London, United Kingdom
| |
Collapse
|
24
|
Ribera A, Giménez E, Oristrell G, Osorio D, Marsal JR, García-Pérez L, Ballesteros M, Ródenas E, Belahnech Y, Escalona R, Rivas N, Roca-Luque I, Ferreira-González I, Espallargues M. Cost-effectiveness of implantable cardioverter-defibrillators for primary prevention of sudden cardiac death. ACTA ACUST UNITED AC 2021; 75:12-21. [PMID: 34099431 DOI: 10.1016/j.rec.2021.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 02/23/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION AND OBJECTIVES Implantable cardioverter-defibrillators (ICD) are a cost-effective alternative for secondary prevention of sudden cardiac death, but their efficiency in primary prevention, especially among patients with nonischemic heart disease, is still uncertain. METHODS We performed a cost-effectiveness analysis of ICD plus conventional medical treatment (CMT) vs CMT for primary prevention of cardiac arrhythmias from the perspective of the national health service. We simulated the course of the disease by using Markov models in patients with ischemic and nonischemic heart disease. The parameters of the model were based on the results obtained from a meta-analysis of clinical trials published between 1996 and 2018 comparing ICD plus CMT vs CMT, the safety results of the DANISH trial, and analysis of real-world clinical practice in a tertiary hospital. RESULTS We estimated that ICD reduced the likelihood of all-cause death in patients with ischemic heart disease (HR, 0.70; 95%CI, 0.58-0.85) and in those with nonischemic heart disease (HR, 0.79; 95%CI, 0.66-0.96). The incremental cost-effectiveness ratio (ICER) estimated with probabilistic analysis was €19 171/quality adjusted life year (QALY) in patients with ischemic heart disease and €31 084/QALY in those with nonischemic dilated myocardiopathy overall and €23 230/QALY in patients younger than 68 years. CONCLUSIONS The efficiency of single-lead ICD systems has improved in the last decade, and these devices are cost-effective in patients with ischemic and nonischemic left ventricular dysfunction younger than 68 years, assuming willingness to pay as €25 000/QALY. For older nonischemic patients, the ICER was around €30 000/QALY.
Collapse
Affiliation(s)
- Aida Ribera
- Unidad de Epidemiología Cardiovascular, Servicio de Cardiología, Hospital Universitario Vall d'Hebron, Institut de Recerca Vall d'Hebron (VHIR), Barcelona, Spain; Centro de Investigación en Red de Epidemiología y Salud Pública (CIBERESP), Spain.
| | - Emmanuel Giménez
- Agència de Qualitat i Avaluació Sanitàries de Catalunya (AQuAS), Departament de Salut, Barcelona, Spain
| | - Gerard Oristrell
- Servicio de Cardiología, Hospital Universitario Vall d'Hebron, Barcelona, Spain; Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Dimelza Osorio
- Centro de Investigación en Red de Epidemiología y Salud Pública (CIBERESP), Spain; Unidad de Calidad-Mejora de la Práctica Clínica, Dirección de Procesos y Calidad, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Josep Ramón Marsal
- Unidad de Epidemiología Cardiovascular, Servicio de Cardiología, Hospital Universitario Vall d'Hebron, Institut de Recerca Vall d'Hebron (VHIR), Barcelona, Spain; Centro de Investigación en Red de Epidemiología y Salud Pública (CIBERESP), Spain
| | - Lidia García-Pérez
- Servicio de Evaluación del Servicio Canario de la Salud (SESCS), Tenerife, Spain; Red Española de Agencias de Evaluación de Tecnologías Sanitarias y Prestaciones del Sistema Nacional de Salud (RedETS), Spain; Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Madrid, Spain
| | - Mónica Ballesteros
- Centro de Investigación en Red de Epidemiología y Salud Pública (CIBERESP), Spain; Unidad de Calidad-Mejora de la Práctica Clínica, Dirección de Procesos y Calidad, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Eduard Ródenas
- Servicio de Cardiología, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Yassin Belahnech
- Servicio de Cardiología, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Roxana Escalona
- Servicio de Cardiología, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Núria Rivas
- Servicio de Cardiología, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Ivo Roca-Luque
- Unidad de Arritmias, Institut Cardiovascular, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Ignacio Ferreira-González
- Unidad de Epidemiología Cardiovascular, Servicio de Cardiología, Hospital Universitario Vall d'Hebron, Institut de Recerca Vall d'Hebron (VHIR), Barcelona, Spain; Centro de Investigación en Red de Epidemiología y Salud Pública (CIBERESP), Spain; Servicio de Cardiología, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Mireia Espallargues
- Agència de Qualitat i Avaluació Sanitàries de Catalunya (AQuAS), Departament de Salut, Barcelona, Spain; Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Madrid, Spain
| |
Collapse
|
25
|
MR CLEAN-NO IV: intravenous treatment followed by endovascular treatment versus direct endovascular treatment for acute ischemic stroke caused by a proximal intracranial occlusion-study protocol for a randomized clinical trial. Trials 2021; 22:141. [PMID: 33588908 PMCID: PMC7885482 DOI: 10.1186/s13063-021-05063-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 01/20/2021] [Indexed: 12/15/2022] Open
Abstract
Background Endovascular treatment (EVT) has greatly improved the prognosis of acute ischemic stroke (AIS) patients with a proximal intracranial large vessel occlusion (LVO) of the anterior circulation. Currently, there is clinical equipoise concerning the added benefit of intravenous alteplase administration (IVT) prior to EVT. The aim of this study is to assess the efficacy and safety of omitting IVT before EVT in patients with AIS caused by an anterior circulation LVO. Methods MR CLEAN-NO IV is a multicenter randomized open-label clinical trial with blinded outcome assessment (PROBE design). Patients ≥ 18 years of age with a pre-stroke mRS < 3 with an LVO confirmed on CT angiography/MR angiography eligible for both IVT and EVT are randomized to receive either IVT (0.9 mg/kg) followed by EVT, or direct EVT in a 1:1 ratio. The primary objective is to assess superiority of direct EVT. Secondarily, non-inferiority of direct EVT compared to IVT before EVT will be explored. The primary outcome is the score on the modified Rankin Scale at 90 days. Ordinal regression with adjustment for prognostic variables will be used to estimate treatment effect. Secondary outcomes include reperfusion graded with the eTICI scale after EVT and stroke severity (National Institutes of Health Stroke Scale) at 24 h. Safety outcomes include intracranial hemorrhages scored according to the Heidelberg criteria. A total of 540 patients will be included. Discussion IVT prior to EVT might facilitate early reperfusion before EVT or improved reperfusion rates during EVT. Conversely, among other potential adverse effects, the increased risk of bleeding could nullify the beneficial effects of IVT. MR CLEAN-NO IV will provide insight into whether IVT is still of added value in patients eligible for EVT. Trial registration www.isrctn.com: ISRCTN80619088. Registered on 31 October 2017. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05063-5.
Collapse
|
26
|
Waqas M, Gong AD, Levy BR, Dossani RH, Vakharia K, Cappuzzo JM, Becker A, Sonig A, Tutino VM, Almayman F, Davies JM, Snyder KV, Siddiqui AH, Levy EI. Is Endovascular Therapy for Stroke Cost-Effective Globally? A Systematic Review of the Literature. J Stroke Cerebrovasc Dis 2021; 30:105557. [PMID: 33556672 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105557] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 12/11/2020] [Accepted: 12/13/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Cost-effectiveness of endovascular therapy (EVT) is a key consideration for broad use of this approach for emergent large vessel occlusion stroke. We evaluated the evidence on cost-effectiveness of EVT in comparison with best medical management from a global perspective. MATERIALS AND METHODS This systematic review of studies published between January 2010 and May 2020 evaluated the cost effectiveness of EVT for patients with large vessel occlusion acute ischemic stroke. The gain in quality adjusted life year (QALY) and incremental cost-effectiveness ratio (ICER), expressed as cost per QALY resulting from EVT, were recorded. The study setting (country, economic perspective), decision model, and data sources used in economic models of EVT cost-effectiveness were recorded. RESULTS Twenty-five original studies from 12 different countries were included in our review. Five of these studies were reported from a societal perspective; 18 were reported from a healthcare system perspective. Two studies used real-world data. The time horizon varied from 1 year to a lifetime; however, 18 studies reported a time horizon of >10 years. Twenty studies reported using outcome data from randomized, controlled clinical trials for their models. Nineteen studies reported using a Markov model. Incremental QALYs ranged from 0.09-3.5. All studies but 1 reported that EVT was cost-effective. CONCLUSIONS Evidence from different countries and economic perspectives suggests that EVT for stroke treatment is cost-effective. Most cost-effectiveness studies are based on outcome data from randomized clinical trials. However, there is a need to study the cost-effectiveness of EVT based solely on real-world outcome data.
