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Pinckaers FM, Evers SM, Olthuis SG, Boogaarts HD, Postma AA, van Oostenbrugge RJ, van Zwam WH, Grutters JP. Cost-effectiveness of endovascular treatment after 6-24 h in ischaemic stroke patients with collateral flow on CT-angiography: A model-based economic evaluation of the MR CLEAN-LATE trial. Eur Stroke J 2024; 9:348-355. [PMID: 38153049 DOI: 10.1177/23969873231220464] [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: 12/29/2023] Open
Abstract
BACKGROUND The MR CLEAN-LATE trial has shown that patient selection for endovascular treatment (EVT) in the late window (6-24 h after onset or last-seen-well) based on the presence of collateral flow on CT-angiography is safe and effective. We aimed to assess the cost-effectiveness of late-window collateral-based EVT-selection compared to best medical management (BMM) over a lifetime horizon (until 95 years of age). MATERIALS AND METHODS A model-based economic evaluation was performed from a societal perspective in The Netherlands. A decision tree was combined with a state-transition (Markov) model. Health states were defined by the modified Rankin Scale (mRS). Initial probabilities at 3-months post-stroke were based on MR CLEAN-LATE data. Transition probabilities were derived from previous literature. Information on short- and long-term resource use and utilities was obtained from a study using MR CLEAN-LATE and cross-sectional data. All costs are expressed in 2022 euros. Costs and quality-adjusted life years (QALYs) were discounted at a rate of 4% and 1.5%, respectively. The effect of parameter uncertainty was assessed using probabilistic sensitivity analysis (PSA). RESULTS On average, the EVT strategy cost €159,592 (95% CI: €140,830-€180,154) and generated 3.46 QALYs (95% CI: 3.04-3.90) per patient, whereas the costs and QALYs associated with BMM were €149,935 (95% CI: €130,841-€171,776) and 2.88 (95% CI: 2.48-3.29), respectively. The incremental cost-effectiveness ratio per QALY and the incremental net monetary benefit were €16,442 and €19,710, respectively. At a cost-effectiveness threshold of €50,000/QALY, EVT was cost-effective in 87% of replications. DISCUSSION AND CONCLUSION Collateral-based selection for late-window EVT is likely cost-effective from a societal perspective in The Netherlands.
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Affiliation(s)
- Florentina Me Pinckaers
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
- Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Silvia Maa Evers
- Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
- Department of Health Services Research, Maastricht University, Maastricht, The Netherlands
- Centre of Economic Evaluation and Machine Learning, Trimbos Institute, Utrecht, The Netherlands
| | - Susanne Gh Olthuis
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Neurology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | - Alida A Postma
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
- School for Mental Health and Neuroscience (MHENS), Maastricht University, Maastricht, The Netherlands
| | - Robert J van Oostenbrugge
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Neurology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Wim H van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
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Yang W, Lee RP, Hung AL, Young CC, Sattari SA, Urrutia V, Gailloud PE, Xu R, Caplan J, Gonzalez LF. Cost-Effectiveness of a Direct-Aspiration First-Pass Technique versus Stent Retriever in Mechanical Thrombectomy. World Neurosurg 2024; 183:e495-e501. [PMID: 38159607 DOI: 10.1016/j.wneu.2023.12.129] [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: 11/09/2023] [Revised: 12/22/2023] [Accepted: 12/23/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVE A direct-aspiration first-pass technique (ADAPT) in mechanical thrombectomy has been described in recent studies as an efficacious strategy compared with using a stent retriever (SR). We sought to evaluate for cost differences of ADAPT technique versus SR as an initial approach. METHODS We conducted a retrospective analysis of consecutive patients with mechanical thrombectomy at our institution between 2022 and 2023. Patients were grouped into ADAPT with/without SR as a rescue strategy and SR as an initial approach with allowance of concomitant aspiration. Direct cost data (consumables) were obtained. Baseline demographics, stroke metrics, procedure outcomes and cost, and last follow-up outcomes in modified Rankin Scale were compared between 2 groups. RESULTS Fifty-six patients were included. Thirty-seven (66.1%) underwent ADAPT, with 11 (29.7%) eventually requiring an SR. Mean age was 64.8 years. The average National Institutes of Health Stroke Scale score was 13.2 in the ADAPT group and 14.0 in the SR group (P = 0.68), with a similar proportion of tissue plasminogen activator (P = 0.53), site of occlusion (P = 0.66), and tandem occlusion (P = 0.69) between the groups. Recanalization was achieved in 94.6% of all patients, with an average of 1.9 passes, 89.3% being TICI 2B or above, with no differences between the 2 groups. Significantly lower cost (P < 0.01) was observed in ADAPT ($14,243.4) compared with SR ($19,003.6). Average follow-up duration was 180.2 days, with mortality of 23.2%. At last follow-up, 55.4% remained functionally independent (modified Rankin Scale score <3) with no difference (P = 0.56) between the ADAPT (59.5%) and SR (47.4%) groups. CONCLUSIONS Outcomes were comparable between the ADAPT and SR groups. ADAPT reduced procedural consumables cost by approximately $5000 (25%), even if stent retrievers were allowed to be used for rescue. Establishing ADPAT as initial approach may bring significant direct cost savings while obtaining similar outcomes.
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Affiliation(s)
- Wuyang Yang
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Ryan P Lee
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Alice L Hung
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Christopher C Young
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Shahab Aldin Sattari
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Victor Urrutia
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Philipe E Gailloud
- Division of Interventional Neuroradiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Risheng Xu
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Justin Caplan
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - L Fernando Gonzalez
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.
