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Aref H, El Nahas N, Elsisi GH, Shokri H, Roushdy T. The budget impact of alteplase in the treatment of acute ischemic stroke in Egypt. Front Neurol 2023; 14:1220615. [PMID: 38020606 PMCID: PMC10663356 DOI: 10.3389/fneur.2023.1220615] [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: 05/10/2023] [Accepted: 10/16/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Stroke is the second leading cause of mortality worldwide. Five percent of all the disability-adjusted life years (DALYs) lost around the world are attributed to stroke. This study aimed to assess the economic burden of acute ischemic stroke (AIS) in Egypt and reveal the benefits of alteplase treatment by measuring the resource use and costs associated with this treatment compared to the standard of care and extrapolate the overall budget impact of alteplase to the local Egyptian setting over a 5-year time horizon from a societal perspective. Methods A budget impact model was developed to estimate the impact of adding alteplase to the current treatment of AIS patients within the Egyptian healthcare setting. The efficacy data for both arms of the model were sourced from a systematic review of the literature. Resource use and cost data were sourced from a retrospective study. Proportions of patients potentially eligible for treatment and the treatment time distributions were estimated from an analysis of the results of this retrospective data collection. A univariate sensitivity analysis was conducted to assess the robustness of the model results. The input parameters varied between plausible extremes based on a review of available evidence. Results The total annual costs with alteplase treatment [i.e., drug, symptomatic intracerebral hemorrhage (ICH) management, acute hospitalization, and post-hospitalization costs] for the targeted patients from a societal perspective were estimated to be less than the total annual costs without alteplase. This resulted in savings of approximately EGP 37.2 million ($ 1.2 million), EGP 14.2 million ($ 458.06), EGP -33.0 million ($ -1.06 million), EGP -54.0 million ($ -1.74 million), and EGP -89.8 million ($ -2.89 million) for each of the 5 years, respectively. In year 1, more than 2,787 patients (+30.1%) achieved an excellent outcome and <1,204 patients (-22.3%) had a poor outcome when treated with alteplase. The savings in acute hospitalization and post-hospitalization costs offset the increase in drug and ICH management costs in the alteplase group compared to treatment without alteplase. The total cumulative cost savings for alteplase in AIS patients were estimated at EGP -228,146,871 ($ -7,359,576) over 5 years. Conclusion The budget impact model estimates suggest that from a societal perspective, alteplase is likely to be a cost-saving option for the treatment of AIS in Egypt due to the treatment benefits, resulting in savings in acute hospitalization and annual post-hospitalization costs.
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Affiliation(s)
- Hany Aref
- Department of Neurology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Nevine El Nahas
- Department of Neurology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Gihan Hamdy Elsisi
- HTA Office, LLC, Cairo, Egypt
- Department of Economics, American University in Cairo, Cairo, Egypt
| | - Hossam Shokri
- Department of Neurology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Tamer Roushdy
- Department of Neurology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Zheng B, Li Y, Gu G, Yang J, Jiang J, Chen Z, Fan Y, Wang S, Pei H, Wang J. Comparing 5G mobile stroke unit and emergency medical service in patients acute ischemic stroke eligible for t-PA treatment: A prospective, single-center clinical trial in Ya'an, China. Brain Behav 2023; 13:e3231. [PMID: 37632149 PMCID: PMC10636411 DOI: 10.1002/brb3.3231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 07/12/2023] [Accepted: 08/09/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND This study aims to assess and compare the functional outcomes of patients with acute ischemic stroke (AIS) eligible for tissue plasminogen activator (t-PA) treatment who received care from either a fifth-generation(5G) mobile stroke unit (MSU) or traditional emergency medical service (EMS). METHOD The study recruited patients between February 2020 and January 2022, with the final 90-day follow-up concluded in April 2022. Prior to enrollment, patients were assigned to either EMS or MSU care based on predetermined rules. The primary outcome measure was the Modified Rankin Scale (mRS) score at 90 days, with secondary outcome measures including time metrics, mRS and National Institutes of Health Stroke Scale scores at 7-day follow-up, and hospitalization costs. RESULTS Of the 2281 enrolled patients, 207 were eligible for t-PA treatment, with 101 allocated to MSU care and 106 to EMS care. The percentage of patients achieving a favorable mRS score (0-2) at 90 days was 82.2% in the MSU group compared to 72.6% in the EMS group (p < .05). Median times from symptom onset to thrombolysis were 146 min in the MSU group and 204 min in the EMS group, while median times from ambulance alert to computed tomography (CT) completion were 53 and 128 min, respectively. Hospitalization charges averaged approximately $3592 in the MSU group and $4800 in the EMS group. CONCLUSIONS Our findings indicate that 5G MSU care significantly reduces the time from symptom onset to stroke diagnosis and intravenous thrombolysis in patients with AIS, resulting in improved functional outcomes compared to EMS care. As China continues its deployment of 5G technology and other digital infrastructures, the adoption of 5G MSU care on a broader scale may eventually supplant traditional stroke treatment approaches.
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Affiliation(s)
- Bo Zheng
- Department of NeurologyYa'an Peoples HospitalYa'anChina
| | - Yan Li
- Department of NeurologyYa'an Peoples HospitalYa'anChina
| | - Gangfeng Gu
- Department of NeurologyYa'an Peoples HospitalYa'anChina
| | - Jian Yang
- Department of NeurologyYa'an Peoples HospitalYa'anChina
| | - Junyao Jiang
- Department of NeurologyYa'an Peoples HospitalYa'anChina
| | - Zhao Chen
- Department of NeurologyYa'an Peoples HospitalYa'anChina
| | - Yang Fan
- Department of NeurologyYa'an Peoples HospitalYa'anChina
| | - Sheng Wang
- Department of NeurologyYa'an Peoples HospitalYa'anChina
| | - Han Pei
- Department of NeurologyYa'an Peoples HospitalYa'anChina
| | - Jian Wang
- Department of NeurologyYa'an Peoples HospitalYa'anChina
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Siskou O, Galanis P, Konstantakopoulou O, Stafylas P, Karagkouni I, Tsampalas E, Garefou D, Alexopoulou H, Gamvroula A, Lypiridou M, Kalliontzakis I, Fragkoulaki A, Kouridaki A, Tountopoulou A, Kouzi I, Vassilopoulou S, Manios E, Mavraganis G, Vemmou A, Karagkiozi E, Savopoulos C, Dimas G, Myrou A, Milionis H, Siopis G, Evaggelou H, Protogerou A, Samara S, Karapiperi A, Kakaletsis N, Papastefanatos G, Papastefanatos S, Sourtzi P, Ntaios G, Vemmos K, Korompoki E, Kaitelidou D. The Cost and the Value of Stroke Care in Greece: Results from the SUN4P Study. Healthcare (Basel) 2023; 11:2545. [PMID: 37761742 PMCID: PMC10530928 DOI: 10.3390/healthcare11182545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 09/06/2023] [Accepted: 09/09/2023] [Indexed: 09/29/2023] Open
Abstract
The aim of this study was to measure the one-year total cost of strokes and to investigate the value of stroke care, defined as cost per QALY. The study population included 892 patients with first-ever acute strokes, hemorrhagic strokes, and ischemic strokes, (ICD-10 codes: I61, I63, and I64) admitted within 48 h of symptoms onset to nine public hospitals located in six cities. We conducted a bottom-up cost analysis from the societal point of view. All cost components including direct medical costs, productivity losses due to morbidity and mortality, and informal care costs were considered. We used an annual time horizon, including all costs for 2021, irrespective of the time of disease onset. The average cost (direct and indirect) was extrapolated in order to estimate the national annual burden associated with stroke. We estimated the total cost of stroke in Greece at EUR 343.1 mil. a year in 2021, (EUR 10,722/patient or EUR 23,308 per QALY). Out of EUR 343.1 mil., 53.3% (EUR 182.9 mil.) consisted of direct healthcare costs, representing 1.1% of current health expenditure in 2021. Overall, productivity losses were calculated at EUR 160.2 mil. The mean productivity losses were estimated to be 116 work days with 55.1 days lost due to premature retirement and absenteeism from work, 18.5 days lost due to mortality, and 42.4 days lost due to informal caregiving by family members. This study highlights the burden of stroke and underlines the need for stakeholders and policymakers to re-organize stroke care and promote interventions that have been proven cost-effective.
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Affiliation(s)
- Olga Siskou
- Center for Health Services Management and Evaluation, Department of Nursing National and Kapodistrian, University of Athens, 115 27 Athens, Greece (D.K.)
- Department of Tourism Studies University of Piraeus, 185 34 Piraeus, Greece
| | - Petros Galanis
- Center for Health Services Management and Evaluation, Department of Nursing National and Kapodistrian, University of Athens, 115 27 Athens, Greece (D.K.)
| | - Olympia Konstantakopoulou
- Center for Health Services Management and Evaluation, Department of Nursing National and Kapodistrian, University of Athens, 115 27 Athens, Greece (D.K.)
| | | | - Iliana Karagkouni
- Center for Health Services Management and Evaluation, Department of Nursing National and Kapodistrian, University of Athens, 115 27 Athens, Greece (D.K.)
| | - Evangelos Tsampalas
- Department of Neurology, Panarkadikon General Hospital, 221 00 Tripoli, Greece
| | - Dafni Garefou
- Department of Neurology, Panarkadikon General Hospital, 221 00 Tripoli, Greece
| | - Helen Alexopoulou
- Department of Neurology, Panarkadikon General Hospital, 221 00 Tripoli, Greece
| | - Anastasia Gamvroula
- Department of Neurology, Panarkadikon General Hospital, 221 00 Tripoli, Greece
| | - Maria Lypiridou
- Department of Neurology, Panarkadikon General Hospital, 221 00 Tripoli, Greece
| | | | | | - Aspasia Kouridaki
- Department of Neurology, General Hospital of Chania, 733 00 Creta, Greece
| | - Argyro Tountopoulou
- 1st Department of Neurology, Eginition Hospital, National and Kapodistrian University of Athens, 115 28 Athens, Greece; (A.T.)
| | - Ioanna Kouzi
- 1st Department of Neurology, Eginition Hospital, National and Kapodistrian University of Athens, 115 28 Athens, Greece; (A.T.)
| | - Sofia Vassilopoulou
- 1st Department of Neurology, Eginition Hospital, National and Kapodistrian University of Athens, 115 28 Athens, Greece; (A.T.)