Collapse
Affiliation(s)
- Muhammad Waqas
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA.
| | - Andrew D Gong
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA.
| | - Bennett R Levy
- George Washington School of Medicine and Health Sciences, Washington, DC, USA.
| | - Rimal H Dossani
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA
| | - Kunal Vakharia
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA.
| | - Justin M Cappuzzo
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA.
| | - Alexander Becker
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA.
| | - Ashish Sonig
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA.
| | - Vincent M Tutino
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Biomedical Engineering, University at Buffalo, Buffalo, NY, USA; Department of Pathology and Anatomical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY USA.
| | - Faisal Almayman
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA.
| | - Jason M Davies
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY USA; Department of Bioinformatics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Kenneth V Snyder
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY USA.
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY USA; Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA.
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY USA; Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA.
| |
Collapse
|
27
|
A Prospective Economic Evaluation of Rapid Endovascular Therapy for Acute Ischemic Stroke. Can J Neurol Sci 2021; 48:791-798. [PMID: 33431075 DOI: 10.1017/cjn.2021.4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND During the Randomized Assessment of Rapid Endovascular Treatment (EVT) of Ischemic Stroke (ESCAPE) trial, patient-level micro-costing data were collected. We report a cost-effectiveness analysis of EVT, using ESCAPE trial data and Markov simulation, from a universal, single-payer system using a societal perspective over a patient's lifetime. METHODS Primary data collection alongside the ESCAPE trial provided a 3-month trial-specific, non-model, based cost per quality-adjusted life year (QALY). A Markov model utilizing ongoing lifetime costs and life expectancy from the literature was built to simulate the cost per QALY adopting a lifetime horizon. Health states were defined using the modified Rankin Scale (mRS) scores. Uncertainty was explored using scenario analysis and probabilistic sensitivity analysis. RESULTS The 3-month trial-based analysis resulted in a cost per QALY of $201,243 of EVT compared to the best standard of care. In the model-based analysis, using a societal perspective and a lifetime horizon, EVT dominated the standard of care; EVT was both more effective and less costly than the standard of care (-$91). When the time horizon was shortened to 1 year, EVT remains cost savings compared to standard of care (∼$15,376 per QALY gained with EVT). However, if the estimate of clinical effectiveness is 4% less than that demonstrated in ESCAPE, EVT is no longer cost savings compared to standard of care. CONCLUSIONS Results support the adoption of EVT as a treatment option for acute ischemic stroke, as the increase in costs associated with caring for EVT patients was recouped within the first year of stroke, and continued to provide cost savings over a patient's lifetime.Clinical Trial Registration: NCT01778335.
Collapse
|
28
|
Sarraj A, Pizzo E, Lobotesis K, Grotta JC, Hassan AE, Abraham MG, Blackburn S, Day AL, Dannenbaum MJ, Hicks W, Vora NA, Budzik RF, Sharrief AZ, Martin-Schild S, Sitton CW, Pujara DK, Lansberg MG, Gupta R, Albers GW, Kunz WG. Endovascular thrombectomy in patients with large core ischemic stroke: a cost-effectiveness analysis from the SELECT study. J Neurointerv Surg 2020; 13:875-882. [DOI: 10.1136/neurintsurg-2020-016766] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/16/2020] [Accepted: 10/19/2020] [Indexed: 11/04/2022]
Abstract
BackgroundIt is unknown whether endovascular thrombectomy (EVT) is cost effective in large ischemic core infarcts.MethodsIn the prospective, multicenter, cohort study of imaging selection study (SELECT), large core was defined as computed tomography (CT) ASPECTS<6 or computed tomography perfusion (CTP) ischemic core volume (rCBF<30%) ≥50 cc. A Markov model estimated costs, quality-adjusted life years (QALYs) and the incremental cost-effectiveness ratio (ICER) of EVT compared with medical management (MM) over lifetime. The willingness to pay (WTP) per QALY was set at $50 000 and $100 000 and the net monetary benefits (NMB) were calculated. Probabilistic sensitivity analysis (PSA) and cost-effectiveness acceptability curves (CEAC) for EVT were assessed in SELECT and other pivotal trials.ResultsFrom 361 patients enrolled in SELECT, 105 had large core on CT or CTP (EVT 62, MM 43). 19 (31%) EVT vs 6 (14%) MM patients achieved modified Rankin Scale (mRS) score 0–2 (OR 3.27, 95% CI 1.11 to 9.62, P=0.03) with a shift towards better mRS (cOR 2.12, 95% CI 1.05 to 4.31, P=0.04). Over the projected lifetime of patients presenting with large core, EVT led to incremental costs of $33 094 and a gain of 1.34 QALYs per patient, resulting in ICER of $24 665 per QALY. EVT has a higher NMB compared with MM at lower (EVT -$42 747, MM -$76 740) and upper (EVT $155 041, MM $57 134) WTP thresholds. PSA confirmed the results and CEAC showed 77% and 92% acceptability of EVT at the WTP of $50 000 and $100 000, respectively. EVT was associated with an increment of $29 225 in societal costs. The pivotal EVT trials (HERMES, DAWN, DEFUSE 3) were dominant in a sensitivity analysis at the same inputs, with societal cost-savings of $37 901, $86 164 and $22 501 and a gain of 1.62, 2.36 and 2.21 QALYs, respectively.ConclusionsIn a non-randomized prospective cohort study, EVT resulted in better outcomes in large core patients with higher QALYs, NMB and high cost-effectiveness acceptability rates at current WTP thresholds. Randomized trials are needed to confirm these results.Clinical trial registrationNCT02446587
Collapse
|
29
|
Kunz WG, Hunink MG, Almekhlafi MA, Menon BK, Saver JL, Dippel DWJ, Majoie CBLM, Jovin TG, Davalos A, Bracard S, Guillemin F, Campbell BCV, Mitchell PJ, White P, Muir KW, Brown S, Demchuk AM, Hill MD, Goyal M. Public health and cost consequences of time delays to thrombectomy for acute ischemic stroke. Neurology 2020; 95:e2465-e2475. [PMID: 32943483 DOI: 10.1212/wnl.0000000000010867] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 06/12/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine public health and cost consequences of time delays to endovascular thrombectomy (EVT) for patients, health care systems, and society, we estimated quality-adjusted life-years (QALYs) of EVT-treated patients and associated costs based on times to treatment. METHODS The Markov model analysis was performed from US health care and societal perspectives over a lifetime horizon. Contemporary data from 7 trials within the Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials (HERMES) collaboration served as data source. Aside from cumulative lifetime costs, we calculated the net monetary benefit (NMB) to determine the economic value of care. We used a contemporary willingness-to-pay threshold of $100,000 per QALY for NMB calculations. RESULTS Every 10 minutes of earlier treatment resulted in an average gain of 39 days (95% prediction interval 23-53 days) of disability-free life. Overall, the cumulative lifetime costs for patients with earlier or later treatment were similar. Patients with later treatment had higher morbidity-related costs but over a shorter time span due to their shorter life expectancy, resulting in similar lifetime costs as in patients with early treatment. Regarding the economic value of care, every 10 minutes of earlier treatment increased the NMB by $10,593 (95% prediction interval $5,549-$14,847) and by $10,915 (95% prediction interval $5,928-$15,356) taking health care and societal perspectives, respectively. CONCLUSIONS Any time delay to EVT reduces QALYs and decreases the economic value of care provided by this intervention. Health care policies to implement efficient prehospital triage and to accelerate in-hospital workflow are urgently needed.
Collapse
Affiliation(s)
- Wolfgang G Kunz
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Myriam G Hunink
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Mohammed A Almekhlafi
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Bijoy K Menon
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Jeffrey L Saver
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Diederik W J Dippel
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Charles B L M Majoie
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Tudor G Jovin
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Antoni Davalos
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Serge Bracard
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Francis Guillemin
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Bruce C V Campbell
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Peter J Mitchell
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Philip White
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Keith W Muir
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Scott Brown
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Andrew M Demchuk
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Michael D Hill
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Mayank Goyal
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN.
| | | |
Collapse
|
30
|
Ni W, Kunz WG, Goyal M, Ng YL, Tan K, De Silva DA. Lifetime quality of life and cost consequences of delays in endovascular treatment for acute ischaemic stroke: a cost-effectiveness analysis from a Singapore healthcare perspective. BMJ Open 2020; 10:e036517. [PMID: 32948553 PMCID: PMC7500292 DOI: 10.1136/bmjopen-2019-036517] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Endovascular therapy (EVT) significantly improves clinical outcomes in patients with acute ischaemic stroke (AIS), while the time of EVT initiation after stroke onset influences both patient clinical outcomes and healthcare costs. This study determined the impact of EVT treatment delay on cost effectiveness of EVT in the Singapore healthcare setting. DESIGN A short-term decision tree and long-term Markov health state transition model was constructed. For each time window of symptom onset to EVT, the probability of receiving EVT or non-EVT treatment was varied, thereby varying clinical outcomes (modified Rankin Scale scores), short-term costs and long-term modelled (lifetime) costs; all of which were used in calculating an incremental cost-effectiveness ratio of EVT vs non-EVT treatment. Clinical outcomes and cost data were derived from clinical trials, literature, expert opinion, electronic medical records and community-based surveys from Singapore. Deterministic one-way and probabilistic sensitivity analyses were performed to assess the uncertainty of the model. The willingness to pay for per quality-adjusted life-year (QALY) was set to Singapore $50 000 (US$36 500). SETTING Singapore healthcare perspective. PARTICIPANTS The model included patients with AIS in Singapore. INTERVENTIONS EVT performed within 6 hours of stroke onset. OUTCOME MEASURES The model estimated incremental cost-effectiveness ratios (ICERs) and net monetary benefits (NMB) for EVT versus non-EVT treatment, varied by time from symptom onset to time of treatment. RESULTS EVT performed between 61 min and 120 min after the stroke onset was most cost-effective time window to perform EVT in the Singapore population, with an ICER of Singapore $7197 per QALY (US$5254) for performing EVT at 61-120 min versus 121-180 min. The resulting incremental NMB associated with receipt of EVT at the earlier time point is Singapore $39 827 (US$29 074) per patient at the willingness-to-pay threshold of Singapore $50 000. Each hour delay in EVT resulted in an average loss of 0.54 QALYs and 195.35 healthy days, with an average net monetary loss of Singapore $26 255 (US$19 166). CONCLUSIONS From the Singapore healthcare perspective, although EVT is more expensive than alternative treatments in the short term, the lifetime ICER is below the willingness-to-pay threshold. Thus, healthcare policies and procedures should aim to improve efficiency of pre-hospital and in-hospital workflow processes to reduce the onset-to-puncture duration.