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Ospel JM, Zerna C, Harrison E, Kleinig TJ, Puetz V, Kaiser DPO, Graham B, Yu AYX, van Adel B, Shankar JJ, McTaggart RA, Pereira V, Frei DF, Kunz WG, Goyal M, Hill MD. Cost-Effectiveness of Late Endovascular Thrombectomy vs. Best Medical Management in a Clinical Trial Setting and Real-World Setting. Can J Neurol Sci 2024:1-8. [PMID: 38403588 DOI: 10.1017/cjn.2024.19] [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: 02/27/2024]
Abstract
BACKGROUND AND PURPOSE To assess cost-effectiveness of late time-window endovascular treatment (EVT) in a clinical trial setting and a "real-world" setting. METHODS Data are from the randomized ESCAPE trial and a prospective cohort study (ESCAPE-LATE). Anterior circulation large vessel occlusion patients presenting > 6 hours from last-known-well were included, whereby collateral status was an inclusion criterion for ESCAPE but not ESCAPE-LATE. A Markov state transition model was built to estimate lifetime costs and quality-adjusted life-years (QALYs) for EVT in addition to best medical care vs. best medical care only in a clinical trial setting (comparing ESCAPE-EVT to ESCAPE control arm patients) and a "real-world" setting (comparing ESCAPE-LATE to ESCAPE control arm patients). We performed an unadjusted analysis, using 90-day modified Rankin Scale(mRS) scores as model input and analysis adjusted for baseline factors. Acceptability of EVT was calculated using upper/lower willingness-to-pay thresholds of 100,000 USD/50,000 USD/QALY. RESULTS Two-hundred and forty-nine patients were included (ESCAPE-LATE:n = 200, ESCAPE EVT-arm:n = 29, ESCAPE control-arm:n = 20). Late EVT in addition to best medical care was cost effective in the unadjusted analysis both in the clinical trial and real-world setting, with acceptability 96.6%-99.0%. After adjusting for differences in baseline variables between the groups, late EVT was marginally cost effective in the clinical trial setting (acceptability:49.9%-61.6%), but not the "real-world" setting (acceptability:32.9%-42.6%). CONCLUSION EVT for LVO-patients presenting beyond 6 hours was cost effective in the clinical trial setting and "real-world" setting, although this was largely related to baseline patient differences favoring the "real-world" EVT group. After adjusting for these, EVT benefit was reduced in the trial setting, and absent in the real-world setting.
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Affiliation(s)
- Johanna Maria Ospel
- Department of Diagnostic Imaging, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
| | - Charlotte Zerna
- Department of Neurology, Städtisches Klinikum Dresden, Dresden, Germany
| | - Emma Harrison
- Department of Neurology, Princess Alexandra Hospital, Brisbane, QL, Australia
| | - Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, Australia
| | - Volker Puetz
- Department of Neurology, Technical University Dresden, Dresden, Germany
| | - Daniel P O Kaiser
- Department of Neurology, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Brett Graham
- Department of Neurology, Royal University Hospital of Saskatchewan, Saskatoon, Canada
| | - Amy Y X Yu
- Department of Neurology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Canada
| | - Brian van Adel
- Division of Neurology, Neurosurgery and Diagnostic Imaging, Hamilton General Hospital, McMaster University, Hamilton, Canada
| | - Jai J Shankar
- Department of Neurology, University of Manitoba, Winnipeg, Canada
| | - Ryan A McTaggart
- Department of Radiology, Rhode Island Hospital, Providence, RI, USA
| | - Vitor Pereira
- Department of Neurosurgery, St Michaels Hospital, University of Toronto, Toronto, Canada
| | | | - Wolfgang G Kunz
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Mayank Goyal
- Department of Diagnostic Imaging, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
| | - Michael D Hill
- Department of Diagnostic Imaging, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
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Xia H, Yang Q, Wang Q, Jia J, Liu X, Meng S. Economic evaluation of stent retrievers in basilar artery occlusion: An analysis from Chinese healthcare system perspective. PLoS One 2023; 18:e0294929. [PMID: 38033030 PMCID: PMC10688905 DOI: 10.1371/journal.pone.0294929] [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: 04/28/2023] [Accepted: 11/11/2023] [Indexed: 12/02/2023] Open
Abstract
PURPOSE This study aimed to investigate the cost-effectiveness of stent retriever (SR) versus best medical management (BMM) in patients with basilar artery occlusion (BAO) in China. METHODS We used a two-step approach to compare the cost-effectiveness of SR plus BMM with that of BMM alone over 20 years. A decision tree was initially constructed for the first 3 months, followed by a Markov model for the subsequent period. Collected data on clinical aspects were extracted from the BAOCHE investigation, while costs-related information was sourced from previously published research. The key metric for evaluating the primary outcome was the incremental cost-effectiveness ratio (ICER), achieved $/QALY. The threshold for identifying SR as highly cost-effective was set at an ICER below $12,551/QALY, SR was deemed cost-effective if the ICER ranged from $12,551 to $37,654 per QALY. Uncertainty was addressed using scenario, one-way sensitivity, and probabilistic sensitivity analyses (PSA). FINDINGS For Chinese patients with BAO, the 20-year cost per patient was $8678 with BMM alone and $21,988 for SR plus BMM. Effectiveness was 1.45 QALY for BMM alone, and 2.77 QALY for SR plus BMM. The ICER of SR + BMM versus BMM alone was $10,050 per QALY. The scenario and one-way sensitivity analyses revealed that in certain situations the ICER could exceed $12,551 per QALY, but remain below $37,654 per QALY. Results from the PSA suggested that SR was likely to be cost-effective for Chinese patients with BAO, with a probability exceeding 98% when considering a willingness-to-pay (WTP) threshold of $12,551 per QALY. IMPLICATIONS Our study indicates that SR is an intervention option that is highly likely to be cost-effective for Chinese patients with BAO, with a probability of over 98% under the current WTP threshold of $12,551 per QALY.