| | - Efstathios Manios
- Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens, 115 28 Athens, Greece (E.K.)
| | - Georgios Mavraganis
- Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens, 115 28 Athens, Greece (E.K.)
| | - Anastasia Vemmou
- Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens, 115 28 Athens, Greece (E.K.)
| | - Efstathia Karagkiozi
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, 413 34 Larissa, Greece (G.N.)
| | - Christos Savopoulos
- 1st Medical Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, AHEPA Hospital, 546 36 Thessaloniki, Greece
| | - Gregorios Dimas
- 1st Medical Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, AHEPA Hospital, 546 36 Thessaloniki, Greece
| | - Athina Myrou
- 1st Medical Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, AHEPA Hospital, 546 36 Thessaloniki, Greece
| | - Haralampos Milionis
- Department of Internal Medicine, School of Medicine, University of Ioannina, 455 00 Ioannina, Greece
| | - Georgios Siopis
- Department of Internal Medicine, School of Medicine, University of Ioannina, 455 00 Ioannina, Greece
| | - Hara Evaggelou
- Department of Internal Medicine, School of Medicine, University of Ioannina, 455 00 Ioannina, Greece
| | - Athanasios Protogerou
- Cardiovascular Prevention & Research Unit, Laiko General Hospital of Athens at the Medical School, National & Kapodistrian University of Athens, 115 27 Athens, Greece
| | - Stamatina Samara
- Cardiovascular Prevention & Research Unit, Laiko General Hospital of Athens at the Medical School, National & Kapodistrian University of Athens, 115 27 Athens, Greece
| | - Asteria Karapiperi
- Cardiovascular Prevention & Research Unit, Laiko General Hospital of Athens at the Medical School, National & Kapodistrian University of Athens, 115 27 Athens, Greece
| | - Nikolaos Kakaletsis
- Second Department of Internal Medicine, Aristotle University of Thessaloniki, Hippokrateion General Hospital of Thessaloniki, 546 42 Thessaloniki, Greece
| | - George Papastefanatos
- Center for Health Services Management and Evaluation, Department of Nursing National and Kapodistrian, University of Athens, 115 27 Athens, Greece (D.K.)
- Information Management Systems Institute, ATHENA Research Center, 151 25 Athens, Greece
| | - Stefanos Papastefanatos
- Center for Health Services Management and Evaluation, Department of Nursing National and Kapodistrian, University of Athens, 115 27 Athens, Greece (D.K.)
| | - Panayota Sourtzi
- Center for Health Services Management and Evaluation, Department of Nursing National and Kapodistrian, University of Athens, 115 27 Athens, Greece (D.K.)
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, 413 34 Larissa, Greece (G.N.)
- Hellenic Stroke Organization, 115 28 Athens, Greece;
| | | | - Eleni Korompoki
- Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens, 115 28 Athens, Greece (E.K.)
- Hellenic Stroke Organization, 115 28 Athens, Greece;
| | - Daphne Kaitelidou
- Center for Health Services Management and Evaluation, Department of Nursing National and Kapodistrian, University of Athens, 115 27 Athens, Greece (D.K.)
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Muntendorf LK, Konnopka A, König HH, Boutitie F, Ebinger M, Endres M, Fiebach JB, Thijs V, Lemmens R, Muir KW, Nighoghossian N, Pedraza S, Simonsen CZ, Gerloff C, Thomalla G. Cost-Effectiveness of Magnetic Resonance Imaging-Guided Thrombolysis for Patients With Stroke With Unknown Time of Onset. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:1620-1627. [PMID: 34711362 DOI: 10.1016/j.jval.2021.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 04/06/2021] [Accepted: 05/08/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES Patients waking up with stroke symptoms are often excluded from intravenous thrombolysis with alteplase (IV-tpa). The WAKE-UP trial, a European multicenter randomized controlled trial, proved the clinical effectiveness of magnetic resonance imaging-guided IV-tpa for these patients. This analysis aimed to assess the cost-effectiveness of the intervention compared to placebo. METHODS A Markov model was designed to analyze the cost-effectiveness over a 25-year time horizon. The model consisted of an inpatient acute care phase and a rest-of-life phase. Health states were defined by the modified Rankin Scale (mRS). Initial transition probabilities to mRS scores were based on WAKE-UP data and health state utilities on literature search. Costs were based on data from the University Medical Center Hamburg-Eppendorf, literature, and expert opinion. Incremental costs and effects over the patients' lifetime were estimated. The analysis was conducted from a formal German healthcare perspective. Univariate and probabilistic sensitivity analyses were performed. RESULTS Treatment with IV-tpa resulted in cost savings of €51 009 and 1.30 incremental gains in quality-adjusted life-years at a 5% discount rate. Univariate sensitivity analysis revealed incremental cost-effectiveness ratio being sensitive to the relative risk of favorable outcome on mRS for placebo patients after stroke, the costs of long-term care for patients with mRS 4, and patient age at initial stroke event. In all cases, IV-tpa remained cost-effective. Probabilistic sensitivity analysis proved IV-tpa cost-effective in >95% of the simulations results. CONCLUSIONS Magnetic resonance imaging-guided IV-tpa compared to placebo is cost-effective in patients with ischemic stroke with unknown time of onset.
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Affiliation(s)
- Louisa-Kristin Muntendorf
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Alexander Konnopka
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hans-Helmut König
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Florent Boutitie
- Hospices Civils de Lyon, Service de Biostatistique, Lyon, France
| | - Martin Ebinger
- Klinik für Neurologie, Medical Park Berlin Humboldtmühle, Berlin, Germany; Zentrum für Schlaganfallforschung Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Endres
- Zentrum für Schlaganfallforschung Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany; Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany; German Centre for Cardiovascular Research, Partner Site, Berlin, Germany; German Center for Neurodegenerative Diseases, Partner Site, Berlin, Germany
| | - Jochen B Fiebach
- Zentrum für Schlaganfallforschung Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Vincent Thijs
- Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Australia; Department of Neurology, Austin Health, Heidelberg, Australia
| | - Robin Lemmens
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium; Division of Experimental Neurology, Department of Neurosciences, KU Leuven, University of Leuven, Leuven, Belgium; Laboratory of Neurobiology, VIB-KU Leuven Center for Brain and Disease Research, Leuven, Belgium
| | - Keith W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, Scotland, UK
| | - Norbert Nighoghossian
- Department of Stroke Medicine, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Salvador Pedraza
- Department of Radiology, Dr Josep Trueta University Hospital, Institut d'Investigació Biomèdica de Girona, Girona, Italy
| | - Claus Z Simonsen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Christian Gerloff
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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5
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Pandya A, Soeteman DI, Gupta A, Kamel H, Mushlin AI, Rosenthal MB. Can Pay-for Performance Incentive Levels be Determined Using a Cost-Effectiveness Framework? Circ Cardiovasc Qual Outcomes 2020; 13:e006492. [PMID: 32615799 PMCID: PMC7375940 DOI: 10.1161/circoutcomes.120.006492] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Healthcare payers in the United States are increasingly tying provider payments to quality and value using pay-for-performance policies. Cost-effectiveness analysis quantifies value in healthcare but is not currently used to design or prioritize pay-for-performance strategies or metrics. Acute ischemic stroke care provides a useful application to demonstrate how simulation modeling can be used to determine cost-effective levels of financial incentives used in pay-for-performance policies and associated challenges with this approach. METHODS AND RESULTS Our framework requires a simulation model that can estimate quality-adjusted life years and costs resulting from improvements in a quality metric. A monetary level of incentives can then be back-calculated using the lifetime discounted quality-adjusted life year (which includes effectiveness of quality improvement) and cost (which includes incentive payments and cost offsets from quality improvements) outputs from the model. We applied this framework to an acute ischemic stroke microsimulation model to calculate the difference in population-level net monetary benefit (willingness-to-pay of $50 000 to $150 000/quality-adjusted life year) accrued under current Medicare policy (stroke payment not adjusted for performance) compared with various hypothetical pay-for-performance policies. Performance measurement was based on time-to-thrombolytic treatment with tPA (tissue-type plasminogen activator). Compared with current payment, equivalent population-level net monetary benefit was achieved in pay-for-performance policies with 10-minute door-to-needle time reductions (5057 more acute ischemic stroke cases/y in the 0-3-hour window) incentivized by increasing tPA payment by as much as 18% to 44% depending on willingness-to-pay for health. CONCLUSIONS Cost-effectiveness modeling can be used to determine the upper bound of financial incentives used in pay-for-performance policies, although currently, this approach is limited due to data requirements and modeling assumptions. For tPA payments in acute ischemic stroke, our model-based results suggest financial incentives leading to a 10-minute decrease in door-to-needle time should be implemented but not exceed 18% to 44% of current tPA payment. In general, the optimal level of financial incentives will depend on willingness-to-pay for health and other modeling assumptions around parameter uncertainty and the relationship between quality improvements and long-run quality-adjusted life expectancy and costs.
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Affiliation(s)
- Ankur Pandya
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Djøra I. Soeteman
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Ajay Gupta
- Department of Radiology, Weill Cornell Medicine, New York, NY
| | - Hooman Kamel
- Department of Neurology and Neuroscience, Weill Cornell Medicine, New York, NY, USA
| | - Alvin I. Mushlin
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, USA
| | - Meredith B. Rosenthal
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA
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6
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Pan Y, Zhang L, Li Z, Meng X, Wang Y, Li H, Liu L, Wang Y. Cost-Effectiveness of a Multifaceted Quality Improvement Intervention for Acute Ischemic Stroke in China. Stroke 2020; 51:1265-1271. [PMID: 32019480 DOI: 10.1161/strokeaha.119.027980] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Multifaceted quality improvement interventions of stroke care have been shown to improve hospital personnel adherence to evidence-based performance measures and subsequent stroke outcomes. This study aimed to evaluate the cost-effectiveness of a multifaceted quality improvement intervention for stroke care in China, the world's largest low- and middle-income country. Methods- A short-term decision tree model and a long-term Markov model were used to analyze the cost-effectiveness of a multifaceted quality improvement intervention for patients with acute ischemic stroke. Outcomes, transition probability, and cost data were obtained from a recent clinical trial and the published literature. The benefit of the intervention was assessed by the costs per quality-adjusted life-years gained in the short- and long-term. One-way and probabilistic sensitivity analyses were performed to assess the uncertainty of the findings. Results- Compared with usual care, a multifaceted quality improvement intervention for stroke care was found to be cost-effective in the first year and highly cost-effective from the second year onward. In the long-term, the intervention yielded a lifetime gain of 0.246 quality-adjusted life-years at an additional cost of Chinese Yuan Renminbi 1510 (US $230), resulting in a cost of Chinese Yuan Renminbi 6138 (US $940) per quality-adjusted life-year gained. Probabilistic sensitivity analysis indicated that the intervention was highly cost-effective in 99.9% of the simulation runs at a willingness-to-pay threshold of Chinese Yuan Renminbi 59 700 (1× gross domestic product per capita of China in 2017, US $9200) per quality-adjusted life-year. Conclusions- A multifaceted quality improvement intervention for stroke care was highly cost-effective in China. The results of this study may be used as a reference for delivering such interventions in low- and middle-income countries and in underserved areas of high-income countries.