Collapse
Affiliation(s)
- Weiyi Ni
- Health Economics and Reimbursement, Medtronic Neurovascular, Irvine, California, USA
| | - Wolfgang G Kunz
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Mayank Goyal
- Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Yu Li Ng
- Research and Evaluation Division, Ministry of Health, Singapore
| | - Kelvin Tan
- Research and Evaluation Division, Ministry of Health, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
- Centre of Regulatory Excellence, Duke-NUS Medical School, Singapore
| | | |
Collapse
|
31
|
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
|
32
|
Ospel JM, Kashani N, Turjman F, Fischer U, Baxter B, Rabinstein A, Coutts S, Menon BK, Almekhlafi M, Hill MD, Saposnik G, Goyal M. Discrepancies between current and ideal endovascular stroke treatment practice in Europe and North America: Results from UNMASK EVT, a multidisciplinary survey. Interv Neuroradiol 2020; 26:420-424. [PMID: 32077353 PMCID: PMC7446587 DOI: 10.1177/1591019920908131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 01/18/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Since 2015, endovascular therapy has been established as a standard of care for acute stroke. This has caused major challenges regarding the organization of systems of care, which have to meet the increasing demand for thrombectomies. This study aims to evaluate how endovascular therapy decisions made by European and North American physicians under their current local resources differ from those made under assumed ideal conditions. METHODS In an international, multidisciplinary survey, physicians involved in acute stroke care were asked to give their treatment decisions to 10 out of 22 randomly assigned stroke case-scenarios. Participants stated (a) their treatment approach under assumed ideal conditions (without any external limitations) and (b) the treatment they would pursue under their current local resources. Resources gaps (ideal minus current endovascular therapy rates) were calculated for different countries/states/provinces and correlated to economic and healthcare key metrics (gross domestic product-per-capita, public or private health insurance coverage, etc.). RESULTS A total of 607 physicians, among them 218 from North America and 136 from 25 European countries, responded to the survey. Resources gaps in the majority of North American states/provinces and European countries were small (<5%). The highest gaps were observed among few European countries, namely Poland (30%) and the United Kingdom (33%). The magnitude of the resources gap did not correlate to national economic or healthcare metrics. DISCUSSION AND CONCLUSION In the majority of North American states/provinces and European countries covered in this study, the discrepancy between endovascular therapy decisions under current local resources and assumed ideal conditions seems to be small, even in countries with a limited economic status and healthcare infrastructure.
Collapse
Affiliation(s)
- Johanna M Ospel
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Division of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Nima Kashani
- Department of Radiology, University of Calgary, Calgary, Canada
| | - Francis Turjman
- Department of Interventional Neuroradiology at Lyon University Hospital, University of Lyon, Lyon, France
| | - Urs Fischer
- Department of Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Blaise Baxter
- College of Medicine, University of Tennessee, Chattanooga, TN, USA
| | | | - Sheilagh Coutts
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Community Health Sciences, University of Calgary, Calgary, Canada
| | - Bijoy K Menon
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Department of Radiology, University of Calgary, Calgary, Canada
| | - Mohammed Almekhlafi
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Department of Radiology, University of Calgary, Calgary, Canada
| | - Michael D Hill
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Department of Radiology, University of Calgary, Calgary, Canada
| | - Gustavo Saposnik
- Division of Neurology, Department of Medicine, St. Michael’s Hospital, University of Toronto, Toronto, Canada
| | - Mayank Goyal
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Department of Radiology, University of Calgary, Calgary, Canada
| |
Collapse
|
33
|
Daou BJ, Yost ML, Syrjamaki JD, Fearer KJ, Koduri S, Burke JF, Gemmete JJ, Chaudhary N, Thompson BG, Pandey AS. Drivers of variation in 90-day episode payments after mechanical thrombectomy for acute ischemic stroke. J Neurointerv Surg 2020; 13:519-523. [PMID: 32737204 DOI: 10.1136/neurintsurg-2020-016389] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 06/29/2020] [Accepted: 07/05/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND Although mechanical thrombectomy for acute ischemic stroke from a large vessel occlusion is now the standard of care, little is known about cost variations in stroke patients following thrombectomy and factors that influence these variations. METHODS We evaluated claims data for 2016 to 2018 for thrombectomy-performing hospitals within Michigan through a registry that includes detailed episode payment information for both Medicare and privately insured patients. We aimed to analyze price-standardized and risk-adjusted 90-day episode payments in patients who underwent thrombectomy. Hospitals were grouped into three payment terciles for comparison. Statistical analysis was carried out using unpaired t-test, Chi-square, and ANOVA tests. RESULTS 1076 thrombectomy cases treated at 16 centers were analyzed. The average 90-day episode payment by hospital ranged from $53 046 to $81,767, with a mean of $65 357. A $20 467 difference (35.1%) existed between the high and low payment hospital terciles (P<0.0001), highlighting a significant payment variation across hospital terciles. The primary drivers of payment variation were related to post-discharge care which accounted for 38% of the payment variation (P=0.0058, inter-tercile range $11,977-$19,703) and readmissions accounting for 26% (P=0.016, inter-tercile range $3,315-$7,992). This was followed by professional payments representing 20% of the variation (P<0.0001, inter-tercile range $7525-$9,922), while index hospitalization payment was responsible for only 16% of the 90-day episode payment variation (P=0.10, inter-tercile range $35,432-$41,099). CONCLUSIONS There is a wide variation in 90-day episode payments for patients undergoing mechanical thrombectomy across centers. The main drivers of payment variation are related to differences in post-discharge care and readmissions.
Collapse
Affiliation(s)
- Badih J Daou
- Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Monica L Yost
- Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Kelsey J Fearer
- Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | | | - James F Burke
- Neurology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Joseph J Gemmete
- Radiology and Neurosurgery, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Neeraj Chaudhary
- Radiology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | | | - Aditya S Pandey
- Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| |
Collapse
|
34
|
Kurz MW, Ospel JM, Advani R, Sandset EC, Aamodt AH, Tennøe B, Ersdal HL, Fjetland L, Ajmi S, Kurz KD, Goyal M. Simulation Methods in Acute Stroke Treatment: Current State of Affairs and Implications. Stroke 2020; 51:1978-1982. [PMID: 32568639 DOI: 10.1161/strokeaha.119.026732] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Martin W Kurz
- Department of Neurology (M.W.K., S.A.), Stavanger University Hospital, Norway.,Neuroscience Research Group (M.W.K., R.A., S.A.), Stavanger University Hospital, Norway.,Department of Clinical Science, University of Bergen, Norway (M.W.K.)
| | - Johanna M Ospel
- Department of Clinical Neurosciences (J.M.O.), University of Calgary, Alberta, Canada.,Department of Radiology, Universitätsspital Basel, Switzerland (J.M.O.)
| | - Rajiv Advani
- Neuroscience Research Group (M.W.K., R.A., S.A.), Stavanger University Hospital, Norway.,Department of Neurology, Stroke Unit (R.A., E.C.S.), Oslo University Hospital, Norway
| | - Else Charlotte Sandset
- Department of Neurology, Stroke Unit (R.A., E.C.S.), Oslo University Hospital, Norway.,Department of Research and Development, The Norwegian Air Ambulance Foundation, Oslo, Norway (E.C.S.)