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Affiliation(s)
- Hailong Xia
- Department of Neurosurgery, Chongqing Red Cross Hospital(Jiangbei District People’s Hospital), Chongqing, China
| | - Qi Yang
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qibo Wang
- Department of Neurosurgery, Chongqing Red Cross Hospital(Jiangbei District People’s Hospital), Chongqing, China
| | - Jielin Jia
- Department of Neurosurgery, Chongqing Red Cross Hospital(Jiangbei District People’s Hospital), Chongqing, China
| | - Xipeng Liu
- Department of Orthopaedic, Chongqing Red Cross Hospital(Jiangbei District People’s Hospital), Chongqing, China
| | - Shu Meng
- Internal medicine department, Chongqing Red Cross Hospital(Jiangbei District People’s Hospital), Chongqing, China
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Pouget AM, Costa N, Mounié M, Gombault-Datzenko E, Derumeaux H, Pagès A, Rouzaud-Laborde C, Molinier L. Mechanical Thrombectomy with Intravenous Thrombolysis versus Thrombolysis Alone for the Treatment of Stroke: A Systematic Review of Economic Evaluations. J Vasc Interv Radiol 2023; 34:1749-1759.e2. [PMID: 37331591 DOI: 10.1016/j.jvir.2023.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 05/25/2023] [Accepted: 06/08/2023] [Indexed: 06/20/2023] Open
Abstract
Mechanical thrombectomy has revolutionized the management of stroke by improving the recanalization rates and reducing deleterious consequences. It is now the standard of care despite the high financial cost. A considerable number of studies have evaluated its cost effectiveness. Therefore, this study aimed to identify economic evaluations of mechanical thrombectomy with thrombolysis compared with thrombolysis alone to provide an update of existing evidence, focusing on the period after proof of effectiveness of mechanical thrombectomy. Twenty-one studies were included in the review: 18 were model-based economic evaluations to simulate long-term outcomes and costs, and 19 were conducted in high-income countries. Incremental cost-effectiveness ratios ranged from -$5,670 to $74,216 per quality-adjusted life year. Mechanical thrombectomy is cost-effective in high-income countries and in the populations selected for clinical trials. However, most of the studies used the same data. There is a lack of real-world and long-term data to analyze the cost effectiveness of mechanical thrombectomy in treating the global burden of stroke.
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Affiliation(s)
- Alix Marie Pouget
- Health Economic Unit, Toulouse University Hospital, Toulouse, France; Department of Pharmacy, Toulouse University Hospital, Toulouse, France; French National Institute for Health and Medical Research (INSERM), Mixed Research Unit 1297 (UMR), Institute of Metabolic and Cardiac Diseases (I2MC), Toulouse III University, Toulouse, France.
| | - Nadège Costa
- Health Economic Unit, Toulouse University Hospital, Toulouse, France; French National Institute for Health and Medical Research (INSERM), Mixed Research Unit 1297 (UMR), Centre for Epidemiology and Population Health Research (for CERPOP), Toulouse III University, Toulouse, France
| | - Michael Mounié
- Health Economic Unit, Toulouse University Hospital, Toulouse, France; French National Institute for Health and Medical Research (INSERM), Mixed Research Unit 1297 (UMR), Centre for Epidemiology and Population Health Research (for CERPOP), Toulouse III University, Toulouse, France
| | - Eugénie Gombault-Datzenko
- Health Economic Unit, Toulouse University Hospital, Toulouse, France; French National Institute for Health and Medical Research (INSERM), Mixed Research Unit 1297 (UMR), Centre for Epidemiology and Population Health Research (for CERPOP), Toulouse III University, Toulouse, France
| | - Hélène Derumeaux
- Health Economic Unit, Toulouse University Hospital, Toulouse, France; French National Institute for Health and Medical Research (INSERM), Mixed Research Unit 1297 (UMR), Centre for Epidemiology and Population Health Research (for CERPOP), Toulouse III University, Toulouse, France
| | - Arnaud Pagès
- Health Economic Unit, Toulouse University Hospital, Toulouse, France
| | - Charlotte Rouzaud-Laborde
- Department of Pharmacy, Toulouse University Hospital, Toulouse, France; French National Institute for Health and Medical Research (INSERM), Mixed Research Unit 1297 (UMR), Institute of Metabolic and Cardiac Diseases (I2MC), Toulouse III University, Toulouse, France
| | - Laurent Molinier
- Health Economic Unit, Toulouse University Hospital, Toulouse, France; French National Institute for Health and Medical Research (INSERM), Mixed Research Unit 1297 (UMR), Centre for Epidemiology and Population Health Research (for CERPOP), Toulouse III University, Toulouse, France
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Morii Y, Abiko K, Osanai T, Takami J, Tanikawa T, Fujiwara K, Houkin K, Ogasawara K. Cost-effectiveness of seven-days-per-week rehabilitation schedule for acute stroke patients. Cost Eff Resour Alloc 2023; 21:12. [PMID: 36726117 PMCID: PMC9893661 DOI: 10.1186/s12962-023-00421-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 01/23/2023] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Rehabilitation is an essential medical service for patients who have suffered acute stroke. Although the effectiveness of 7-days-per-week rehabilitation schedule has been studied in comparison with 5- or 6-days-per-week rehabilitation schedule, its cost-effectiveness has not been analyzed. In this research, to help formulate more cost-effective medical treatments for acute stroke patients, we analyzed the cost-effectiveness of 7-days-per-week rehabilitation for acute stroke from public health payer's perspective, and public healthcare and long-term care payer's perspective in Japan. METHODS Cost-effectiveness of 7-days-per-week rehabilitation for acute stroke patients was analyzed based on the result from a previous study using a Japanese database examining the efficacy of 7-days-per-week rehabilitation. Cost utility analysis was conducted by comparing 7-days-per-week rehabilitation with 5- or 6-days-per-week rehabilitation, with its main outcome incremental cost-effectiveness ratio (ICER) calculated by dividing estimated incremental medical and long-term care costs by incremental quality-adjusted life years (QALY). The costs were estimated using the Japanese fee table and from published sources. The time horizon was 5 years, and Markov modeling was used for the analysis. RESULTS The ICER was $6339/QALY from public health payer's perspective, lower than 5,000,000 Yen/QALY (approximately US$37,913), which was the willingness-to-pay used for the cost-effectiveness evaluation in Japan. The 7-day-per-week rehabilitation was dominant from public healthcare and long-term care payer's perspective. The result of sensitivity analysis confirmed the results. CONCLUSION The results indicated that 7-days-per-week rehabilitation for acute stroke rehabilitation was likely to be cost-effective.