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Affiliation(s)
- Yuesong Pan
- From the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (Y.P., L.Z., Z.L., X.M., Y.W., H.L., L.L., Y.W.).,China National Clinical Research Centre for Neurological Diseases, Beijing (Y.P., L.Z., Z.L., X.M., Y.W., H.L., L.L., Y.W.)
| | - Lei Zhang
- From the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (Y.P., L.Z., Z.L., X.M., Y.W., H.L., L.L., Y.W.).,China National Clinical Research Centre for Neurological Diseases, Beijing (Y.P., L.Z., Z.L., X.M., Y.W., H.L., L.L., Y.W.).,Changping District Hospital, Beijing, China (L.Z.)
| | - Zixiao Li
- From the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (Y.P., L.Z., Z.L., X.M., Y.W., H.L., L.L., Y.W.).,China National Clinical Research Centre for Neurological Diseases, Beijing (Y.P., L.Z., Z.L., X.M., Y.W., H.L., L.L., Y.W.)
| | - Xia Meng
- From the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (Y.P., L.Z., Z.L., X.M., Y.W., H.L., L.L., Y.W.).,China National Clinical Research Centre for Neurological Diseases, Beijing (Y.P., L.Z., Z.L., X.M., Y.W., H.L., L.L., Y.W.)
| | - Yilong Wang
- From the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (Y.P., L.Z., Z.L., X.M., Y.W., H.L., L.L., Y.W.).,China National Clinical Research Centre for Neurological Diseases, Beijing (Y.P., L.Z., Z.L., X.M., Y.W., H.L., L.L., Y.W.)
| | - Hao Li
- From the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (Y.P., L.Z., Z.L., X.M., Y.W., H.L., L.L., Y.W.).,China National Clinical Research Centre for Neurological Diseases, Beijing (Y.P., L.Z., Z.L., X.M., Y.W., H.L., L.L., Y.W.)
| | - Liping Liu
- From the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (Y.P., L.Z., Z.L., X.M., Y.W., H.L., L.L., Y.W.).,China National Clinical Research Centre for Neurological Diseases, Beijing (Y.P., L.Z., Z.L., X.M., Y.W., H.L., L.L., Y.W.)
| | - Yongjun Wang
- From the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (Y.P., L.Z., Z.L., X.M., Y.W., H.L., L.L., Y.W.).,China National Clinical Research Centre for Neurological Diseases, Beijing (Y.P., L.Z., Z.L., X.M., Y.W., H.L., L.L., Y.W.)
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7
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Affiliation(s)
- Patrick D Lyden
- From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA
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8
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Betts KA, Hurley D, Song J, Sajeev G, Guo J, Du EX, Paschoalin M, Wu EQ. Real-World Outcomes of Acute Ischemic Stroke Treatment with Intravenous Recombinant Tissue Plasminogen Activator. J Stroke Cerebrovasc Dis 2017; 26:1996-2003. [PMID: 28689999 DOI: 10.1016/j.jstrokecerebrovasdis.2017.06.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 05/11/2017] [Accepted: 06/03/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND AND PURPOSE In clinical trials, intravenous (IV) recombinant tissue-type plasminogen activator (rt-PA) reduces the likelihood of disability if given within 3 hours of acute ischemic stroke. This study compared real-world outcomes between patients treated and patients not treated with IV rt-PA. METHODS In this retrospective study, United States-based neurologists randomly selected eligible acute ischemic stroke patients from their charts who were and were not treated with IV rt-PA. Mortality, hospital readmission, and independence were compared between patients treated and patients not treated with IV rt-PA using Kaplan-Meier curves, log-rank tests, and Cox proportional hazards models. RESULTS A total of 1026 charts were reviewed with a median follow-up time of 15.5 months. Pretreatment stroke severity, as measured by the National Institutes of Health Stroke Scale, was comparable between cohorts (IV rt-PA =11.7; non-rt-PA = 11.3; P = .165). IV rt-PA patients experienced significantly longer survival (P = .013), delayed hospital readmission (P = .012), and shorter time to independence (P < .001) compared with patients not treated with rt-PA. After adjusting for baseline characteristics, IV rt-PA patients had significantly lower mortality (hazard ratio [95% confidence interval] = .52 [.30, .90]) and greater rates of independence (hazard ratio [95% confidence interval] = 1.42 [1.17, 1.71]) than patients not treated with rt-PA. CONCLUSIONS This real-world study indicated that acute ischemic stroke patients treated with IV rt-PA experience long-term clinical benefits in survival and functional status.
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Affiliation(s)
| | | | - Jinlin Song
- Analysis Group, Inc., Los Angeles, California
| | | | - Jenny Guo
- Analysis Group, Inc., Boston, Massachusetts
| | | | | | - Eric Q Wu
- Analysis Group, Inc., Boston, Massachusetts
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Joo H, Wang G, George MG. A literature review of cost-effectiveness of intravenous recombinant tissue plasminogen activator for treating acute ischemic stroke. Stroke Vasc Neurol 2017; 2:73-83. [PMID: 28736623 PMCID: PMC5516524 DOI: 10.1136/svn-2016-000063] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 02/04/2017] [Accepted: 02/06/2017] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Intravenous recombinant tissue plasminogen activator (IV rtPA) is recommended treatment for acute ischemic stroke patients, but the cost-effectiveness of IV rtPA within different time windows after the onset of acute ischemic stroke is not well reviewed. AIMS To conduct a literature review of the cost-effectiveness studies about IV rtPA by treatment times. SUMMARY OF REVIEW A literature search was conducted using MEDLINE, EMBASE, CINAHL and Cochrane Library, with the key words acute ischemic stroke, tissue plasminogen activator, cost, economic benefit, saving, and incremental cost-effectiveness analysis. The review is limited to original research articles published during 1995-2016 in English-language peer-reviewed journals. We found 16 studies meeting our criteria for this review. Nine of them were cost-effectiveness studies of IV rtPA treatment within 0-3 hours after stroke onset, 2 studies within 3-4.5 hours, 3 studies within 0-4.5 hours, and 2 study within 0-6 hours. IV rtPA is a cost-saving or a cost-effectiveness strategy from most of the study results. Only one study showed incremental cost-effectiveness ratio of IV rtPA within one year was marginally above $50,000 per QALY threshold. IV rtPA within 0-3 hours after stroke led to cost savings for lifetime or 30 years, and IV rtPA within 3-4.5 hours after stroke increased costs but still was cost-effective. CONCLUSIONS The literature generally showed that intravenous IV rtPA was a dominant or a cost-effective strategy compared to traditional treatment for acute ischemic stroke patients without IV rtPA. The findings from the literature lacked generalizability because of limited data and various assumptions.
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Affiliation(s)
- Heesoo Joo
- Division for Heart Disease and Stroke Prevention, CDC; IHRC Inc., Atlanta, Georgia, USA
| | - Guijing Wang
- Division for Heart Disease and Stroke Prevention, CDC, Atlanta, Georgia, USA
| | - Mary G George
- Division for Heart Disease and Stroke Prevention, CDC, Atlanta, Georgia, USA
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Lekander I, Willers C, von Euler M, Lilja M, Sunnerhagen KS, Pessah-Rasmussen H, Borgström F. Relationship between functional disability and costs one and two years post stroke. PLoS One 2017; 12:e0174861. [PMID: 28384164 PMCID: PMC5383241 DOI: 10.1371/journal.pone.0174861] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 03/16/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND PURPOSE Stroke affects mortality, functional ability, quality of life and incurs costs. The primary objective of this study was to estimate the costs of stroke care in Sweden by level of disability and stroke type (ischemic (IS) or hemorrhagic stroke (ICH)). METHOD Resource use during first and second year following a stroke was estimated based on a research database containing linked data from several registries. Costs were estimated for the acute and post-acute management of stroke, including direct (health care consumption and municipal services) and indirect (productivity losses) costs. Resources and costs were estimated per stroke type and functional disability categorised by Modified Rankin Scale (mRS). RESULTS The results indicated that the average costs per patient following a stroke were 350,000SEK/€37,000-480,000SEK/€50,000, dependent on stroke type and whether it was the first or second year post stroke. Large variations were identified between different subgroups of functional disability and stroke type, ranging from annual costs of 100,000SEK/€10,000-1,100,000SEK/€120,000 per patient, with higher costs for patients with ICH compared to IS and increasing costs with more severe functional disability. CONCLUSION Functional outcome is a major determinant on costs of stroke care. The stroke type associated with worse outcome (ICH) was also consistently associated to higher costs. Measures to improve function are not only important to individual patients and their family but may also decrease the societal burden of stroke.