| | - Anne Hege Aamodt
- Department of Neurology (A.H.A.), Oslo University Hospital, Norway
| | - Bjørn Tennøe
- Department of Radiology and Nuclear Medicine, Division of Diagnostics and Intervention (B.T.), Oslo University Hospital, Norway
| | - Hege L Ersdal
- Department of Anesthesiology and Intensive Care (H.L.E.), Stavanger University Hospital, Norway.,Faculty of Health Sciences (H.L.E.), University of Stavanger, Norway
| | - Lars Fjetland
- Department of Radiology (L.F., K.D.K.), Stavanger University Hospital, Norway.,SMIL Stavanger Medical Imaging Laboratory (L.F., K.D.K.), Stavanger University Hospital, Norway
| | - Soffien Ajmi
- Department of Neurology (M.W.K., S.A.), Stavanger University Hospital, Norway.,Neuroscience Research Group (M.W.K., R.A., S.A.), Stavanger University Hospital, Norway
| | - Kathinka D Kurz
- Department of Radiology (L.F., K.D.K.), Stavanger University Hospital, Norway.,SMIL Stavanger Medical Imaging Laboratory (L.F., K.D.K.), Stavanger University Hospital, Norway.,Department of Electrical and Computer Engineering (K.D.K.), University of Stavanger, Norway
| | - Mayank Goyal
- Diagnostic Imaging (M.G.), University of Calgary, Alberta, Canada.,Department of Clinical Neurosciences (M.G.), University of Calgary, Alberta, Canada
| |
Collapse
|
35
|
Kunz WG, Almekhlafi MA, Menon BK, Saver JL, Hunink MG, Dippel DW, Majoie CB, Liebeskind DS, Jovin TG, Davalos A, Bracard S, Guillemin F, Campbell BC, Mitchell PJ, White P, Muir KW, Brown S, Demchuk AM, Hill MD, Goyal M. Public Health and Cost Benefits of Successful Reperfusion After Thrombectomy for Stroke. Stroke 2020; 51:899-907. [DOI: 10.1161/strokeaha.119.027874] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background and Purpose—
The benefit that endovascular thrombectomy offers to patients with stroke with large vessel occlusions depends strongly on reperfusion grade as defined by the expanded Thrombolysis in Cerebral Infarction (eTICI) scale. Our aim was to determine the lifetime health and cost consequences of the quality of reperfusion for patients, healthcare systems, and society.
Methods—
A Markov model estimated lifetime quality-adjusted life years (QALY) and lifetime costs of endovascular thrombectomy–treated patients with stroke based on eTICI grades. The analysis was performed over a lifetime horizon in a United States setting, adopting healthcare and societal perspectives. The reference case analysis was conducted for stroke at 65 years of age. National health and cost consequences of improved eTICI 2c/3 reperfusion rates were estimated. Input parameters were based on best available evidence.
Results—
Lifetime QALYs increased for every grade of improved reperfusion (median QALYs for eTICI 0/1: 2.62; eTICI 2a: 3.46; eTICI 2b: 5.42; eTICI 2c: 5.99; eTICI 3: 6.73). Achieving eTICI 3 over eTICI 2b reperfusion resulted on average in 1.31 incremental QALYs as well as healthcare and societal cost savings of $10 327 and $20 224 per patient. A 10% increase in the eTICI 2c/3 reperfusion rate of all annually endovascular thrombectomy–treated patients with stroke in the United States is estimated to yield additional 3656 QALYs and save $21.0 million and $36.8 million for the healthcare system and society, respectively.
Conclusions—
Improved reperfusion grants patients with stroke additional QALYs and leads to long-term cost savings. Procedural strategies to achieve complete reperfusion should be assessed for safety and feasibility, even when initial reperfusion seems to be adequate.
Collapse
Affiliation(s)
- Wolfgang G. Kunz
- From the University of Calgary, Alberta, Canada (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.)
- Department of Radiology, University Hospital, LMU Munich, Germany (W.G.K.)
- David Geffen School of Medicine, University of California-Los Angeles (J.L.S., D.S.L.)
- Harvard T.H. Chan School of Public Health, Boston, MA (M.G.H.)
- Erasmus MC, University Medical Center Rotterdam, the Netherlands (M.G.H., D.W.J.D.)
| | - Mohammed A. Almekhlafi
- From the University of Calgary, Alberta, Canada (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.)
- Department of Radiology, University Hospital, LMU Munich, Germany (W.G.K.)
- David Geffen School of Medicine, University of California-Los Angeles (J.L.S., D.S.L.)
- Harvard T.H. Chan School of Public Health, Boston, MA (M.G.H.)
- Erasmus MC, University Medical Center Rotterdam, the Netherlands (M.G.H., D.W.J.D.)
| | - Bijoy K. Menon
- From the University of Calgary, Alberta, Canada (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.)
- Department of Radiology, University Hospital, LMU Munich, Germany (W.G.K.)
- David Geffen School of Medicine, University of California-Los Angeles (J.L.S., D.S.L.)
- Harvard T.H. Chan School of Public Health, Boston, MA (M.G.H.)
- Erasmus MC, University Medical Center Rotterdam, the Netherlands (M.G.H., D.W.J.D.)
| | - Jeffrey L. Saver
- From the University of Calgary, Alberta, Canada (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.)
- Department of Radiology, University Hospital, LMU Munich, Germany (W.G.K.)
- David Geffen School of Medicine, University of California-Los Angeles (J.L.S., D.S.L.)
- Harvard T.H. Chan School of Public Health, Boston, MA (M.G.H.)
- Erasmus MC, University Medical Center Rotterdam, the Netherlands (M.G.H., D.W.J.D.)
| | - Myriam G. Hunink
- From the University of Calgary, Alberta, Canada (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.)
- Department of Radiology, University Hospital, LMU Munich, Germany (W.G.K.)
- David Geffen School of Medicine, University of California-Los Angeles (J.L.S., D.S.L.)
- Harvard T.H. Chan School of Public Health, Boston, MA (M.G.H.)
- Erasmus MC, University Medical Center Rotterdam, the Netherlands (M.G.H., D.W.J.D.)
| | - Diederik W.J. Dippel
- From the University of Calgary, Alberta, Canada (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.)
- Department of Radiology, University Hospital, LMU Munich, Germany (W.G.K.)
- David Geffen School of Medicine, University of California-Los Angeles (J.L.S., D.S.L.)
- Harvard T.H. Chan School of Public Health, Boston, MA (M.G.H.)
- Erasmus MC, University Medical Center Rotterdam, the Netherlands (M.G.H., D.W.J.D.)
| | - Charles B.L.M. Majoie
- From the University of Calgary, Alberta, Canada (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.)
- Department of Radiology, University Hospital, LMU Munich, Germany (W.G.K.)
- David Geffen School of Medicine, University of California-Los Angeles (J.L.S., D.S.L.)
- Harvard T.H. Chan School of Public Health, Boston, MA (M.G.H.)
- Erasmus MC, University Medical Center Rotterdam, the Netherlands (M.G.H., D.W.J.D.)
| | - David S. Liebeskind
- From the University of Calgary, Alberta, Canada (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.)
- Department of Radiology, University Hospital, LMU Munich, Germany (W.G.K.)
- David Geffen School of Medicine, University of California-Los Angeles (J.L.S., D.S.L.)
- Harvard T.H. Chan School of Public Health, Boston, MA (M.G.H.)
- Erasmus MC, University Medical Center Rotterdam, the Netherlands (M.G.H., D.W.J.D.)
| | - Tudor G. Jovin
- From the University of Calgary, Alberta, Canada (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.)
- Department of Radiology, University Hospital, LMU Munich, Germany (W.G.K.)
- David Geffen School of Medicine, University of California-Los Angeles (J.L.S., D.S.L.)
- Harvard T.H. Chan School of Public Health, Boston, MA (M.G.H.)
- Erasmus MC, University Medical Center Rotterdam, the Netherlands (M.G.H., D.W.J.D.)
| | - Antoni Davalos
- From the University of Calgary, Alberta, Canada (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.)
- Department of Radiology, University Hospital, LMU Munich, Germany (W.G.K.)
- David Geffen School of Medicine, University of California-Los Angeles (J.L.S., D.S.L.)
- Harvard T.H. Chan School of Public Health, Boston, MA (M.G.H.)
- Erasmus MC, University Medical Center Rotterdam, the Netherlands (M.G.H., D.W.J.D.)
| | - Serge Bracard
- From the University of Calgary, Alberta, Canada (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.)
- Department of Radiology, University Hospital, LMU Munich, Germany (W.G.K.)
- David Geffen School of Medicine, University of California-Los Angeles (J.L.S., D.S.L.)
- Harvard T.H. Chan School of Public Health, Boston, MA (M.G.H.)
- Erasmus MC, University Medical Center Rotterdam, the Netherlands (M.G.H., D.W.J.D.)
| | - Francis Guillemin
- From the University of Calgary, Alberta, Canada (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.)
- Department of Radiology, University Hospital, LMU Munich, Germany (W.G.K.)
- David Geffen School of Medicine, University of California-Los Angeles (J.L.S., D.S.L.)
- Harvard T.H. Chan School of Public Health, Boston, MA (M.G.H.)
- Erasmus MC, University Medical Center Rotterdam, the Netherlands (M.G.H., D.W.J.D.)
| | - Bruce C.V. Campbell
- From the University of Calgary, Alberta, Canada (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.)
- Department of Radiology, University Hospital, LMU Munich, Germany (W.G.K.)
- David Geffen School of Medicine, University of California-Los Angeles (J.L.S., D.S.L.)
- Harvard T.H. Chan School of Public Health, Boston, MA (M.G.H.)