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Affiliation(s)
- Yasuhiro Morii
- grid.415776.60000 0001 2037 6433Center for Outcomes Research and Economic Evaluation for Health, National Institute of Public Health, 2-3-6 Minami, Wako, Saitama Japan ,grid.39158.360000 0001 2173 7691Faculty of Health Sciences, Hokkaido University, N12-W5, Kita-Ku, Sapporo, Hokkaido Japan
| | - Kagari Abiko
- grid.415260.40000 0004 1769 060XDepartment of Rehabilitation Medicine, Sapporo Azabu Neurosurgical Hospital, N22-E1, Higashi-Ku, Sapporo, Hokkaido Japan ,grid.412167.70000 0004 0378 6088Department of Rehabilitation Medicine, Hokkaido University Hospital, N15-W7, Kita-Ku, Sapporo, Hokkaido Japan
| | - Toshiya Osanai
- grid.39158.360000 0001 2173 7691Department of Neurosurgery, Graduate School of Medicine, Hokkaido University, N15-W7, Kita-Ku, Sapporo, Hokkaido Japan
| | - Jiro Takami
- Department of Rehabilitation, Nishi Sapporo Hospital, 5-1, Yamanote 3-2, Nishi-Ku, Sapporo, Hokkaido Japan
| | - Takumi Tanikawa
- grid.39158.360000 0001 2173 7691Faculty of Health Sciences, Hokkaido University, N12-W5, Kita-Ku, Sapporo, Hokkaido Japan ,grid.444700.30000 0001 2176 3638Faculty of Health Sciences, Hokkaido University of Science, 4-1, Maeda 7-15, Teine-Ku, Sapporo, Hokkaido Japan
| | - Kensuke Fujiwara
- grid.39158.360000 0001 2173 7691Faculty of Health Sciences, Hokkaido University, N12-W5, Kita-Ku, Sapporo, Hokkaido Japan ,grid.444620.00000 0001 0666 3591Graduate School of Commerce, Otaru University of Commerce, 5-21, Midori 3, Otaru, Hokkaido Japan
| | - Kiyohiro Houkin
- grid.39158.360000 0001 2173 7691Department of Neurosurgery, Graduate School of Medicine, Hokkaido University, N15-W7, Kita-Ku, Sapporo, Hokkaido Japan
| | - Katsuhiko Ogasawara
- grid.39158.360000 0001 2173 7691Faculty of Health Sciences, Hokkaido University, N12-W5, Kita-Ku, Sapporo, Hokkaido Japan
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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.
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Gao L, Bivard A, Parsons M, Spratt NJ, Levi C, Butcher K, Kleinig T, Yan B, Dong Q, Cheng X, Lou M, Yin C, Chen C, Wang P, Lin L, Choi P, Miteff F, Moodie M. Real-World Cost-Effectiveness of Late Time Window Thrombectomy for Patients With Ischemic Stroke. Front Neurol 2022; 12:780894. [PMID: 34970213 PMCID: PMC8712752 DOI: 10.3389/fneur.2021.780894] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 10/26/2021] [Indexed: 11/13/2022] Open
Abstract
Background: To compare the cost-effectiveness of providing endovascular thrombectomy (EVT) for patients with ischemic stroke in the >4.5 h time window between patient groups who met and did not meet the perfusion imaging trial criteria. Methods: A discrete event simulation (DES) model was developed to simulate the long-term outcome post EVT in patients meeting or not meeting the extended time window clinical trial perfusion imaging criteria at presentation, vs. medical treatment alone (including intravenous thrombolysis). The effectiveness of thrombectomy in patients meeting the landmark trial criteria (DEFUSE 3 and DAWN) was derived from a prospective cohort study of Australian patients who received EVT for ischemic stroke, between 2015 and 2019, in the extended time window (>4.5 h). Results: Endovascular thrombectomy was shown to be a cost-effective treatment for patients satisfying the clinical trial criteria in our prospective cohort [incremental cost-effectiveness ratio (ICER) of $11,608/quality-adjusted life year (QALY) for DEFUSE 3-postive or $34,416/QALY for DAWN-positive]. However, offering EVT to patients outside of clinical trial criteria was associated with reduced benefit (−1.02 QALY for DEFUSE 3; −1.43 QALY for DAWN) and higher long-term patient costs ($8,955 for DEFUSE 3; $9,271 for DAWN), thereby making it unlikely to be cost-effective in Australia. Conclusions: Treating patients not meeting the DAWN or DEFUSE 3 clinical trial criteria in the extended time window for EVT was associated with less gain in QALYs and higher cost. Caution should be exercised when considering this procedure for patients not satisfying the trial perfusion imaging criteria for EVT.
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Affiliation(s)
- Lan Gao
- Deakin Health Economics, Institute for Health Transformation, Deakin University, Geelong, VIC, Australia
| | - Andrew Bivard
- Melbourne Brain Centre, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Mark Parsons
- Melbourne Brain Centre, Royal Melbourne Hospital, Parkville, VIC, Australia.,Departments of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, NSW, Australia.,Department of Neurology, UNSW South Western Clinical School, Liverpool Hospital, University of New South Wales, Kensington, NSW, Australia
| | - Neil J Spratt
- Departments of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, NSW, Australia
| | - Christopher Levi
- Departments of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, NSW, Australia
| | - Kenneth Butcher
- Department of Neurology, Prince of Wales Hospital, University of New South Wales, Sydney, NSW, Australia
| | - Timothy Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Bernard Yan
- Melbourne Brain Centre, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Qiang Dong
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xin Cheng
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Min Lou
- Department of Neurology, Second Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Congguo Yin
- Department of Neurology, Hangzhou First Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chushuang Chen
- Departments of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, NSW, Australia
| | - Peng Wang
- Zhejiang Provincial People's Hospital, Zhejiang, China
| | - Longting Lin
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
| | - Philip Choi
- Department of Neurology, Box Hill Hospital, Eastern Health, Box Hill, VIC, Australia
| | - Ferdinand Miteff
- Departments of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, NSW, Australia
| | - Marj Moodie
- Deakin Health Economics, Institute for Health Transformation, Deakin University, Geelong, VIC, Australia
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9
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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.
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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
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10
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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: 2] [Impact Index Per Article: 0.7] [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.