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Affiliation(s)
- Ingrid Lekander
- Ivbar Institute AB, Stockholm, Sweden
- Medical Management Center, LIME, Karolinska Institutet, Stockholm, Sweden
| | - Carl Willers
- Ivbar Institute AB, Stockholm, Sweden
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Mia von Euler
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Karolinska Institutet Stroke research Network at Södersjukhuset, Stockholm, Sweden
| | - Mikael Lilja
- Department of Public Health and Clinical Medicine, Unit of Research, Education, and Development, Östersund Hospital, Umeå University, Östersund, Sweden
| | - Katharina S Sunnerhagen
- Institute of Neuroscience and Physiology, Rehabilitation medicine, University of Gothenburg, Gothenburg, Sweden
| | - Hélène Pessah-Rasmussen
- Department of Health Sciences, Lund University, Lund, Sweden
- Department of Neurology and Rehabilitation medicine, Skåne University Hospital, Malmö, Sweden
| | - Fredrik Borgström
- Medical Management Center, LIME, Karolinska Institutet, Stockholm, Sweden
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Aoki J, Kimura K, Sakamoto Y. Early administration of tissue-plasminogen activator improves the long-term clinical outcome at 5years after onset. J Neurol Sci 2016; 362:33-9. [DOI: 10.1016/j.jns.2016.01.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 01/11/2016] [Accepted: 01/12/2016] [Indexed: 10/22/2022]
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Pandya A, Eggman AA, Kamel H, Gupta A, Schackman BR, Sanelli PC. Modeling the Cost Effectiveness of Neuroimaging-Based Treatment of Acute Wake-Up Stroke. PLoS One 2016; 11:e0148106. [PMID: 26840397 PMCID: PMC4740488 DOI: 10.1371/journal.pone.0148106] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 01/13/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Thrombolytic treatment (tissue-type plasminogen activator [tPA]) is only recommended for acute ischemic stroke patients with stroke onset time <4.5 hours. tPA is not recommended when stroke onset time is unknown. Diffusion-weighted MRI (DWI) and fluid attenuated inversion recovery (FLAIR) MRI mismatch information has been found to approximate stroke onset time with some accuracy. Therefore, we developed a micro-simulation model to project health outcomes and costs of MRI-based treatment decisions versus no treatment for acute wake-up stroke patients. METHODS AND FINDINGS The model assigned simulated patients a true stroke onset time from a specified probability distribution. DWI-FLAIR mismatch estimated stroke onset <4.5 hours with sensitivity and specificity of 0.62 and 0.78, respectively. Modified Rankin Scale (mRS) scores reflected tPA treatment effectiveness accounting for patients' true stroke onset time. Discounted lifetime costs and benefits (quality-adjusted life years [QALYs]) were projected for each strategy. Incremental cost-effectiveness ratios (ICERs) were calculated for the MRI-based strategy in base-case and sensitivity analyses. With no treatment, 45.1% of simulated patients experienced a good stroke outcome (mRS score 0-1). Under the MRI-based strategy, in which 17.0% of all patients received tPA despite stroke onset times >4.5 hours, 46.3% experienced a good stroke outcome. Lifetime discounted QALYs and costs were 5.312 and $88,247 for the no treatment strategy and 5.342 and $90,869 for the MRI-based strategy, resulting in an ICER of $88,000/QALY. Results were sensitive to variations in patient- and provider-specific factors such as sleep duration, hospital travel and door-to-needle times, as well as onset probability distribution, MRI specificity, and mRS utility values. CONCLUSIONS Our model-based findings suggest that an MRI-based treatment strategy for this population could be cost-effective and quantifies the impact that patient- and provider-specific factors, such as sleep duration, hospital travel and door-to-needle times, could have on the optimal decision for wake-up stroke patients.
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Affiliation(s)
- Ankur Pandya
- Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, United States of America
- * E-mail:
| | - Ashley A. Eggman
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, United States of America
| | - Hooman Kamel
- Department of Neurology, New York-Presbyterian/Weill Cornell Medical College, New York, NY, United States of America
| | - Ajay Gupta
- Department of Radiology, New York-Presbyterian/Weill Cornell Medical College, New York, NY, United States of America
| | - Bruce R. Schackman
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, United States of America
| | - Pina C. Sanelli
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, United States of America
- Department of Radiology, New York-Presbyterian/Weill Cornell Medical College, New York, NY, United States of America
- Department of Radiology, North Shore–LIJ Health System, Manhasset, NY, United States of America
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Sun MC, Hsiao PJ. Time cost of a nonclosing intravenous thrombolysis service for acute ischemic stroke. J Formos Med Assoc 2015; 114:910-5. [DOI: 10.1016/j.jfma.2015.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 07/05/2015] [Accepted: 07/06/2015] [Indexed: 11/24/2022] Open
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Parody E, Pedraza S, García-Gil MM, Crespo C, Serena J, Dávalos A. Cost-Utility Analysis of Magnetic Resonance Imaging Management of Patients with Acute Ischemic Stroke in a Spanish Hospital. Neurol Ther 2015; 4:25-37. [PMID: 26847673 PMCID: PMC4470974 DOI: 10.1007/s40120-015-0029-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Stroke has a high rate of long-term disability and mortality and therefore has a significant economic impact. The objective of this study was to determine from a social perspective, the cost-utility of magnetic resonance imaging (MRI) compared to computed tomography (CT) as the first imaging test in acute ischemic stroke (AIS). METHODS A cost-utility analysis of MRI compared to CT as the first imaging test in AIS was performed. Economic evaluation data were obtained from a prospective study of patients with AIS ≤12 h from onset in one Spanish hospital. The measure of effectiveness was quality-adjusted life-years (QALYs) calculated from utilities of the modified Rankin Scale. Both hospital and post-discharge expenses were included in the costs. The incremental cost-effectiveness ratio (ICER) was calculated and sensitivity analysis was carried out. The costs were expressed in Euros at the 2004 exchange rate. RESULTS A total of 130 patients were analyzed. The first imaging test was CT in 87 patients and MRI in 43 patients. Baseline variables were similar in the two groups. The mean direct cost was €5830.63 for the CT group and €5692.95 for the MRI group (P = not significant). The ICER was €11,868.97/QALY. The results were sensitive when the indirect costs were included in the analysis. CONCLUSION Total direct costs and QALYs were lower in the MRI group; however, this difference was not statistically significant. MRI was shown to be a cost-effective strategy for the first imaging test in AIS in 22% of the iterations according to the efficiency threshold in Spain.
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Affiliation(s)
| | - Salvador Pedraza
- Department of Radiology-IDI, IDIBGI, Hospital Doctor Josep Trueta, UDG, Girona, Spain
| | - María M García-Gil
- Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Catalunya, Spain
| | - Carlos Crespo
- Health Economics and Pricing, Boehringer Ingelheim, Sant Cugat del Valles (Barcelona), Spain
| | - Joaquín Serena
- Department of Neurology, Hospital Doctor Josep Trueta, Girona, Spain
| | - Antoni Dávalos
- Department of Neurology, Germans Trias i Pujol Hospital, Badalona, Spain
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Gyrd-Hansen D, Olsen KR, Bollweg K, Kronborg C, Ebinger M, Audebert HJ. Cost-effectiveness estimate of prehospital thrombolysis: results of the PHANTOM-S study. Neurology 2015; 84:1090-7. [PMID: 25672925 DOI: 10.1212/wnl.0000000000001366] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To analyze the cost-effectiveness of shorter delays to treatment and increased thrombolysis rate as shown in the PHANTOM-S (Prehospital Acute Neurological Treatment and Optimization of Medical Care in Stroke) Study. METHODS In addition to intermediate outcomes (time to thrombolysis) and treatment rates, we registered all resource consequences of the intervention. The analyzed treatment effects of the intervention were restricted to distribution of IV thrombolysis (IVT) administrations according to time intervals. Intermediate outcomes were extrapolated to final outcomes according to numbers needed to treat derived from pooled IVT trials and translated to gains in quality-adjusted life-years (QALYs). RESULTS The net annual cost of the Stroke Emergency Mobile (STEMO) prehospital stroke concept was €963,954. The higher frequency of IVT administrations per year (310 vs 225) and higher proportions of patients treated in the early time interval (within 90 minutes: 48.1% vs 37.4%; 91-180 minutes: 37.4% vs 50%; 181-270 minutes: 14.5% vs 12.8%) resulted in an annual expected health gain of avoidance of 18 cases of disability equaling 29.7 QALYs. This produced an incremental cost-effectiveness ratio of €32,456 per QALY. CONCLUSIONS Depending on willingness-to-pay thresholds in societal perspectives, the STEMO prehospital stroke concept has the potential of providing a reasonable innovation even in health-economic dimensions.
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Affiliation(s)
- Dorte Gyrd-Hansen
- From IVØ Analysis, Department of Business and Economics (D.G.-H., K.R.O., C.K.), and Institute of Public Health (D.G.-H.), University of Southern Denmark; Department of Neurology (K.B., H.J.A.), Charité, Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin; Department of Neurology (M.E.), Charité, Universitätsmedizin Berlin, Campus Mitte, Berlin; and Center for Stroke Research Berlin (K.B., M.E., H.J.A.), Charité, Universitätsmedizin Berlin, Germany.