- Erasmus MC, University Medical Center Rotterdam, the Netherlands (M.G.H., D.W.J.D.)
| | - Peter J. Mitchell
- From the University of Calgary, Alberta, Canada (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.)
- Department of Radiology, University Hospital, LMU Munich, Germany (W.G.K.)
- David Geffen School of Medicine, University of California-Los Angeles (J.L.S., D.S.L.)
- Harvard T.H. Chan School of Public Health, Boston, MA (M.G.H.)
- Erasmus MC, University Medical Center Rotterdam, the Netherlands (M.G.H., D.W.J.D.)
| | - Philip White
- From the University of Calgary, Alberta, Canada (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.)
- Department of Radiology, University Hospital, LMU Munich, Germany (W.G.K.)
- David Geffen School of Medicine, University of California-Los Angeles (J.L.S., D.S.L.)
- Harvard T.H. Chan School of Public Health, Boston, MA (M.G.H.)
- Erasmus MC, University Medical Center Rotterdam, the Netherlands (M.G.H., D.W.J.D.)
| | - Keith W. Muir
- From the University of Calgary, Alberta, Canada (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.)
- Department of Radiology, University Hospital, LMU Munich, Germany (W.G.K.)
- David Geffen School of Medicine, University of California-Los Angeles (J.L.S., D.S.L.)
- Harvard T.H. Chan School of Public Health, Boston, MA (M.G.H.)
- Erasmus MC, University Medical Center Rotterdam, the Netherlands (M.G.H., D.W.J.D.)
| | - Scott Brown
- From the University of Calgary, Alberta, Canada (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.)
- Department of Radiology, University Hospital, LMU Munich, Germany (W.G.K.)
- David Geffen School of Medicine, University of California-Los Angeles (J.L.S., D.S.L.)
- Harvard T.H. Chan School of Public Health, Boston, MA (M.G.H.)
- Erasmus MC, University Medical Center Rotterdam, the Netherlands (M.G.H., D.W.J.D.)
| | - Andrew M. Demchuk
- From the University of Calgary, Alberta, Canada (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.)
- Department of Radiology, University Hospital, LMU Munich, Germany (W.G.K.)
- David Geffen School of Medicine, University of California-Los Angeles (J.L.S., D.S.L.)
- Harvard T.H. Chan School of Public Health, Boston, MA (M.G.H.)
- Erasmus MC, University Medical Center Rotterdam, the Netherlands (M.G.H., D.W.J.D.)
| | - Michael D. Hill
- From the University of Calgary, Alberta, Canada (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.)
- Department of Radiology, University Hospital, LMU Munich, Germany (W.G.K.)
- David Geffen School of Medicine, University of California-Los Angeles (J.L.S., D.S.L.)
- Harvard T.H. Chan School of Public Health, Boston, MA (M.G.H.)
- Erasmus MC, University Medical Center Rotterdam, the Netherlands (M.G.H., D.W.J.D.)
| | - Mayank Goyal
- From the University of Calgary, Alberta, Canada (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.)
- Department of Radiology, University Hospital, LMU Munich, Germany (W.G.K.)
- David Geffen School of Medicine, University of California-Los Angeles (J.L.S., D.S.L.)
- Harvard T.H. Chan School of Public Health, Boston, MA (M.G.H.)
- Erasmus MC, University Medical Center Rotterdam, the Netherlands (M.G.H., D.W.J.D.)
| | | |
Collapse
|
36
|
Malhotra A, Wu X, Payabvash S, Matouk CC, Forman HP, Gandhi D, Sanelli P, Schindler J. Comparative Effectiveness of Endovascular Thrombectomy in Elderly Stroke Patients. Stroke 2020; 50:963-969. [PMID: 30908156 DOI: 10.1161/strokeaha.119.025031] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background and Purpose- Strokes in patients aged ≥80 years are common, and advanced age is associated with relatively poor poststroke functional outcome. The current guidelines do not recommend an upper age limit for endovascular thrombectomy (EVT). The purpose of this study is to evaluate the effectiveness of EVT in acute stroke because of large vessel occlusion for elderly patients >age 80 years. Methods- A Markov decision analytic model was constructed from a societal perspective to evaluate health outcomes in terms of quality-adjusted life years (QALYs) after EVT for acute ischemic stroke because of large vessel occlusion in patients above age 80 years. Age-specific input parameters were obtained from the most recent/comprehensive literature. Good outcome was defined as a modified Rankin Scale score ≤2. Probabilistic, 1-way, and 2-way sensitivity analyses were performed for both healthy patients and patients with disability at baseline. Results- Base case calculation showed in functionally independent patients at baseline, intravenous thrombolysis (IVT) with tPA (tissue-type plasminogen activator) only to be the better strategy with 3.76 QALYs compared to 2.93 QALYs for patients undergoing EVT. The difference in outcome is 0.83 QALY (equivalent to 303 days of life in perfect health). For patients with baseline disability, IVT only yields a utility of 1.92 QALYs and EVT yields a utility of 1.65 QALYs. The difference is 0.27 QALYs (equivalent to 99 days of life in perfect health). Multiple sensitivity analyses showed that the effectiveness of EVT is significantly determined by the morbidity and mortality after both IVT and EVT strategies, respectively. Conclusions- Our study demonstrates the impact of relevant factors on the effectiveness of EVT in patients above 80 years of age. Morbidity and mortality after both IVT and EVT strategies significantly influence the outcomes in both healthy and disabled patients at baseline. Better identification of patients not benefiting from IVT would optimize the selective use of EVT thereby improving its effectiveness.
Collapse
Affiliation(s)
- Ajay Malhotra
- From the Department of Radiology and Biomedical Imaging (A.M., X.W., S.P., C.C.M., H.P.F.), Yale University School of Medicine, New Haven, CT
| | - Xiao Wu
- From the Department of Radiology and Biomedical Imaging (A.M., X.W., S.P., C.C.M., H.P.F.), Yale University School of Medicine, New Haven, CT
| | - Seyedmehdi Payabvash
- From the Department of Radiology and Biomedical Imaging (A.M., X.W., S.P., C.C.M., H.P.F.), Yale University School of Medicine, New Haven, CT
| | - Charles C Matouk
- From the Department of Radiology and Biomedical Imaging (A.M., X.W., S.P., C.C.M., H.P.F.), Yale University School of Medicine, New Haven, CT.,Department of Neurosurgery (C.C.M.), Yale University School of Medicine, New Haven, CT
| | - Howard P Forman
- From the Department of Radiology and Biomedical Imaging (A.M., X.W., S.P., C.C.M., H.P.F.), Yale University School of Medicine, New Haven, CT.,Department of Economics, Management, and Public Health (H.P.F.), Yale University School of Medicine, New Haven, CT
| | - Dheeraj Gandhi
- Interventional Neuroradiology, Nuclear Medicine, Neurology and Neurosurgery, University of Maryland School of Medicine, Baltimore (D.G.)
| | - Pina Sanelli
- and Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, NY (P.S.)
| | - Joseph Schindler
- Division of Vascular Neurology (J.S.), Yale University School of Medicine, New Haven, CT
| |
Collapse
|
37
|
Heggie R, Wu O, White P, Ford GA, Wardlaw J, Brown MM, Clifton A, Muir KW. Mechanical thrombectomy in patients with acute ischemic stroke: A cost-effectiveness and value of implementation analysis. Int J Stroke 2019; 15:881-898. [DOI: 10.1177/1747493019879656] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Recent clinical trials have demonstrated the efficacy of mechanical thrombectomy in acute ischemic stroke. Aims To determine the cost-effectiveness, value of future research, and value of implementation of mechanical thrombectomy. Methods Using UK clinical and cost data from the Pragmatic Ischemic Stroke Thrombectomy Evaluation (PISTE) trial, we estimated the cost-effectiveness of mechanical thrombectomy over time horizons of 90-days and lifetime, based on a decision-analytic model, using all existing evidence. We performed a meta-analysis of seven clinical trials to estimate treatment effects. We used sensitivity analysis to address uncertainty. Value of implementation analysis was used to estimate the potential value of additional implementation activities to support routine delivery of mechanical thrombectomy. Results Over the trial period (90 days), compared with best medical care alone, mechanical thrombectomy incurred an incremental cost of £5207 and 0.025 gain in QALY (incremental cost-effectiveness ratio (ICER) £205,279), which would not be considered cost-effective. However, mechanical thrombectomy was shown to be cost-effective over a lifetime horizon, with an ICER of £3466 per QALY gained. The expected value of perfect information per patient eligible for mechanical thrombectomy in the UK is estimated at £3178. The expected value of full implementation of mechanical thrombectomy is estimated at £1.3 billion over five years. Conclusion Mechanical thrombectomy was cost-effective compared with best medical care alone over a patient’s lifetime. On the assumption of 30% implementation being achieved throughout the UK healthcare system, we estimate that the population health benefits obtained from this treatment are greater than the cost of implementation. Trial registration NCT01745692.