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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
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11
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Natera-Villalba E, Cruz-Culebras A, García-Madrona S, Vera-Lechuga R, de Felipe-Mimbrera A, Matute-Lozano C, Gómez-López A, Ros-Castelló V, Sánchez-Sánchez A, Martínez-Poles J, Nedkova-Hristova V, Escribano-Paredes JB, García-Bermúdez I, Méndez J, Fandiño E, Masjuan J. Mechanical thrombectomy beyond 6 hours in acute ischaemic stroke with large vessel occlusion in the carotid artery territory: experience at a tertiary hospital. NEUROLOGÍA (ENGLISH EDITION) 2021; 38:236-245. [PMID: 34092537 DOI: 10.1016/j.nrleng.2020.08.013] [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: 02/04/2020] [Accepted: 08/04/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Thrombectomy in the carotid artery territory was recently shown to be effective up to 24 hours after symptoms onset. METHODS We conducted a retrospective review of a prospective registry of patients treated at our stroke reference centre between November 2016 and April 2019 in order to assess the safety and effectiveness of mechanical thrombectomy performed beyond 6 hours after symptoms onset in patients with acute ischaemic stroke and large vessel occlusion in the carotid artery territory. RESULTS Data were gathered from 59 patients (55.9% women; median age, 71 years). In 33 cases, stroke was detected upon awakening; 57.6% of patients were transferred from another hospital. Median baseline NIHSS score was 16, and median ASPECTS score was 8, with 94.9% of patients presenting > 50% of salvageable tissue. Satisfactory recanalisation was achieved in 88.1% of patients, beyond 24 hours after onset in 5 cases. At 90 days of follow-up, 67.8% were functionally independent; those who were not were older and presented higher prevalence of atrial fibrillation, greater puncture-to-recanalisation time, and higher NIHSS scores, both at baseline and at discharge. CONCLUSION In our experience, mechanical thrombectomy beyond 6 hours was associated with good 90-day functional outcomes. Age, NIHSS score, puncture-to-recanalisation time, and presence of atrial fibrillation affected functional prognosis. The efficacy of the treatment beyond 24 hours after onset merits study.
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Affiliation(s)
- E Natera-Villalba
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, Spain.
| | - A Cruz-Culebras
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - S García-Madrona
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - R Vera-Lechuga
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - A de Felipe-Mimbrera
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - C Matute-Lozano
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - A Gómez-López
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - V Ros-Castelló
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - A Sánchez-Sánchez
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - J Martínez-Poles
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - V Nedkova-Hristova
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - J B Escribano-Paredes
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - I García-Bermúdez
- Servicio de Radiología, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - J Méndez
- Servicio de Radiología, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - E Fandiño
- Servicio de Radiología, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - J Masjuan
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, Spain; Servicio de Neurología, Hospital Ramón y Cajal, Departamento de Medicina, Facultad de Medicina, Universidad de Alcalá, IRYCIS, Madrid, Spain
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12
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MacKenzie IER, Arusoo T, Sigounas D. Impact of Direct Admission Versus Interfacility Transfer on Endovascular Treatment Outcomes for Acute Ischemic Stroke: Systematic Review and Meta-Analysis. World Neurosurg 2021; 152:e387-e397. [PMID: 34087463 DOI: 10.1016/j.wneu.2021.05.106] [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: 04/15/2021] [Revised: 05/22/2021] [Accepted: 05/24/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Mechanical thrombectomy is a proven treatment for large-vessel ischemic stroke with improved functional outcomes compared with intravenous thrombolytics. Access to thrombectomy-capable sites varies greatly by geography, often necessitating interhospital transfer of patients who first present to hospitals unable to provide thrombectomy. The purpose of this meta-analysis was to examine the impact of interhospital transportation on patient outcomes to better inform recommendations for prehospital protocols. METHODS A meta-analysis was performed following systematic literature searches. Outcomes of interest included successful reperfusion, symptomatic intracranial hemorrhage, 90-day modified Rankin Scale score 0-2, 90-day mortality, onset-to-puncture times, and door-to-puncture times. RESULTS Pooled analysis comprised >27,000 patients. Door-to-puncture time was 35.6 minutes shorter among transferred patients; however, symptom onset-to-puncture time was 91.6 minutes longer. Rate of reperfusion or symptomatic intracranial hemorrhage as well as 90-day mortality did not differ significantly between transferred and directly admitted patients. While the proportion of patients achieving good functional outcome at 90 days with modified Rankin Scale score 0-2 did not differ by admission type, when modified Rankin Scale score was narrowed to 0-1, direct transport showed 20% greater probability of achieving excellent functional outcome (P < 0.001). CONCLUSIONS This meta-analysis represents the largest pooled population examined to date to assess how interfacility transportation to thrombectomy-capable sites affects patient outcomes. Our results indicate that direct admission is a significant predictor of excellent functional outcome. The findings presented here can be used to better inform quality improvement projects to streamline access to facilities providing endovascular mechanical thrombectomy capabilities.
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Affiliation(s)
- Isobel E R MacKenzie
- George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Toomas Arusoo
- Department of Radiology, George Washington University, Washington, DC, USA
| | - Dimitri Sigounas
- Department of Neurosurgery, George Washington University, Washington, DC, USA.
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13
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Yaeger KA, Rossitto CP, Marayati NF, Lara-Reyna J, Ladner T, Hardigan T, Shoirah H, Mocco J, Fifi JT. Time from image acquisition to endovascular team notification: a new target for enhancing acute stroke workflow. J Neurointerv Surg 2021; 14:237-241. [PMID: 33832969 DOI: 10.1136/neurintsurg-2021-017297] [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: 01/19/2021] [Revised: 03/25/2021] [Accepted: 03/26/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To quantify the time between initial image acquisition (CT angiography (CTA)) and notification of the neuroendovascular surgery (NES) team, a potentially high yield time window to target for optimization of endovascular thrombectomy (ET) treatment times. METHODS We reviewed our multihospital database for all patients with a stroke with emergent large vessel occlusion treated with ET between January 1, 2017 and August 5, 2020. We dichotomized patients into rapid (≤20 min) and delayed (>20 min) notification times and analyzed treatment characteristics and outcomes. RESULTS Of 367 patients with ELVO undergoing ET for whom notification data were available, the median time from CTA to NES team notification was 24 min (IQR 12-47). The median total treatment time was 180 min (IQR 129-252). The median times from CTA to NES team notification for rapid (n=163) and delayed (n=204) cohorts were 11 (IQR 6-15) and 43 (IQR 30-80) min, respectively (p<0.001). The median overall times to reperfusion were 134 min (IQR 103-179) and 213 min (IQR 172-291), respectively (p<0.001). The delayed patients had a significantly lower National Institutes of Health Stroke Scale (NIHSS) score on presentation (15 (IQR 9-20) vs 16 (IQR 11-22), p=0.03), were younger (70 (IQR 60-79) vs 77 (IQR 64-85), p<0.001), and more often presented with posterior circulation occlusion (16.7% vs 7.4%, p<0.01). The group with rapid notification time had a statistically larger median improvement in NIHSS score from admission to discharge (6 (IQR 0.5-14) vs 5 (IQR 0.5-10), p=0.04). CONCLUSIONS Time delays from initial CTA acquisition to NES team notification can prevent expedient treatment with ET. Process improvements and automated stroke detection on imaging with automated notification of the NES team may ultimately improve time to reperfusion.