| | - Kim Rose Olsen
- From IVØ Analysis, Department of Business and Economics (D.G.-H., K.R.O., C.K.), and Institute of Public Health (D.G.-H.), University of Southern Denmark; Department of Neurology (K.B., H.J.A.), Charité, Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin; Department of Neurology (M.E.), Charité, Universitätsmedizin Berlin, Campus Mitte, Berlin; and Center for Stroke Research Berlin (K.B., M.E., H.J.A.), Charité, Universitätsmedizin Berlin, Germany
| | - Kerstin Bollweg
- From IVØ Analysis, Department of Business and Economics (D.G.-H., K.R.O., C.K.), and Institute of Public Health (D.G.-H.), University of Southern Denmark; Department of Neurology (K.B., H.J.A.), Charité, Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin; Department of Neurology (M.E.), Charité, Universitätsmedizin Berlin, Campus Mitte, Berlin; and Center for Stroke Research Berlin (K.B., M.E., H.J.A.), Charité, Universitätsmedizin Berlin, Germany
| | - Christian Kronborg
- From IVØ Analysis, Department of Business and Economics (D.G.-H., K.R.O., C.K.), and Institute of Public Health (D.G.-H.), University of Southern Denmark; Department of Neurology (K.B., H.J.A.), Charité, Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin; Department of Neurology (M.E.), Charité, Universitätsmedizin Berlin, Campus Mitte, Berlin; and Center for Stroke Research Berlin (K.B., M.E., H.J.A.), Charité, Universitätsmedizin Berlin, Germany
| | - Martin Ebinger
- From IVØ Analysis, Department of Business and Economics (D.G.-H., K.R.O., C.K.), and Institute of Public Health (D.G.-H.), University of Southern Denmark; Department of Neurology (K.B., H.J.A.), Charité, Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin; Department of Neurology (M.E.), Charité, Universitätsmedizin Berlin, Campus Mitte, Berlin; and Center for Stroke Research Berlin (K.B., M.E., H.J.A.), Charité, Universitätsmedizin Berlin, Germany
| | - Heinrich J Audebert
- From IVØ Analysis, Department of Business and Economics (D.G.-H., K.R.O., C.K.), and Institute of Public Health (D.G.-H.), University of Southern Denmark; Department of Neurology (K.B., H.J.A.), Charité, Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin; Department of Neurology (M.E.), Charité, Universitätsmedizin Berlin, Campus Mitte, Berlin; and Center for Stroke Research Berlin (K.B., M.E., H.J.A.), Charité, Universitätsmedizin Berlin, Germany
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Schmidt A, Heroum C, Caumette D, Le Lay K, Bénard S. Acute Ischemic Stroke (AIS) patient management in French stroke units and impact estimation of thrombolysis on care pathways and associated costs. Cerebrovasc Dis 2015; 39:94-101. [PMID: 25660476 DOI: 10.1159/000369525] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 11/03/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Stroke is the second leading cause of death and a first leading cause of acquired disability in adults worldwide. This study aims to evaluate the current management and associated costs of acute ischemic stroke (AIS) for patients admitted in stroke units in France and over a one-year follow-up period as well as to assess the impact of improved thrombolytic management in terms of increasing the proportion of patients receiving thrombolysis and/or treated within 3 h from the onset of symptoms. METHODS A decision model was developed, which comprises two components: the first corresponding to the acute hospital management phase of patients with AIS up until hospital discharge, extracted from the national hospital discharge database (PMSI 2011), and the second corresponding to the post-acute (post-discharge) phase, based on national treatment guidelines and stroke experts' advice. Five post-acute clinical care pathways were defined. In-hospital mortality and mortality at 3 months post-discharge was taken into account into the model. Patient journeys and costs were determined for both phases. Improved thrombolytic management was modeled by increasing the proportion of patients receiving thrombolysis from the current estimated level of 16.7 to 25% as well as subsequently increasing the proportion of patients treated within 3 h of the onset of symptoms post-stroke from 50 to 100%. The impact on care pathways was derived from clinical data. RESULTS Among 202,078 hospitalizations for a stroke or a transient ischemic attack (TIA), 90,528 were for confirmed AIS, and 33% (29,999) of them managed within a stroke unit. After hospitalization, 60% of discharges were to home, 25% to rehabilitative care and then home, 2% to rehabilitative care and then a nursing home, 7% to long-term care, and 6% of stays ended with patient death. Of a total cost over 1 year of €610 million (mean cost per patient of €20,326), 70% concern the post-acute phase. By increasing the proportion of patients being thrombolyzed, costs are reduced primarily by a decrease in rehabilitative care, with savings per additional treated patient of €1,462. By adding improved timing, savings are more than doubled (€3,183 per additional treated patient). CONCLUSIONS This study confirms that the burden of AIS in France is heavy. By improving thrombolytic management in stroke units, patient journeys through care pathways can be modified, with increased discharges home, a change in post-acute resource consumption and net savings.
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Dietrich M, Walter S, Ragoschke-Schumm A, Helwig S, Levine S, Balucani C, Lesmeister M, Haass A, Liu Y, Lossius HM, Fassbender K. Is prehospital treatment of acute stroke too expensive? An economic evaluation based on the first trial. Cerebrovasc Dis 2014; 38:457-63. [PMID: 25531507 DOI: 10.1159/000371427] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Accepted: 12/08/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Recently, a strategy for treating stroke directly at the emergency site was developed. It was based on the use of an ambulance equipped with a scanner, a point-of-care laboratory, and telemedicine capabilities (Mobile Stroke Unit). Despite demonstrating a marked reduction in the delay to thrombolysis, this strategy is criticized because of potentially unacceptable costs. METHODS We related the incremental direct costs of prehospital stroke treatment based on data of the first trial on this concept to one year direct cost savings taken from published research results. Key parameters were configuration of emergency medical service personnel, operating distance, and population density. Model parameters were varied to cover 5 different relevant emergency medical service scenarios. Additionally, the effects of operating distance and population density on benefit-cost ratios were analyzed. RESULTS Benefits of the concept of prehospital stroke treatment outweighed its costs with a benefit-cost ratio of 1.96 in the baseline experimental setting. The benefit-cost ratio markedly increased with the reduction of the staff and with higher population density. Maximum benefit-cost ratios between 2.16 and 6.85 were identified at optimum operating distances in a range between 43.01 and 64.88 km (26.88 and 40.55 miles). Our model implies that in different scenarios the Mobile Stroke Unit strategy is cost-efficient starting from an operating distance of 15.98 km (9.99 miles) or from a population density of 79 inhabitants per km2 (202 inhabitants per square mile). CONCLUSION This study indicates that based on a one-year benefit-cost analysis that prehospital treatment of acute stroke is highly cost-effective across a wide range of possible scenarios. It is the highest when the staff size of the Mobile Stroke Unit can be reduced, for example, by the use of telemedical support from hospital experts. Although efficiency is positively related to population density, benefit-cost ratios can be greater than 1 even in rural settings.
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Affiliation(s)
- Martin Dietrich
- Chair of Business Administration and Health Services Management Research, Saarbrücken, Germany
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Pan Y, Chen Q, Zhao X, Liao X, Wang C, Du W, Liu G, Liu L, Wang C, Wang Y, Wang Y. Cost-effectiveness of thrombolysis within 4.5 hours of acute ischemic stroke in China. PLoS One 2014; 9:e110525. [PMID: 25329637 PMCID: PMC4203798 DOI: 10.1371/journal.pone.0110525] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 09/22/2014] [Indexed: 11/18/2022] Open
Abstract
Background Previous economic studies conducted in developed countries showed intravenous tissue-type plasminogen activator (tPA) is cost-effective for acute ischemic stroke. The present study aimed to determine the cost-effectiveness of tPA treatment in China, the largest developing country. Methods A combination of decision tree and Markov model was developed to determine the cost-effectiveness of tPA treatment versus non-tPA treatment within 4.5 hours after stroke onset. Outcomes and costs data were derived from the database of Thrombolysis Implementation and Monitor of acute ischemic Stroke in China (TIMS-China) study. Efficacy data were derived from a pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials. Costs and quality-adjusted life-years (QALYs) were compared in both short term (2 years) and long term (30 years). One-way and probabilistic sensitivity analyses were performed to test the robustness of the results. Results Comparing to non-tPA treatment, tPA treatment within 4.5 hours led to a short-term gain of 0.101 QALYs at an additional cost of CNY 9,520 (US$ 1,460), yielding an incremental cost-effectiveness ratio (ICER) of CNY 94,300 (US$ 14,500) per QALY gained in 2 years; and to a long-term gain of 0.422 QALYs at an additional cost of CNY 6,530 (US$ 1,000), yielding an ICER of CNY 15,500 (US$ 2,380) per QALY gained in 30 years. Probabilistic sensitivity analysis showed that tPA treatment is cost-effective in 98.7% of the simulations at a willingness-to-pay threshold of CNY 105,000 (US$ 16,200) per QALY. Conclusions Intravenous tPA treatment within 4.5 hours is highly cost-effective for acute ischemic strokes in China.
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Affiliation(s)
- Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Qidong Chen
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaoling Liao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chunjuan Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wanliang Du
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Gaifen Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chunxue Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- * E-mail: (YW); (YW)
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- * E-mail: (YW); (YW)
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Abstract
Background:Tissue plasminogen activator has been found to significantly improve patient outcomes post stroke. Previous economic evaluations have adjusted for fewer admissions to inpatient rehabilitation but not for decreased length of stay in rehabilitation. Our objective was to estimate the potential cost savings associated with a decreased length of stay in inpatient rehabilitation for patients who receive tissue plasminogen activator compared to those who do not, in a Canadian context.Methods:Decreased length of stay in inpatient rehabilitation for patients who received tissue plasminogen activator compared to controls was reported previously in a population of 1962 patients admitted to hospital with an ischemic stroke in Ontario between July 1, 2003 and March 31, 2008. Average per diem cost savings associated with the use of tissue plasminogen activator were calculated using a literature based cost estimate. Sensitivity analysis varying the length of stay in inpatient rehabilitation was performed.Results:The estimated mean per diem cost of inpatient rehabilitation derived from the literature was $626. Based on previously reported estimates for reduced length of stay, receipt of tissue plasminogen activator was estimated to result in savings of $939 per patient during inpatient rehabilitation. Sensitivity analysis suggested that these cost savings could range from $501 to $1377 per patient on average.Conclusions:Future economic evaluations of tissue plasminogen activator should consider adjusting for shortened length of stay in inpatient rehabilitation for patients who receive tissue plasminogen activator.
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Boudreau DM, Guzauskas GF, Chen E, Lalla D, Tayama D, Fagan SC, Veenstra DL. Cost-Effectiveness of Recombinant Tissue-Type Plasminogen Activator Within 3 Hours of Acute Ischemic Stroke. Stroke 2014; 45:3032-9. [DOI: 10.1161/strokeaha.114.005852] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Despite the availability of results from multiple newer clinical trials and changing healthcare costs, the cost-effectiveness of recombinant tissue-type plasminogen activator (r-tPA) for treatment of acute ischemic stroke within 0 to 3 hours of symptom onset was last evaluated in 1998 for the United States Using current evidence, we evaluate the long-term cost-effectiveness of r-tPA administered 0 to 3 hours after acute ischemic stroke onset versus no r-tPA.
Methods—
A disease-based decision model to project lifetime outcomes of patients after acute ischemic stroke by r-tPA treatment status from the US payer perspective was developed. Model inputs were derived from a recent meta-analysis of r-tPA trials, cohort studies, and health state preference studies. Cost data, inflated to 2013 dollars, were based on drug wholesale acquisition cost and the literature. To compare r-tPA to no r-tPA, we calculated incremental total direct costs, incremental quality-adjusted life years, and incremental cost-effectiveness ratios. We performed 1-way and probabilistic sensitivity analyses to evaluate uncertainty in the results.
Results—
r-tPA resulted in a gain of 0.39 quality-adjusted life years (95% confidence range, 0.16–0.66) on average per patient and a lifetime cost-saving of $25 000 (95% confidence range, −$42 500 to −$11 000) compared with no r-tPA. In probabilistic sensitivity analyses, r-tPA was dominant compared with no r-tPA in ≈100% of simulations. The model was sensitive to inputs for r-tPA efficacy, healthcare costs for disabled patients, mortality rates for disabled and nondisabled patients, and quality of life estimates.
Conclusions—
Our analysis supports earlier economic evaluations that r-tPA is a cost-effective method to treat stroke. Appropriate use of r-tPA should be prioritized nationally.