Collapse
Affiliation(s)
- Robert Heggie
- Health Economics and Health Technology Assessment (HEHTA), Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Olivia Wu
- Health Economics and Health Technology Assessment (HEHTA), Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Phil White
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Gary A Ford
- Division of Medical Sciences, Oxford University Hospitals NHS Trust, Oxford University, Oxford, UK
| | - Joanna Wardlaw
- Brain Research Imaging Centre, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Martin M Brown
- Stroke Research Centre, UCL Institute of Neurology, University College London, London, UK
| | | | - Keith W Muir
- Institute of Neuroscience & Psychology, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, UK
| |
Collapse
|
38
|
Kamal N, Rogers E, Stang J, Mann B, Butcher KS, Rempel J, Jeerakathil T, Shuaib A, Goyal M, Menon BK, Demchuk AM, Hill MD. One-Year Healthcare Utilization for Patients That Received Endovascular Treatment Compared With Control. Stroke 2019; 50:1883-1886. [PMID: 31154945 DOI: 10.1161/strokeaha.119.024870] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Endovascular therapy has been shown to be highly efficacious based on 90-day modified Rankin Scale score. We examined actual daily healthcare utilization from stroke onset to 1 year afterward from the ESCAPE trial (Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis on Minimizing CT to Recanalization Time) and registry data. Methods- We examined patients from Alberta, Canada, that was enrolled into the ESCAPE trial and the Quality Improvement and Clinical Research registry in the 2016/2017 fiscal year. Through data linkages to several administrative data sets, the daily location of each patient was assessed in various healthcare settings. Results- A total of 286 patients were analyzed, 52 patients were in the treatment arm, and 47 patients were in the control arm of the ESCAPE trial while 187 patients received endovascular therapy as usual care (2016/2017 fiscal year). The odds of a patient being out of a healthcare setting over 1 year was significantly higher when they received endovascular therapy: 3.46 (1.68-7.30) in ESCAPE trial patients and 2.00 (1.08-3.75) in the Quality Improvement And Clinical Research patients. Conclusions- Endovascular therapy significantly reduces healthcare utilization up to 1 year after a stroke.
Collapse
Affiliation(s)
- Noreen Kamal
- From the Department of Industrial Engineering, Dalhousie University, Halifax, Nova Scotia, Canada (N.K.)
| | - Edwin Rogers
- Data Analytics, Alberta Health Services, Canada (E.R., J.S.)
| | - Jillian Stang
- Data Analytics, Alberta Health Services, Canada (E.R., J.S.)
| | - Balraj Mann
- Cardiovascular Health and Stroke, Strategic Clinical Network, Alberta Health Services, Edmonton, Canada (B.M.)
| | - Kenneth S Butcher
- Prince of Wales Clinical School, University of New South Wales, Sydney, Australia (K.S.B., T.J., A.S.).,Division of Neurology, Department of Medicine (K.S.B.), University of Alberta, Edmonton, Canada
| | - Jeremy Rempel
- Department of Radiology and Diagnostic Imaging (J.R.), University of Alberta, Edmonton, Canada
| | - Thomas Jeerakathil
- Prince of Wales Clinical School, University of New South Wales, Sydney, Australia (K.S.B., T.J., A.S.)
| | - Ashfaq Shuaib
- Prince of Wales Clinical School, University of New South Wales, Sydney, Australia (K.S.B., T.J., A.S.)
| | - Mayank Goyal
- Department of Clinical Neurosciences (M.G., B.K.M., A.M.D., M.D.H.).,Department of Radiology (M.G., B.K.M., M.D.H.).,Hotchkiss Brain Institute (M.G., B.K.M., A.M.D., M.D.H.)
| | - Bijoy K Menon
- Department of Clinical Neurosciences (M.G., B.K.M., A.M.D., M.D.H.).,Department of Radiology (M.G., B.K.M., M.D.H.).,Hotchkiss Brain Institute (M.G., B.K.M., A.M.D., M.D.H.)
| | - Andrew M Demchuk
- Department of Clinical Neurosciences (M.G., B.K.M., A.M.D., M.D.H.).,Hotchkiss Brain Institute (M.G., B.K.M., A.M.D., M.D.H.)
| | - Michael D Hill
- Department of Clinical Neurosciences (M.G., B.K.M., A.M.D., M.D.H.).,Department of Radiology (M.G., B.K.M., M.D.H.).,Hotchkiss Brain Institute (M.G., B.K.M., A.M.D., M.D.H.).,Department of Community Health Sciences (M.D.H.).,Department of Medicine, University of Calgary, Alberta, Canada (M.D.H.)
| |
Collapse
|
39
|
Pizzo E, Dumba M, Lobotesis K. Cost-utility analysis of mechanical thrombectomy between 6 and 24 hours in acute ischemic stroke. Int J Stroke 2019; 15:75-84. [DOI: 10.1177/1747493019830587] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Recently, two randomized controlled trials demonstrated the benefit of mechanical thrombectomy performed between 6 and 24 h in acute ischemic stroke. The current economic evidence is supporting the intervention only within 6 h, but extended thrombectomy treatment times may result in better long-term outcomes for a larger cohort of patients. Aims We compared the cost-utility of mechanical thrombectomy in addition to medical treatment versus medical treatment alone performed beyond 6 h from stroke onset in the UK National Health Service (NHS). Methods A cost-utility analysis of mechanical thrombectomy compared to medical treatment was performed using a Markov model that estimates expected costs and quality-adjusted life years (QALYs) over a 20-year time horizon. We present the results of three models using the data from the DEFUSE 3 and DAWN trials and evidence from published sources. Results Over a 20-year period, the incremental cost per QALY of mechanical thrombectomy was $1564 (£1219) when performed after 12 h from onset, $5253 (£4096) after 16 h and $3712 (£2894) after 24 h. The probabilistic sensitivity analysis demonstrated that thrombectomy had a 99.9% probability of being cost-effective at the minimum willingness to pay for a QALY commonly used in the UK. Conclusions The results of this study demonstrate that performing mechanical thrombectomy up to 24 h from acute ischemic stroke symptom onset is still cost-effective, suggesting that this intervention should be implemented by the NHS on the basis of improvement in quality of life as well as economic grounds.
Collapse
Affiliation(s)
- Elena Pizzo
- Department of Applied Health Research, University College London, London, UK
| | - Maureen Dumba
- Imaging Department, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
| | - Kyriakos Lobotesis
- Imaging Department, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
| |
Collapse
|
40
|
Teljeur C, Harrington P, Glynn RW, Ryan M. Acute ischaemic stroke: a systematic review of the cost-effectiveness of emergency endovascular therapy using mechanical thrombectomy. Ir J Med Sci 2018; 188:751-759. [PMID: 30536140 DOI: 10.1007/s11845-018-1946-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 12/03/2018] [Indexed: 12/15/2022]
Abstract
PURPOSE Although good evidence exists regarding the clinical effectiveness of mechanical thrombectomy for people with acute ischaemic stroke, cost-effectiveness should also be considered. The aim of this study was to systematically review the evidence of cost-effectiveness of emergency endovascular therapy using mechanical thrombectomy in the management of acute ischaemic stroke. METHODS The search was carried out in PubMed, EMBASE, Cochrane Library, and a grey literature search. Studies were included if they compared the costs and consequences of mechanical thrombectomy added to usual medical care compared to usual care alone for people with acute ischaemic stroke in the anterior and/or posterior region. Study quality was assessed using two appraisal tools tailored to economic evaluations. FINDINGS Thirteen studies were identified including twelve cost-utility analyses and one cost-benefit analysis. Studies could be dichotomised into those that evaluated first-generation (n = 4) and second-generation (n = 9) mechanical thrombectomy devices. Six studies had low applicability, six had moderate applicability, and one had high applicability to other settings. All cost-utility studies reported incremental cost-effectiveness ratios that would be considered cost-effective under typical willingness-to-pay thresholds. CONCLUSIONS If the outcomes of the trials underpinning the evidence of clinical effectiveness can be replicated, then mechanical thrombectomy is likely to be cost-effective by typical willingness-to-pay thresholds. This finding holds under the assumption that no investment is required to develop stroke centres to the standard required to provide a safe emergency endovascular service and that additional expenditure on timely patient transport is not required.