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Affiliation(s)
- Kurt A Yaeger
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christina P Rossitto
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Naoum Fares Marayati
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jacques Lara-Reyna
- Department of Neurosurgery, Mount Sinai Health System, New York, New York, USA
| | - Travis Ladner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Trevor Hardigan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Hazem Shoirah
- Department of Neurosurgery, Mount Sinai Health System, New York, New York, USA
| | - J Mocco
- Department of Neurosurgery, Mount Sinai Health System, New York, New York, USA
| | - Johanna T Fifi
- Department of Neurosurgery, Mount Sinai Health System, New York, New York, USA
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14
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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.
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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.
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15
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Natera-Villalba E, Cruz-Culebras A, García-Madrona S, Vera-Lechuga R, de Felipe-Mimbrera A, Matute-Lozano C, Gómez-López A, Ros-Castelló V, Sánchez-Sánchez A, Martínez-Poles J, Nedkova-Hristova V, Escribano-Paredes JB, García-Bermúdez I, Méndez J, Fandiño E, Masjuan J. Mechanical thrombectomy beyond 6hours in acute ischaemic stroke with large vessel occlusion in the carotid artery territory: Experience at a tertiary hospital. Neurologia 2021; 38:S0213-4853(20)30298-X. [PMID: 33551125 DOI: 10.1016/j.nrl.2020.08.019] [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: 02/04/2020] [Revised: 07/06/2020] [Accepted: 08/04/2020] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Thrombectomy in the carotid artery territory was recently shown to be effective up to 24hours after symptoms onset. METHODS We conducted a retrospective review of a prospective registry of patients treated at our stroke reference centre between November 2016 and April 2019 in order to assess the safety and effectiveness of mechanical thrombectomy performed beyond 6hours after symptoms onset in patients with acute ischaemic stroke and large vessel occlusion in the carotid artery territory. RESULTS Data were gathered from 59 patients (55.9% women; median age, 71 years). In 33 cases, stroke was detected upon awakening; 57.6% of patients were transferred from another hospital. Median baseline NIHSS score was 16, and median ASPECTS score was 8, with 94.9% of patients presenting>50% of salvageable tissue. Satisfactory recanalisation was achieved in 88.1% of patients, beyond 24hours after onset in 5 cases. At 90 days of follow-up, 67.8% were functionally independent; those who were not were older and presented higher prevalence of atrial fibrillation, greater puncture-to-recanalisation time, and higher NIHSS scores, both at baseline and at discharge. CONCLUSION In our experience, mechanical thrombectomy beyond 6hours was associated with good 90-day functional outcomes. Age, NIHSS score, puncture-to-recanalisation time, and presence of atrial fibrillation affected functional prognosis. The efficacy of the treatment beyond 24hours after onset merits study.
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Affiliation(s)
- E Natera-Villalba
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, España.
| | - A Cruz-Culebras
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, España
| | - S García-Madrona
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, España
| | - R Vera-Lechuga
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, España
| | - A de Felipe-Mimbrera
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, España
| | - C Matute-Lozano
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, España
| | - A Gómez-López
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, España
| | - V Ros-Castelló
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, España
| | - A Sánchez-Sánchez
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, España
| | - J Martínez-Poles
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, España
| | - V Nedkova-Hristova
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, España
| | - J B Escribano-Paredes
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, España
| | - I García-Bermúdez
- Servicio de Radiología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - J Méndez
- Servicio de Radiología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - E Fandiño
- Servicio de Radiología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - J Masjuan
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, España; Servicio de Neurología, Hospital Ramón y Cajal, Departamento de Medicina, Facultad de Medicina, Universidad de Alcalá, IRYCIS, Madrid, España
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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
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Martini ML, Neifert SN, Lara-Reyna JJ, Shuman WH, Ladner TR, Hardigan TH, Fifi JT, Mocco J, Yaeger KA. Trials in thrombectomy for acute ischemic stroke: Describing the state of clinical research in the field. Clin Neurol Neurosurg 2020; 200:106360. [PMID: 33249326 DOI: 10.1016/j.clineuro.2020.106360] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 10/19/2020] [Accepted: 11/06/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Endovascular thrombectomy has revolutionized treatment of ischemic stroke. Given the clinical and socioeconomic support for thrombectomy, new devices, procedures, and pharmaceuticals have emerged in recent years, and have been subject to a growing number of clinical trials worldwide. OBJECTIVE To define the current state of thrombectomy clinical trials, highlight recent trends, and help guide future research in this area. METHODS Current and previous clinical trials involving thrombectomy for ischemic stroke were queried from the Clinicaltrials.gov database. Trials were categorized by their current status, study design, funding type, exclusion criteria, study phase, enrollment, start and completion dates, country of origin, item of investigation, outcome metrics, and whether a peer-reviewed publication was linked to the trial. RESULTS Querying the ClinicalTrials.gov registry yielded 196 trials, of which 161 (82.1 %) were started within the past 5 years. The average time to completion was 30.6 months. A total of 62 studies (31.6 %) examined the safety or efficacy of a thrombectomy device, 29 (14.8 %) investigated a pharmacological intervention alone or in combination with a device, 59 (30.1 %) examined aspects of the endovascular procedure on patient outcomes, and 14 (7.2 %) examined diagnostic utility during thrombectomy. Most trials were funded by academic centers (53.1 %) or industry (34.7 %). Although the United States contributed the most studies overall (59; 30.1 %), studies from European and Asian countries have been increasing since 2015. CONCLUSION These trends indicate an increasing number of trials starting the past few years, with most occurring in Europe and examining devices or aspects of the thrombectomy procedure.