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Affiliation(s)
- Denise M. Boudreau
- From the University of Washington, Seattle (D.M.B., G.F.G., D.L.V.); Genentech, Inc South San Francisco, CA (E.C., D.T.); Palo Alto Outcomes Research, CA (D.L.); and University of Georgia College of Pharmacy, Athens (S.C.F.)
| | - Gregory F. Guzauskas
- From the University of Washington, Seattle (D.M.B., G.F.G., D.L.V.); Genentech, Inc South San Francisco, CA (E.C., D.T.); Palo Alto Outcomes Research, CA (D.L.); and University of Georgia College of Pharmacy, Athens (S.C.F.)
| | - Er Chen
- From the University of Washington, Seattle (D.M.B., G.F.G., D.L.V.); Genentech, Inc South San Francisco, CA (E.C., D.T.); Palo Alto Outcomes Research, CA (D.L.); and University of Georgia College of Pharmacy, Athens (S.C.F.)
| | - Deepa Lalla
- From the University of Washington, Seattle (D.M.B., G.F.G., D.L.V.); Genentech, Inc South San Francisco, CA (E.C., D.T.); Palo Alto Outcomes Research, CA (D.L.); and University of Georgia College of Pharmacy, Athens (S.C.F.)
| | - Darren Tayama
- From the University of Washington, Seattle (D.M.B., G.F.G., D.L.V.); Genentech, Inc South San Francisco, CA (E.C., D.T.); Palo Alto Outcomes Research, CA (D.L.); and University of Georgia College of Pharmacy, Athens (S.C.F.)
| | - Susan C. Fagan
- From the University of Washington, Seattle (D.M.B., G.F.G., D.L.V.); Genentech, Inc South San Francisco, CA (E.C., D.T.); Palo Alto Outcomes Research, CA (D.L.); and University of Georgia College of Pharmacy, Athens (S.C.F.)
| | - David L. Veenstra
- From the University of Washington, Seattle (D.M.B., G.F.G., D.L.V.); Genentech, Inc South San Francisco, CA (E.C., D.T.); Palo Alto Outcomes Research, CA (D.L.); and University of Georgia College of Pharmacy, Athens (S.C.F.)
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Penaloza-Ramos MC, Sheppard JP, Jowett S, Barton P, Mant J, Quinn T, Mellor RM, Sims D, Sandler D, McManus RJ, Carr P, Greenfield S, Helliwell B, Nand C, Phillips N, Scott R, Singh S, Ward M. Cost-Effectiveness of Optimizing Acute Stroke Care Services for Thrombolysis. Stroke 2014; 45:553-62. [DOI: 10.1161/strokeaha.113.003216] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Maria Cristina Penaloza-Ramos
- From the Health Economics Unit (M.C.P.-R., S.J., P.B.) and Primary Care Clinical Sciences (J.P.S., R.M.M.), University of Birmingham, Edgbaston, Birmingham, UK; Department of Primary Care Health Sciences, University of Oxford, Oxford, UK (J.P.S., R.J.M.); Primary Care Unit, University of Cambridge, Cambridge, UK (J.M.); Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK (T.Q.); University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK (D. Sims); and Heart of
| | - James P. Sheppard
- From the Health Economics Unit (M.C.P.-R., S.J., P.B.) and Primary Care Clinical Sciences (J.P.S., R.M.M.), University of Birmingham, Edgbaston, Birmingham, UK; Department of Primary Care Health Sciences, University of Oxford, Oxford, UK (J.P.S., R.J.M.); Primary Care Unit, University of Cambridge, Cambridge, UK (J.M.); Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK (T.Q.); University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK (D. Sims); and Heart of
| | - Sue Jowett
- From the Health Economics Unit (M.C.P.-R., S.J., P.B.) and Primary Care Clinical Sciences (J.P.S., R.M.M.), University of Birmingham, Edgbaston, Birmingham, UK; Department of Primary Care Health Sciences, University of Oxford, Oxford, UK (J.P.S., R.J.M.); Primary Care Unit, University of Cambridge, Cambridge, UK (J.M.); Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK (T.Q.); University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK (D. Sims); and Heart of
| | - Pelham Barton
- From the Health Economics Unit (M.C.P.-R., S.J., P.B.) and Primary Care Clinical Sciences (J.P.S., R.M.M.), University of Birmingham, Edgbaston, Birmingham, UK; Department of Primary Care Health Sciences, University of Oxford, Oxford, UK (J.P.S., R.J.M.); Primary Care Unit, University of Cambridge, Cambridge, UK (J.M.); Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK (T.Q.); University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK (D. Sims); and Heart of
| | - Jonathan Mant
- From the Health Economics Unit (M.C.P.-R., S.J., P.B.) and Primary Care Clinical Sciences (J.P.S., R.M.M.), University of Birmingham, Edgbaston, Birmingham, UK; Department of Primary Care Health Sciences, University of Oxford, Oxford, UK (J.P.S., R.J.M.); Primary Care Unit, University of Cambridge, Cambridge, UK (J.M.); Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK (T.Q.); University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK (D. Sims); and Heart of
| | - Tom Quinn
- From the Health Economics Unit (M.C.P.-R., S.J., P.B.) and Primary Care Clinical Sciences (J.P.S., R.M.M.), University of Birmingham, Edgbaston, Birmingham, UK; Department of Primary Care Health Sciences, University of Oxford, Oxford, UK (J.P.S., R.J.M.); Primary Care Unit, University of Cambridge, Cambridge, UK (J.M.); Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK (T.Q.); University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK (D. Sims); and Heart of
| | - Ruth M. Mellor
- From the Health Economics Unit (M.C.P.-R., S.J., P.B.) and Primary Care Clinical Sciences (J.P.S., R.M.M.), University of Birmingham, Edgbaston, Birmingham, UK; Department of Primary Care Health Sciences, University of Oxford, Oxford, UK (J.P.S., R.J.M.); Primary Care Unit, University of Cambridge, Cambridge, UK (J.M.); Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK (T.Q.); University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK (D. Sims); and Heart of
| | - Don Sims
- From the Health Economics Unit (M.C.P.-R., S.J., P.B.) and Primary Care Clinical Sciences (J.P.S., R.M.M.), University of Birmingham, Edgbaston, Birmingham, UK; Department of Primary Care Health Sciences, University of Oxford, Oxford, UK (J.P.S., R.J.M.); Primary Care Unit, University of Cambridge, Cambridge, UK (J.M.); Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK (T.Q.); University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK (D. Sims); and Heart of
| | - David Sandler
- From the Health Economics Unit (M.C.P.-R., S.J., P.B.) and Primary Care Clinical Sciences (J.P.S., R.M.M.), University of Birmingham, Edgbaston, Birmingham, UK; Department of Primary Care Health Sciences, University of Oxford, Oxford, UK (J.P.S., R.J.M.); Primary Care Unit, University of Cambridge, Cambridge, UK (J.M.); Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK (T.Q.); University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK (D. Sims); and Heart of
| | - Richard J. McManus
- From the Health Economics Unit (M.C.P.-R., S.J., P.B.) and Primary Care Clinical Sciences (J.P.S., R.M.M.), University of Birmingham, Edgbaston, Birmingham, UK; Department of Primary Care Health Sciences, University of Oxford, Oxford, UK (J.P.S., R.J.M.); Primary Care Unit, University of Cambridge, Cambridge, UK (J.M.); Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK (T.Q.); University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK (D. Sims); and Heart of
| | | | | | | | | | | | | | - Satinder Singh
- Primary Care Clinical Sciences, University of Birmingham
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Fields JD, Lindsay K, Liu KC, Nesbit GM, Lutsep HL. Mechanical thrombectomy for the treatment of acute ischemic stroke. Expert Rev Cardiovasc Ther 2014; 8:581-92. [DOI: 10.1586/erc.10.8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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24
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Quinn TJ, Dawson J. Acute ‘strokenomics’: efficacy and economic analyses of alteplase for acute ischemic stroke. Expert Rev Pharmacoecon Outcomes Res 2014; 9:513-22. [DOI: 10.1586/erp.09.63] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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25
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Te Ao B, Brown P, Fink J, Vivian M, Feigin V. Potential gains and costs from increasing access to thrombolysis for acute ischemic stroke patients in New Zealand hospitals. Int J Stroke 2013; 10:903-10. [PMID: 24206567 DOI: 10.1111/ijs.12152] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND AIM Treatment of ischemic stroke patients with tissue-type plasminogen activator (tPA) is known to be effective and cost-effective, yet the percentage of patients treated with thrombolysis in hospitals remains low. The purpose of this study is to examine whether providing thrombolysis in New Zealand hospitals is currently cost-effective and to estimate the amount that might be spent on campaigns aimed at increasing thrombolysis receipt rates. METHODS A decision-analytic model was developed and populated using health services data from the literature and the Auckland Regional Community Stroke Outcome Study. The cost-utilities of providing thrombolysis over one-year and patient lifetime were estimated. Using a threshold of NZ$20 000 (US$15 337) per quality-adjusted life year, the analysis identified the maximum amount that might be spent on campaigns aiming to increase rates of receipt of thrombolysis above their current levels. Monte Carlo simulations and probabilistic sensitivity analysis explored the robustness of the findings. RESULTS Providing thrombolysis was cost-effective, especially when long-term costs and effects were considered (NZ$6641 or US$5093 per quality-adjusted life year). The results suggest that better management within hospitals would be more effective in increasing thrombolysis receipt rates (up to 17%) than campaigns aiming at higher awareness of stroke symptoms in the community. The amount that might be spent on a national campaign to increase rate of receipt of thrombolysis from its current level (3% of eligible patients) depended upon the effectiveness of the campaign, ranging from under NZ$6 million for New Zealand for an increase in rate to 30% to over $9 million for an increase in rate to 50%. CONCLUSION While thrombolysis is a cost-effective treatment in New Zealand, resources should be devoted to campaigns, both within hospitals and in the community, to increase coverage.