Collapse
Affiliation(s)
- Conor Teljeur
- Health Information and Quality Authority, George's Court, George's Lane, Dublin, D07 E98Y, Ireland. .,Trinity College Dublin, Dublin, Ireland.
| | - Patricia Harrington
- Health Information and Quality Authority, George's Court, George's Lane, Dublin, D07 E98Y, Ireland.,Trinity College Dublin, Dublin, Ireland
| | - Ronan W Glynn
- Health Information and Quality Authority, George's Court, George's Lane, Dublin, D07 E98Y, Ireland
| | - Máirín Ryan
- Health Information and Quality Authority, George's Court, George's Lane, Dublin, D07 E98Y, Ireland.,Trinity College Dublin, Dublin, Ireland
| |
Collapse
|
41
|
Emergency medical services for acute ischemic stroke: Hub-and-spoke model versus exclusive care in comprehensive centers. J Clin Neurosci 2018; 60:12-16. [PMID: 30348588 DOI: 10.1016/j.jocn.2018.10.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Accepted: 10/05/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND The emergent disposition of acute stroke patients remains an issue of debate. We investigated whether a hub-and-spoke model was associated with worse stroke outcomes when compared to care exclusively in comprehensive centers. METHODS We performed a cohort study of all acute ischemic stroke patients who were hospitalized in endovascular-capable facilities, and were registered in the New York Statewide Planning and Research Cooperative System (SPARCS) database from 2009 to 2015. We examined the association of transfer status (transfer to endovascular capable hospitals versus initial treatment in these facilities) with inpatient case-fatality, discharge to a facility, and length of stay (LOS). An instrumental variable analysis was used to control for unmeasured confounding and simulate a randomized trial. RESULTS During the study period, 128,122 acute stroke patients met inclusion criteria. Instrumental variable analysis demonstrated that patients transferred to endovascular-capable hospitals did not have higher case-fatality (Adjusted difference, 4.4%; 95% CI, -0.1% to 9.0%), rate discharge to a facility (Adjusted difference, -2.3%; 95% CI, -5.2% to 0.6%), or longer LOS (Adjusted difference, 4.2; 95% CI, -2.2 to 10.1) in comparison to patients presenting for initial treatment in these facilities. The same associations were present when restricting the cohort to patients receiving intravenous tissue plasminogen (IV-tPA) and to patients receiving mechanical thrombectomy. CONCLUSIONS Using a comprehensive all-payer cohort of acute ischemic stroke patients in New York State we demonstrated that patients treated in a hub-and-spoke model were not associated with worse outcomes than patients receiving care exclusively in comprehensive institutions. This needs to be taken into consideration when considering acute emergency services in this setting.
Collapse
|
42
|
Yan C, Zheng Y, Hill MD, Mann B, Jeerakathil T, Kamal N, Amlani S, Chuck AW. Health Technology Optimization Analysis: Conceptual Approach and Illustrative Application. MDM Policy Pract 2018; 3:2381468318774804. [PMID: 30288446 PMCID: PMC6157433 DOI: 10.1177/2381468318774804] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 04/06/2018] [Indexed: 01/19/2023] Open
Abstract
We present a conceptual approach to determine the optimal solution to delivering
a health technology, consistent with the objective of maximizing patient
outcomes subject to resources available to a publicly funded health system. The
article addresses two key policy questions: 1) adding system values through
appropriate planning of health services delivery and 2) considering the tradeoff
between patient outcomes and costs to the health system through appropriate use
of health technologies for conditions with time-dependent treatment outcomes. We
develop a health technology optimization framework that considers geographical
variation and searches for the best delivery method through a pairwise
comparison of all possible strategies, factoring in controlled variables
including disease epidemiology, time or distance to hospitals, available medical
services, treatment eligibility, treatment efficacy, and costs. Taking
variations of these factors into account would help support a more efficient
allocation of health resources. Drawing identified strategies together then
creates a map of optimal strategies. We apply the proposed method to a
policy-relevant health technology assessment of endovascular therapy (EVT) for
treating acute ischemic stroke. The best strategy for providing EVT relies on
the geographical location of stroke onset and the decision maker’s preference
for either patient outcomes or economic efficiency. The proposed method produced
an optimization map showing the optimal strategy for EVT delivery, which
maximizes patient outcomes while minimizing health system costs. In the
illustrative case study, there were no tradeoffs between health outcomes and
costs, meaning that the delivery strategies that were clinically optimal for
patients were also the most cost-effective. In conclusion, the health technology
optimization approach is a useful tool for informing implementation decisions
and coordinating the delivery of complex health services such as EVT.
Collapse
Affiliation(s)
- Charles Yan
- Institute of Health Economics, Edmonton, Alberta, Canada
| | - Yufei Zheng
- Institute of Health Economics, Edmonton, Alberta, Canada
| | | | - Balraj Mann
- Cardiovascular Health & Stroke SCN, Alberta Health Services, Alberta, Canada
| | | | | | - Shy Amlani
- Alberta Health Services, Edmonton, Alberta, Canada
| | | |
Collapse
|
43
|
Ruggeri M, Basile M, Zini A, Mangiafico S, Agostoni EC, Lobotesis K, Saver J, Coretti S, Drago C, Cicchetti A. Cost-effectiveness analysis of mechanical thrombectomy with stent retriever in the treatment of acute ischemic stroke in Italy. J Med Econ 2018; 21:902-911. [PMID: 29882711 DOI: 10.1080/13696998.2018.1484748] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
BACKGROUND Stroke has a significant disease burden in terms of acute and long-term disability in Italy and throughout the world. Endovascular treatments for the management of a stroke event have been coupled in the past years with the possibility to mechanically remove the occlusion by means of specially designed thrombectomy devices, and their exclusive use showed levels of effectiveness in line with those of the existing pharmacological treatments. OBJECTIVE To assess the cost-effectiveness of mechanical thrombectomy (MT) with the Solitaire Revascularization Device (stent retriever) for the treatment of acute ischemic stroke (AIS) in patients with large vessel occlusions (LVOs), comparing MT plus intravenous tissue plasminogen activation (MT plus IV t-PA) vs IV t-PA alone, in Italy. METHODS A Markov model was used to simulate costs and benefits of MT plus IV t-PA and IV t-PA alone over a 5-year time horizon and considering the perspective of the Italian National Health Service (NHS). Results are reported in terms of Incremental Cost Effectiveness Ratio (ICER). Deterministic and probabilistic sensitivity analyses are carried out in order to test the robustness of the results. RESULTS Total costs of MT plus IV t-PA and IV t-PA alone are equal to €31,798 and €34,855, respectively. The MT allows incremental QALYs for 0.77, determining a dominant ICER. The utilities associated to the mRS health states are the parameters with the highest impact on the results. Multiway sensitivity analyses determined a 90% probability of dominance. CONCLUSIONS MT plus IV t-PA for AIS patients with LVO is cost-effective from year 1 through year 3, and cost-saving from year 4 onward in the Italian context, achieving better results, both in terms of efficacy and in terms of resource consumption.
Collapse
Affiliation(s)
- Matteo Ruggeri
- a ALTEMS Postgraduate School of Health Economics , Rome , Italy
| | - Michele Basile
- a ALTEMS Postgraduate School of Health Economics , Rome , Italy
| | - Andrea Zini
- b Stroke Unit, Neurology Clinic, Department of Neuroscience , Nuovo Ospedale Civile "S.Agostino-Estense", Modena University Hospital , Modena , Italy
| | - Salvatore Mangiafico
- c Neurovascular Interventional Unit , Careggi University Hospital , Florence , Italy
| | | | | | - Jeffrey Saver
- f Department of Neurology and Comprehensive Stroke Center , David Geffen School of Medicine, University of California, Los Angeles (UCLA) , Los Angeles , CA , USA
| | - Silvia Coretti
- a ALTEMS Postgraduate School of Health Economics , Rome , Italy
| | | | | |
Collapse
|
44
|
Kunz WG, Hunink MG, Dimitriadis K, Huber T, Dorn F, Meinel FG, Sabel BO, Othman AE, Reiser MF, Ertl-Wagner B, Sommer WH, Thierfelder KM. Cost-effectiveness of Endovascular Therapy for Acute Ischemic Stroke: A Systematic Review of the Impact of Patient Age. Radiology 2018; 288:518-526. [DOI: 10.1148/radiol.2018172886] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
45
|
Arora N, Makino K, Tilden D, Lobotesis K, Mitchell P, Gillespie J. Cost-effectiveness of mechanical thrombectomy for acute ischemic stroke: an Australian payer perspective. J Med Econ 2018; 21:799-809. [PMID: 29741126 DOI: 10.1080/13696998.2018.1474746] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
AIMS The goal of this study was to assess the cost-effectiveness of mechanical thrombectomy (MT) for acute ischemic stroke (AIS) from an Australian payer perspective. METHODS This study used a Markov model that employed a life-time time horizon, modeling patients from symptom onset of stroke until end of life. Clinical efficacy and safety data were taken from an individual patient level data (IPD) meta-analysis of clinical studies. The treatment effect of MT compared to usual care was measured by changes in modified Rankin Score (mRS). Post-treatment mRS scores were used to determine short- and long-term stroke care costs. Treatment costs were modeled, with health state utility values determined by literature review. All analyses were conducted using Microsoft Excel. RESULTS In comparison to usual care, MT is associated with higher costs ($10,666 per patient) and additional quality-adjusted life years (QALYs) (0.8281 per patient), resulting in an incremental cost per QALY of $12,880. Sensitivity analyses demonstrated the reliability of the base case results across a range of assumptions. The higher cost associated with MT is, to an extent, offset by the cost savings resulting from lower stroke care costs due to improved patient outcomes. The life-time cost savings in terms of stroke care costs are estimated to be more than $8,000 per patient for patients who had received MT in combination with usual care. LIMITATIONS Stroke care costs based on patient disability/functional level were not available and were derived. As a consequence, long-term care costs for patients with poorer outcomes may be under-estimated. Patient outcomes at 90 days were extrapolated to a lifetime horizon, but this approach was supported by long-term evidence on stroke survival. CONCLUSIONS Mechanical thrombectomy is a cost-effective treatment option for AIS, with clinical benefits translating to short- and long-term cost benefits. This analysis supports rapid update of stroke care pathways to incorporate this therapy as a treatment option.