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Affiliation(s)
- Michael L Martini
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Sean N Neifert
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Jacques J Lara-Reyna
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - William H Shuman
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Travis R Ladner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Trevor H Hardigan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Johanna T Fifi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Kurt A Yaeger
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA.
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18
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Zhou MH, Kansagra AP. Population health impact of extended window thrombectomy in acute ischemic stroke. Interv Neuroradiol 2020; 27:516-522. [PMID: 33153379 DOI: 10.1177/1591019920972209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Recent trials support endovascular thrombectomy (EVT) in select patients beyond the conventional 6-hour window. OBJECTIVE In this work, we estimate the impact of extended window EVT on procedural volumes and population-level clinical outcomes using Monte Carlo simulation. METHODS We simulated extending EVT eligibility in a system comprising an EVT-incapable primary stroke center (PSC) and EVT-capable comprehensive stroke center (CSC) using routing paradigms that initially direct patients to (1) the nearest center, (2) the CSC, or (3) either CSC or nearest center based on stroke severity. EVT eligibility and outcomes are based on HERMES, DEFUSE-3, and DAWN studies in the 0-6, 6-16, and 16-24 hour windows, respectively. Probability of good clinical outcome is determined by type and timing of treatment using clinical trial data. RESULTS Relative increase in EVT volume in the three tested routing paradigms was 15.7-15.8%. The absolute increase in the rate of good clinical outcome 0.4% in all routing paradigms. NNT for extended window EVT was 239.9-246.4 among the entire stroke population. CONCLUSION Extended window EVT with DEFUSE-3 and DAWN criteria increases EVT volume and modestly improves population-level clinical outcomes.
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Affiliation(s)
- Minerva H Zhou
- School of Medicine, Washington University, St. Louis, MO, USA
| | - Akash P Kansagra
- Mallinckrodt Institute of Radiology, Washington University, St. Louis, MO, USA.,Department of Neurological Surgery, Washington University, St. Louis, MO, USA.,Department of Neurology, Washington University, St. Louis, MO, USA
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19
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Peultier AC, Pandya A, Sharma R, Severens JL, Redekop WK. Cost-effectiveness of Mechanical Thrombectomy More Than 6 Hours After Symptom Onset Among Patients With Acute Ischemic Stroke. JAMA Netw Open 2020; 3:e2012476. [PMID: 32840620 PMCID: PMC7448828 DOI: 10.1001/jamanetworkopen.2020.12476] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
IMPORTANCE Two 2018 randomized controlled trials (DAWN and DEFUSE 3) demonstrated the clinical benefit of mechanical thrombectomy (MT) more than 6 hours after onset in acute ischemic stroke (AIS). Health-economic evidence is needed to determine whether the short-term health benefits of late MT translate to a cost-effective option during a lifetime in the United States. OBJECTIVE To compare the cost-effectiveness of 2 strategies (MT added to standard medical care [SMC] vs SMC alone) for various subgroups of patients with AIS receiving care more than 6 hours after symptom onset. DESIGN, SETTING, AND PARTICIPANTS This economic evaluation study used the results of the DAWN and DEFUSE 3 trials to populate a cost-effectiveness model from a US health care perspective combining a decision tree and Markov trace. The DAWN and DEFUSE 3 trials enrolled 206 international patients from 2014 to 2017 and 182 US patients from 2016 to 2017, respectively. Patients were followed until 3 months after stroke. The clinical outcome at 3 months was available for 29 subgroups of patients with AIS and anterior circulation large vessel occlusions. Data analysis was conducted from July 2018 to October 2019. EXPOSURES MT with SMC in the extended treatment window vs SMC alone. MAIN OUTCOMES AND MEASURES Expected costs and quality-adjusted life-years (QALYs) during lifetime were estimated. Deterministic results (incremental costs and effectiveness, incremental cost-effectiveness ratios, and net monetary benefit) were presented, and probabilistic analyses were performed for the total populations and 27 patient subgroups. RESULTS In the DAWN study, the MT group had a mean (SD) age of 69.4 (14.1) years and 42 of 107 (39.3%) were men, and the control group had a mean (SD) age of 70.7 (13.2) years and 51 of 99 (51.5%) were men. In the DEFUSE 3 study, the MT group had a median (interquartile range) age of 70 (59-79) years, and 46 of 92 (50.0%) were men, and the control group had a median (interquartile range) age of 71 (59-80) years, and 44 of 90 (48.9%) were men. For the total trial population, incremental cost-effectiveness ratios were $662/QALY and $13 877/QALY based on the DAWN and DEFUSE 3 trials, respectively. MT with SMC beyond 6 hours had a probability greater than 99.9% of being cost-effective vs SMC alone at a willingness-to-pay threshold of $100 000/QALY. Subgroup analyses showed a wide range of probabilities for MT with SMC to be cost-effective at a willingness-to-pay threshold of $50 000/QALY, with the greatest uncertainty observed for patients with a National Institute of Health Stroke Scale score of at least 16 and for those aged 80 years or older. CONCLUSIONS AND RELEVANCE The results of this study suggest that late MT added to SMC is cost-effective in all subgroups evaluated in the DAWN and DEFUSE 3 trials, with most results being robust in probabilistic sensitivity analyses. Future MT evidence-gathering could focus on older patients and those with National Institute of Health Stroke Scale scores of 16 and greater.