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Affiliation(s)
- Braden Te Ao
- National Institute for Stroke and Applied Neurosciences, Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Paul Brown
- National Institute for Stroke and Applied Neurosciences, Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand.,School of Social Science, Humanities and Arts, University of California, Merced, CA, USA
| | - John Fink
- Department of Neurology, Canterbury District Health Board, Christchurch, New Zealand
| | - Mark Vivian
- New Zealand Stroke Foundation, Wellington, New Zealand
| | - Valery Feigin
- National Institute for Stroke and Applied Neurosciences, Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand
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26
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Kapral MK, Fang J, Silver FL, Hall R, Stamplecoski M, O'Callaghan C, Tu JV. Effect of a provincial system of stroke care delivery on stroke care and outcomes. CMAJ 2013; 185:E483-91. [PMID: 23713072 PMCID: PMC3708028 DOI: 10.1503/cmaj.121418] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Systems of stroke care delivery have been promoted as a means of improving the quality of stroke care, but little is known about their effectiveness. We assessed the effect of the Ontario Stroke System, a province-wide strategy of regionalized stroke care delivery, on stroke care and outcomes in Ontario, Canada. METHODS We used population-based provincial administrative databases to identify all emergency department visits and hospital admissions for acute stroke and transient ischemic attack from Jan. 1, 2001, to Dec. 31, 2010. Using piecewise regression analyses, we assessed the effect of the full implementation of the Ontario Stroke System in 2005 on the proportion of patients who received care at stroke centres, and on rates of discharge to long-term care facilities and 30-day mortality after stroke. RESULTS We included 243 287 visits by patients with acute stroke or transient ischemic attack. The full implementation of the Ontario Stroke System in 2005 was associated with an increase in rates of care at stroke centres (before implementation: 40.0%; after implementation: 46.5%), decreased rates of discharge to long-term care facilities (before implementation: 16.9%; after implementation: 14.8%) and decreased 30-day mortality for hemorrhagic (before implementation: 38.3%; after implementation: 34.4%) and ischemic stroke (before implementation: 16.3%; after implementation: 15.7%). The system's implementation was also associated with marked increases in the proportion of patients who received neuroimaging, thrombolytic therapy, care in a stroke unit and antithrombotic therapy. INTERPRETATION The implementation of an organized system of stroke care delivery was associated with improved processes of care and outcomes after stroke.
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Affiliation(s)
- Moira K Kapral
- Department of Medicine, University of Toronto, Toronto, Ontario.
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27
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Smith S, Horgan F, Sexton E, Cowman S, Hickey A, Kelly P, McGee H, Murphy S, O'Neill D, Royston M, Shelley E, Wiley M. The future cost of stroke in Ireland: an analysis of the potential impact of demographic change and implementation of evidence-based therapies. Age Ageing 2013; 42:299-306. [PMID: 23302602 DOI: 10.1093/ageing/afs192] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND AND PURPOSE this paper examines the impact of demographic change from 2007 to 2021 on the total cost of stroke in Ireland and analyses potential impacts of expanded access to stroke unit care and thrombolytic therapy on stroke outcomes and costs. METHODS total costs of stroke are estimated for the projected number of stroke cases in 2021 in Ireland. Analysis also estimates the potential number of deaths or institutionalised cases averted among incident stroke cases in Ireland in 2007 at different rates of access to stroke unit care and thrombolytic therapy. Drawing on these results, total stroke costs in Ireland in 2007 are recalculated on the basis of the revised numbers of incident stroke patients estimated to survive stroke, and of the numbers estimated to reside at home rather than in a nursing home in the context of expanded access to stroke units or thrombolytic therapy. RESULTS future costs of stroke in Ireland are estimated to increase by 52-57% between 2007 and 2021 on the basis of demographic change. The projected increase in aggregate stroke costs for all incident cases in 1 year in Ireland due to the delivery of stroke unit care and thrombolytic therapy can be offset to some extent by reductions in nursing home and other post-acute costs.
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Affiliation(s)
- Samantha Smith
- Economic and Social Research Institute, Whitaker Square, Sir John Rogerson's Quay, Dublin 2, Ireland.
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28
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Bouvy JC, Fransen PSS, Baeten SA, Koopmanschap MA, Niessen LW, Dippel DWJ. Cost-effectiveness of two endovascular treatment strategies vs intravenous thrombolysis. Acta Neurol Scand 2013; 127:351-9. [PMID: 23278859 DOI: 10.1111/ane.12065] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2012] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To assess the cost-effectiveness of endovascular treatment against intravenous thrombolysis (IVT) when varying assumptions concerning its effectiveness. METHODS We developed a health economic model including a hypothetical population consisting of patients with ischemic stroke, admitted within 4.5 h from onset, without contraindications for IVT or intra-arterial treatment (IAT). A decision tree and life table were used to assess 6-month and lifetime costs (in Euros) and effects in quality-adjusted life years treatment with IVT alone, IAT alone, and IVT followed by IAT if the patient did not respond to treatment. Several analyses were performed to explore the impact of considerable uncertainty concerning the clinical effectiveness of endovascular treatment. RESULTS Probabilistic sensitivity analysis demonstrated a 54% probability of positive incremental lifetime effectiveness of IVT-IAT vs IVT alone. Sensitivity analyses showed significant variation in outcomes and cost-effectiveness of the included treatment strategies at different model assumptions. CONCLUSIONS Acceptable cost-effectiveness of IVT-IAT compared to IVT will only be possible if recanalization rates are sufficiently high (>50%), treatment costs of IVT-IAT do not increase, and complication rates remain similar to those reported in the few randomized studies published to date. Large randomized studies are needed to reduce the uncertainty concerning the effects of endovascular treatment.
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Affiliation(s)
| | - P. S. S. Fransen
- Department of Neurology; Erasmus MC Rotterdam; Rotterdam; The Netherlands
| | - S. A. Baeten
- Department of Health Policy and Management (iBMG); Institute for Medical Technology Assessment; Erasmus MC Rotterdam; Rotterdam; The Netherlands
| | - M. A. Koopmanschap
- Department of Health Policy and Management (iBMG); Institute for Medical Technology Assessment; Erasmus MC Rotterdam; Rotterdam; The Netherlands
| | | | - D. W. J. Dippel
- Department of Neurology; Erasmus MC Rotterdam; Rotterdam; The Netherlands
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Bing F, Jacquin G, Poppe A, Roy D, Raymond J, Weill A. The cost of materials for intra-arterial thrombectomy. Interv Neuroradiol 2013; 19:83-6. [PMID: 23472729 DOI: 10.1177/159101991301900113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2012] [Accepted: 12/06/2012] [Indexed: 11/16/2022] Open
Abstract
This paper reports the cost of endovascular materials used for the treatment of large-vessel ischemic stroke in the anterior circulation according to the angiographic score and clinical results at three months. From November 2009 to July 2011, 57 ischemic patients (mean age, 64.6 ±13.8 years) with anterior large vessel occlusion were included. Mean National Institutes of Health Stroke Scale (NIHSS) on admission was 18.4 ± 4.9. Mean duration of symptoms until the arterial puncture was 207±67 minutes. Recanalization was assessed using the Thrombolysis In Myocardial Infarction (TIMI) score. Patient selection was performed on a non-enhanced CT scanner. According to the TIMI final angiographic score and the modified Rankin score (mRS) at three months, we determined the cost of the material used. Complete (n=12, TIMI grade 3) or partial perfusion (n=35, TIMI grade 2) was achieved in 47 (82.5%) lesions. At three months, 33.3% (n=19) had a mRS score ≤ 2. The mean cost of the material used in the operative room was 5018±2402 euro. Intra-arterial thrombolysis presents a substantial initial cost and the long-term economic impact has to be evaluated. Our health system has to take the price of these new technologies into account for future medical choices and urgently evaluate them in randomized controlled trials.
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Affiliation(s)
- F Bing
- Department of Interventional Radiology, University Hospital of Strasbourg, NHC, Strasbourg, France.
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Lucioni C, Mazzi S, Micieli G, Sacchetti ML, Toni D. Valutazione economica del trattamento con alteplase di pazienti con ictus ischemico in fase acuta, con riferimento all’Italia. ACTA ACUST UNITED AC 2013. [DOI: 10.1007/bf03320667] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Peltola M, Quentin W. Diagnosis-related groups for stroke in Europe: patient classification and hospital reimbursement in 11 countries. Cerebrovasc Dis 2013; 35:113-23. [PMID: 23406838 DOI: 10.1159/000346092] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Accepted: 11/22/2012] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Diagnosis-related groups (DRGs) are increasingly being used for various purposes in many countries. However, there are no studies comparing different DRG systems in the care of stroke. As part of the EuroDRG project, researchers from 11 countries (i.e. Austria, England, Estonia, Finland, France, Germany, Ireland, the Netherlands, Poland, Sweden and Spain) compared how their DRG systems deal with stroke patients. The study aims to assist clinicians and national authorities to optimize their DRG systems. METHODS National or regional databases were used to identify hospital cases with a diagnosis of stroke. DRG classification algorithms and indicators of resource consumption were compared for those DRGs that individually represent at least 1% of stroke cases. In addition, standardized case vignettes were defined, and quasi prices according to national DRG-based hospital payment systems were ascertained. RESULTS European DRG systems vary widely: they classify stroke patients according to different sets of variables (between 1 and 7 classification variables) into diverging numbers of DRGs (between 1 and 10 DRGs). In 6 of the countries more than half of the patients are concentrated within a single DRG. The countries' systems also vary with respect to the evaluation of different kinds of stroke patients. The most complex DRG is considered 3.8 times more resource intensive than an index case in Finland. By contrast, in England, the DRG system does not account for complex cases. Comparisons of quasi prices for the case vignettes show that hypothetical payments for the index case amount to only EUR 907 in Poland but to EUR 7,881 in Ireland. CONCLUSIONS Large variations in the classification of stroke patients raise concerns whether all systems rely on the most appropriate classification variables and whether the DRGs adequately reflect differences in the complexity of treating different groups of patients. Learning from other DRG systems may help in improving the national systems. Clinicians and national DRG authorities should consider how other countries' DRG systems classify stroke patients in order to optimize their DRG system and to ensure fair and appropriate reimbursement. In future, quantitative research is needed to verify whether the most important determinants of cost are considered in different patient classification systems, and whether differences between systems reflect country-specific differences in treatment patterns and, most importantly, what influence they have on patient outcomes.
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Affiliation(s)
- Mikko Peltola
- Centre for Health and Social Economics, National Institute for Health and Welfare, Helsinki, Finland.