Collapse
Affiliation(s)
- Nimita Arora
- a THEMA Consulting Pty Ltd , Pyrmont , New South Wales , Australia
| | - Koji Makino
- a THEMA Consulting Pty Ltd , Pyrmont , New South Wales , Australia
| | - Dominic Tilden
- a THEMA Consulting Pty Ltd , Pyrmont , New South Wales , Australia
| | - Kyriakos Lobotesis
- b Imperial College Healthcare NHS Trust , Charing Cross Hospital , London , UK
| | - Peter Mitchell
- c University of Melbourne , Melbourne , Victoria , Australia
| | - John Gillespie
- d Medtronic Australasia Pty Ltd , Macquarie Park , New South Wales , Australia
| |
Collapse
|
46
|
Ganesh A, Goyal M. Thrombectomy for Acute Ischemic Stroke: Recent Insights and Future Directions. Curr Neurol Neurosci Rep 2018; 18:59. [PMID: 30033493 DOI: 10.1007/s11910-018-0869-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Mechanical thrombectomy has become the standard of care for acute ischemic stroke with proximal large vessel occlusions (LVO). This article reviews recent research relating to thrombectomy. RECENT FINDINGS Thrombectomy for anterior circulation stroke with proximal LVO was first shown to be highly efficacious within 6 h of stroke onset, but "late-window" trials have further demonstrated efficacy until 24-h postonset in select patients with salvageable tissue. However, the concept of "time is brain" remains critical. Thrombectomy trials have further stimulated worldwide efforts to develop systems of care for rapid treatment of eligible patients. Thrombectomy is cost-effective and likely to have long-term efficacy for both disability and mortality outcomes. Thrombectomy is a highly efficacious acute stroke therapy. Enduring uncertainties include efficacy in patients with premorbid disability, posterior circulation, or more distal occlusions; use of bridging thrombolysis; and optimal techniques to achieve consistent revascularization and address tandem occlusions or stenoses.
Collapse
Affiliation(s)
- Aravind Ganesh
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Mayank Goyal
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Canada. .,Department of Radiology, University of Calgary, Calgary, Canada. .,Seaman Family MR Research Centre, Foothills Medical Centre, University of Calgary, 1403 29th St NW, Calgary, AB, T2N 2T9, Canada.
| |
Collapse
|
47
|
Ryu WHA, Yang MMH, Muram S, Jacobs WB, Casha S, Riva-Cambrin J. Systematic review of health economic studies in cranial neurosurgery. Neurosurg Focus 2018; 44:E2. [PMID: 29712519 DOI: 10.3171/2018.2.focus17792] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE As the cost of health care continues to increase, there is a growing emphasis on evaluating the relative economic value of treatment options to guide resource allocation. The objective of this systematic review was to evaluate the current evidence regarding the cost-effectiveness of cranial neurosurgery procedures. METHODS The authors performed a systematic review of the literature using PubMed, EMBASE, and the Cochrane Library, focusing on themes of economic evaluation and cranial neurosurgery following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Included studies were publications of cost-effectiveness analysis or cost-utility analysis between 1995 and 2017 in which health utility outcomes in life years (LYs), quality-adjusted life years (QALYs), or disability-adjusted life years (DALYs) were used. Three independent reviewers conducted the study appraisal, data abstraction, and quality assessment, with differences resolved by consensus discussion. RESULTS In total, 3485 citations were reviewed, with 53 studies meeting the inclusion criteria. Of those, 34 studies were published in the last 5 years. The most common subspecialty focus was cerebrovascular (32%), followed by neurooncology (26%) and functional neurosurgery (24%). Twenty-eight (53%) studies, using a willingness to pay threshold of US$50,000 per QALY or LY, found a specific surgical treatment to be cost-effective. In addition, there were 11 (21%) studies that found a specific surgical option to be economically dominant (both cost saving and having superior outcome), including endovascular thrombectomy for acute ischemic stroke, epilepsy surgery for drug-refractory epilepsy, and endoscopic pituitary tumor resection. CONCLUSIONS There is an increasing number of cost-effectiveness studies in cranial neurosurgery, especially within the last 5 years. Although there are numerous procedures, such as endovascular thrombectomy for acute ischemic stroke, that have been conclusively proven to be cost-effective, there remain promising interventions in current practice that have yet to meet cost-effectiveness thresholds.
Collapse
Affiliation(s)
- Won Hyung A Ryu
- Department of Clinical Neurosciences, University of Calgary, Alberta, Canada
| | - Michael M H Yang
- Department of Clinical Neurosciences, University of Calgary, Alberta, Canada
| | - Sandeep Muram
- Department of Clinical Neurosciences, University of Calgary, Alberta, Canada
| | - W Bradley Jacobs
- Department of Clinical Neurosciences, University of Calgary, Alberta, Canada
| | - Steven Casha
- Department of Clinical Neurosciences, University of Calgary, Alberta, Canada
| | - Jay Riva-Cambrin
- Department of Clinical Neurosciences, University of Calgary, Alberta, Canada
| |
Collapse
|
48
|
Benjamin EJ, Virani SS, Callaway CW, Chamberlain AM, Chang AR, Cheng S, Chiuve SE, Cushman M, Delling FN, Deo R, de Ferranti SD, Ferguson JF, Fornage M, Gillespie C, Isasi CR, Jiménez MC, Jordan LC, Judd SE, Lackland D, Lichtman JH, Lisabeth L, Liu S, Longenecker CT, Lutsey PL, Mackey JS, Matchar DB, Matsushita K, Mussolino ME, Nasir K, O'Flaherty M, Palaniappan LP, Pandey A, Pandey DK, Reeves MJ, Ritchey MD, Rodriguez CJ, Roth GA, Rosamond WD, Sampson UKA, Satou GM, Shah SH, Spartano NL, Tirschwell DL, Tsao CW, Voeks JH, Willey JZ, Wilkins JT, Wu JH, Alger HM, Wong SS, Muntner P. Heart Disease and Stroke Statistics-2018 Update: A Report From the American Heart Association. Circulation 2018; 137:e67-e492. [PMID: 29386200 DOI: 10.1161/cir.0000000000000558] [Citation(s) in RCA: 4508] [Impact Index Per Article: 751.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
|
49
|
Value-based procurement of medical devices: Application to devices for mechanical thrombectomy in ischemic stroke. Clin Neurol Neurosurg 2018; 166:61-65. [DOI: 10.1016/j.clineuro.2018.01.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 01/11/2018] [Accepted: 01/22/2018] [Indexed: 11/19/2022]
|
50
|
Pan Y, Cai X, Huo X, Zhao X, Liu L, Wang Y, Miao Z, Wang Y. Cost-effectiveness of mechanical thrombectomy within 6 hours of acute ischaemic stroke in China. BMJ Open 2018; 8:e018951. [PMID: 29472264 PMCID: PMC5855394 DOI: 10.1136/bmjopen-2017-018951] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 12/29/2017] [Accepted: 01/17/2018] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Endovascular mechanical thrombectomy is an effective but expensive therapy for acute ischaemic stroke with proximal anterior circulation occlusion. This study aimed to determine the cost-effectiveness of mechanical thrombectomy in China, which is the largest developing country. DESIGN A combination of decision tree and Markov model was developed. Outcome and cost data were derived from the published literature and claims database. The efficacy data were derived from the meta-analyses of nine trials. One-way and probabilistic sensitivity analyses were performed in order to assess the uncertainty of the results. SETTING Hospitals in China. PARTICIPANTS The patients with acute ischaemic stroke caused by proximal anterior circulation occlusion within 6 hours. INTERVENTIONS Mechanical thrombectomy within 6 hours with intravenous tissue plasminogen activator (tPA) treatment within 4.5 hours versus intravenous tPA treatment alone. OUTCOME MEASURES The benefit conferred by the treatment was assessed by estimating the cost per quality-adjusted life-year (QALY) gained in the long term (30 years). RESULTS The addition of mechanical thrombectomy to intravenous tPA treatment compared with standard treatment alone yielded a lifetime gain of 0.794 QALYs at an additional cost of CNY 50 000 (US$7700), resulting in a cost of CNY 63 010 (US$9690) per QALY gained. The probabilistic sensitivity analysis indicated that mechanical thrombectomy was cost-effective in 99.9% of the simulation runs at a willingness-to-pay threshold of CNY 125 700 (US$19 300) per QALY. CONCLUSIONS Mechanical thrombectomy for acute ischaemic stroke caused by proximal anterior circulation occlusion within 6 hours was cost-effective in China. The data may be used as a reference with regard to medical resources allocation for stroke treatment in low-income and middle-income countries as well as in the remote areas in the developed countries.
Collapse
Affiliation(s)
- Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
- Centre of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China
| | - Xueli Cai
- Department of Neurology, Lishui Hospital of Zhejiang University (the Central Hospital of Lishui), Lishui, China
| | - Xiaochuan Huo
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
- Centre of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
- Centre of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
- Centre of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
- Centre of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Zhongrong Miao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
- Centre of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
- Centre of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| |
Collapse
|