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Affiliation(s)
- Anne-Claire Peultier
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Ankur Pandya
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Richa Sharma
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut
| | - Johan L. Severens
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - W. Ken Redekop
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, the Netherlands
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20
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McTaggart RA, Holodinsky JK, Ospel JM, Cheung AK, Manning NW, Wenderoth JD, Phan TG, Beare R, Lane K, Haas RA, Kamal N, Goyal M, Jayaraman MV. Leaving No Large Vessel Occlusion Stroke Behind: Reorganizing Stroke Systems of Care to Improve Timely Access to Endovascular Therapy. Stroke 2020; 51:1951-1960. [PMID: 32568640 DOI: 10.1161/strokeaha.119.026735] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ryan A McTaggart
- Department of Diagnostic Imaging (R.A.M., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI.,Department of Neurology (R.A.M., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI.,Department of Neurosurgery (R.A.M., K.L., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI.,The Norman Prince Neuroscience Institute, Rhode Island Hospital, Providence, RI (R.A.M., R.A.H., M.V.J.)
| | - Jessalyn K Holodinsky
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada (J.K.H.)
| | - Johanna M Ospel
- Department of Clinical Neurosciences, University of Calgary, Canada (J.M.O., M.G.).,Division of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Switzerland (J.M.O.)
| | - Andrew K Cheung
- Department of Neurointervention, Institute of Neurological Sciences, Prince of Wales Hospital, Sydney, Australia (A.K.C., N.W.M., J.D.W.).,Department of Neurointervention, Liverpool Hospital, Sydney, Australia (A.K.C., N.W.M., J.D.W.).,Ingham Institute for Applied Medical Research, Sydney, Australia (A.K.C., N.W.M., J.D.W.)
| | - Nathan W Manning
- Department of Neurointervention, Institute of Neurological Sciences, Prince of Wales Hospital, Sydney, Australia (A.K.C., N.W.M., J.D.W.).,Department of Neurointervention, Liverpool Hospital, Sydney, Australia (A.K.C., N.W.M., J.D.W.).,Ingham Institute for Applied Medical Research, Sydney, Australia (A.K.C., N.W.M., J.D.W.).,Prince of Wales Clinical School, University of New South Wales, Sydney, Australia (N.W.M., J.D.W.)
| | - Jason D Wenderoth
- Department of Neurointervention, Institute of Neurological Sciences, Prince of Wales Hospital, Sydney, Australia (A.K.C., N.W.M., J.D.W.).,Department of Neurointervention, Liverpool Hospital, Sydney, Australia (A.K.C., N.W.M., J.D.W.).,Ingham Institute for Applied Medical Research, Sydney, Australia (A.K.C., N.W.M., J.D.W.).,Prince of Wales Clinical School, University of New South Wales, Sydney, Australia (N.W.M., J.D.W.)
| | - Thanh G Phan
- Department of Neurology, Monash Health and School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia (T.G.P.)
| | - Richard Beare
- Department of Medicine, Peninsula Health and Central Clinical School, Monash University and Murdoch Children's Research Institute Melbourne Australia (R.B.)
| | - Kendall Lane
- Department of Neurosurgery (R.A.M., K.L., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI
| | - Richard A Haas
- Department of Diagnostic Imaging (R.A.M., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI.,Department of Neurology (R.A.M., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI.,Department of Neurosurgery (R.A.M., K.L., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI.,The Norman Prince Neuroscience Institute, Rhode Island Hospital, Providence, RI (R.A.M., R.A.H., M.V.J.)
| | - Noreen Kamal
- Department of Industrial Engineering, Dalhousie University, Halifax, Nova Scotia, Canada (N.K.)
| | - Mayank Goyal
- Department of Clinical Neurosciences, University of Calgary, Canada (J.M.O., M.G.).,Department of Radiology, Seaman Family MR Research Centre, Foothills Medical Centre, Calgary, Canada (M.G.)
| | - Mahesh V Jayaraman
- Department of Diagnostic Imaging (R.A.M., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI.,Department of Neurology (R.A.M., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI.,Department of Neurosurgery (R.A.M., K.L., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI.,The Norman Prince Neuroscience Institute, Rhode Island Hospital, Providence, RI (R.A.M., R.A.H., M.V.J.)
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21
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Peultier AC, Redekop WK, Allen M, Peters J, Eker OF, Severens JL. Exploring the Cost-Effectiveness of Mechanical Thrombectomy Beyond 6 Hours Following Advanced Imaging in the United Kingdom. Stroke 2019; 50:3220-3227. [PMID: 31637975 PMCID: PMC6824506 DOI: 10.1161/strokeaha.119.026816] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Supplemental Digital Content is available in the text. In the United Kingdom, mechanical thrombectomy (MT) for acute ischemic stroke patients assessed beyond 6 hours from symptom onset will be commissioned up to 12 hours provided that advanced imaging (AdvImg) demonstrates salvageable brain tissue. While the accuracy of AdvImg differs across technologies, evidence is limited regarding the proportion of patients who would benefit from late MT. We compared the cost-effectiveness of 2 care pathways: (1) MT within and beyond 6 hours based on AdvImg selection versus (2) MT only within 6 hours based on conventional imaging selection. The impact of varying AdvImg accuracy and prior probability for acute ischemic stroke patients to benefit from late MT was assessed.
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Affiliation(s)
- Anne-Claire Peultier
- From Erasmus School of Health Policy and Management (A.-C.P., W.K.R., J.L.S.), Erasmus University Rotterdam, the Netherlands
| | - William K Redekop
- From Erasmus School of Health Policy and Management (A.-C.P., W.K.R., J.L.S.), Erasmus University Rotterdam, the Netherlands.,Institute for Medical Technology Assessment (W.K.R., J.L.S.), Erasmus University Rotterdam, the Netherlands
| | - Michael Allen
- University of Exeter Medical School, United Kingdom (M.A.).,National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South West Peninsula, United Kingdom (M.A.)
| | - Jaime Peters
- Exeter Test Group, University of Exeter Medical School, United Kingdom (J.P.)
| | - Omer Faruk Eker
- Department of Neuroradiology, Lyon University Hospital, France (O.F.E.)
| | - Johan L Severens
- From Erasmus School of Health Policy and Management (A.-C.P., W.K.R., J.L.S.), Erasmus University Rotterdam, the Netherlands.,Institute for Medical Technology Assessment (W.K.R., J.L.S.), Erasmus University Rotterdam, the Netherlands
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