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Boudreau DM, Guzauskas G, Villa KF, Fagan SC, Veenstra DL. A model of cost-effectiveness of tissue plasminogen activator in patient subgroups 3 to 4.5 hours after onset of acute ischemic stroke. Ann Emerg Med 2013; 61:46-55. [PMID: 22633340 PMCID: PMC3598015 DOI: 10.1016/j.annemergmed.2012.04.020] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2011] [Revised: 02/09/2012] [Accepted: 04/06/2012] [Indexed: 11/21/2022]
Abstract
STUDY OBJECTIVE The European Cooperative Acute Stroke Study III (ECASS III) showed that recombinant tissue plasminogen activator (rtPA) administered 3 to 4.5 hours after acute ischemic stroke led to improvement in patient disability versus placebo. We evaluate the long-term incremental cost-effectiveness of rtPA administered 3 to 4.5 hours after acute ischemic stroke onset versus no treatment according to patient clinical and demographic factors. METHODS We developed a disease-based decision analytic model to project lifetime outcomes of patients post-acute ischemic stroke from the payer perspective. Clinical data were derived from the ECASS III trial, longitudinal cohort studies, and health state preference studies. Cost data were based on Medicare reimbursement and other published sources. We performed probabilistic sensitivity analyses to evaluate uncertainty in the analysis. RESULTS rtPA in a hypothetical cohort resulted in a gain of 0.07 years of life (95% credible range 0.0005 to 0.17) and 0.24 quality-adjusted life-years (95% credible range 0.01 to 0.60) and a difference in cost of $1,495 (95% credible range -$4,637 to $6,100) compared with placebo. The incremental cost-effectiveness ratio for all patients was $6,255 per quality-adjusted life-year gained; for patients younger than 65 years, cost saving; for patients aged 65 years or older, $35,813 per quality-adjusted life-year; for patients with baseline National Institutes of Health Stroke Scale (NIHSS) score 0 to 9, $16,322 per quality-adjusted life-year; for patients with NIHSS score 10 to 19, $37,462 per quality-adjusted life-year; and for patients with NIHSS score greater than or equal to 20, $2,432 per quality-adjusted life-year. The majority of other subgroups such as sex, history of stroke, and history of hypertension were either cost saving or cost-effective, with the exceptions of diabetes and atrial fibrillation. CONCLUSION The results indicate that rtPA in the 3- to 4.5-hour therapeutic window provides improvement in long-term patient outcomes in most patient subgroups and is a good economic value versus no treatment.
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Krueger H, Lindsay P, Cote R, Kapral MK, Kaczorowski J, Hill MD. Cost Avoidance Associated With Optimal Stroke Care in Canada. Stroke 2012; 43:2198-206. [DOI: 10.1161/strokeaha.111.646091] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Hans Krueger
- From the School of Population and Public Health (H.K.), Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; H. Krueger & Associates Inc (H.K.), Delta, British Columbia, Canada; Canadian Stroke Network (P.L., M.K.K.), Ottawa, Ontario, Canada; the Institute of Health Policy, Management and Evaluation (P.L., M.K.K.) and the Department of Medicine (M.K.K.), University of Toronto, Toronto, Ontario, Canada; the Department of Neurology and Neurosurgery and Medicine
| | - Patrice Lindsay
- From the School of Population and Public Health (H.K.), Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; H. Krueger & Associates Inc (H.K.), Delta, British Columbia, Canada; Canadian Stroke Network (P.L., M.K.K.), Ottawa, Ontario, Canada; the Institute of Health Policy, Management and Evaluation (P.L., M.K.K.) and the Department of Medicine (M.K.K.), University of Toronto, Toronto, Ontario, Canada; the Department of Neurology and Neurosurgery and Medicine
| | - Robert Cote
- From the School of Population and Public Health (H.K.), Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; H. Krueger & Associates Inc (H.K.), Delta, British Columbia, Canada; Canadian Stroke Network (P.L., M.K.K.), Ottawa, Ontario, Canada; the Institute of Health Policy, Management and Evaluation (P.L., M.K.K.) and the Department of Medicine (M.K.K.), University of Toronto, Toronto, Ontario, Canada; the Department of Neurology and Neurosurgery and Medicine
| | - Moira K. Kapral
- From the School of Population and Public Health (H.K.), Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; H. Krueger & Associates Inc (H.K.), Delta, British Columbia, Canada; Canadian Stroke Network (P.L., M.K.K.), Ottawa, Ontario, Canada; the Institute of Health Policy, Management and Evaluation (P.L., M.K.K.) and the Department of Medicine (M.K.K.), University of Toronto, Toronto, Ontario, Canada; the Department of Neurology and Neurosurgery and Medicine
| | - Janusz Kaczorowski
- From the School of Population and Public Health (H.K.), Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; H. Krueger & Associates Inc (H.K.), Delta, British Columbia, Canada; Canadian Stroke Network (P.L., M.K.K.), Ottawa, Ontario, Canada; the Institute of Health Policy, Management and Evaluation (P.L., M.K.K.) and the Department of Medicine (M.K.K.), University of Toronto, Toronto, Ontario, Canada; the Department of Neurology and Neurosurgery and Medicine
| | - Michael D. Hill
- From the School of Population and Public Health (H.K.), Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; H. Krueger & Associates Inc (H.K.), Delta, British Columbia, Canada; Canadian Stroke Network (P.L., M.K.K.), Ottawa, Ontario, Canada; the Institute of Health Policy, Management and Evaluation (P.L., M.K.K.) and the Department of Medicine (M.K.K.), University of Toronto, Toronto, Ontario, Canada; the Department of Neurology and Neurosurgery and Medicine
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Pan F, Hernandez L, Ward A. Cost-effectiveness of stroke treatments and secondary preventions. Expert Opin Pharmacother 2012; 13:1751-60. [DOI: 10.1517/14656566.2012.699522] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Lansberg MG, O'Donnell MJ, Khatri P, Lang ES, Nguyen-Huynh MN, Schwartz NE, Sonnenberg FA, Schulman S, Vandvik PO, Spencer FA, Alonso-Coello P, Guyatt GH, Akl EA. Antithrombotic and thrombolytic therapy for ischemic stroke: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e601S-e636S. [PMID: 22315273 PMCID: PMC3278065 DOI: 10.1378/chest.11-2302] [Citation(s) in RCA: 307] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2011] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES This article provides recommendations on the use of antithrombotic therapy in patients with stroke or transient ischemic attack (TIA). METHODS We generated treatment recommendations (Grade 1) and suggestions (Grade 2) based on high (A), moderate (B), and low (C) quality evidence. RESULTS In patients with acute ischemic stroke, we recommend IV recombinant tissue plasminogen activator (r-tPA) if treatment can be initiated within 3 h (Grade 1A) or 4.5 h (Grade 2C) of symptom onset; we suggest intraarterial r-tPA in patients ineligible for IV tPA if treatment can be initiated within 6 h (Grade 2C); we suggest against the use of mechanical thrombectomy (Grade 2C) although carefully selected patients may choose this intervention; and we recommend early aspirin therapy at a dose of 160 to 325 mg (Grade 1A). In patients with acute stroke and restricted mobility, we suggest the use of prophylactic-dose heparin or intermittent pneumatic compression devices (Grade 2B) and suggest against the use of elastic compression stockings (Grade 2B). In patients with a history of noncardioembolic ischemic stroke or TIA, we recommend long-term treatment with aspirin (75-100 mg once daily), clopidogrel (75 mg once daily), aspirin/extended release dipyridamole (25 mg/200 mg bid), or cilostazol (100 mg bid) over no antiplatelet therapy (Grade 1A), oral anticoagulants (Grade 1B), the combination of clopidogrel plus aspirin (Grade 1B), or triflusal (Grade 2B). Of the recommended antiplatelet regimens, we suggest clopidogrel or aspirin/extended-release dipyridamole over aspirin (Grade 2B) or cilostazol (Grade 2C). In patients with a history of stroke or TIA and atrial fibrillation we recommend oral anticoagulation over no antithrombotic therapy, aspirin, and combination therapy with aspirin and clopidogrel (Grade 1B). CONCLUSIONS These recommendations can help clinicians make evidence-based treatment decisions with their patients who have had strokes.
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Affiliation(s)
- Maarten G Lansberg
- Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA
| | - Martin J O'Donnell
- HRB-Clinical Research Faculty, National University of Ireland Galway, Galway, Ireland
| | - Pooja Khatri
- Department of Neurology, University of Cincinnati, Cincinnati, OH
| | | | | | - Neil E Schwartz
- Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA
| | - Frank A Sonnenberg
- Division of General Internal Medicine, UMDNJ/Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Sam Schulman
- Department of Medicine, McMaster University, ON, Canada
| | - Per Olav Vandvik
- Norwegian Knowledge Centre for the Health Services, Oslo, Norway
| | | | | | - Gordon H Guyatt
- Department of Medicine, McMaster University, ON, Canada; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Elie A Akl
- State University of New York at Buffalo, Buffalo, NY; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada.
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Sheppard JP, Mellor RM, Bailey SM, Barton P, Boyal A, Greenfield S, Jowett S, Mant J, Quinn T, Singh S, McManus RJ. Protocol for an observation and implementation study investigating optimisation of the management of stroke and transient ischaemic attack (TIA). BMJ Open 2012; 2:bmjopen-2012-001430. [PMID: 22734121 PMCID: PMC3383985 DOI: 10.1136/bmjopen-2012-001430] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Patients benefit from early and intensive treatment in both acute ischaemic stroke and transient ischaemic attack. Recent audits of acute stroke/transient ischaemic attack care suggest that although standards have improved, current services still fall short of optimal care. The aim of this study is to establish a database of patients accessing stroke services. Data will be collected and analysed to provide individualised feedback to healthcare professionals who can then use these findings to develop strategies for service improvement. METHODS AND ANALYSIS This longitudinal observational study will evolve with the ongoing findings from the research output. The project will consist of three phases: assessment of current practice, feedback of findings and evaluation of service change. Consecutive patients will be recruited from participating hospitals, and identifiable data will be collected to link records from the Primary Care, Secondary Care and Emergency Services. As this study focuses on observation of current practice, a sample size calculation is not deemed appropriate. Patients will be sent follow-up questionnaires examining quality of life at 3 and 12 months post-event. Qualitative interviews will examine the care pathway through the experiences of patients, their carers, healthcare personnel and commissioners. Collected data will be used in economic analyses, which will evaluate the impact of current care and service redesign on the NHS costs and patient outcomes (death and quality of life). ETHICS AND DISSEMINATION Ethical approval for this study has been obtained from the National Research Ethics Committee (reference; 09/H0716/71), and site-specific R&D approval has been acquired from the relevant NHS trusts. All findings will be presented at relevant healthcare/academic conferences and written up for publication in peer-reviewed journals. Results will be fed back to patients and participating trusts through a series of reports and presentations. These will be used to facilitate discussions about service redesign and implementation.
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Affiliation(s)
- James Peter Sheppard
- Department of Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Ruth Mary Mellor
- Department of Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Sheila Marie Bailey
- Department of Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Pelham Barton
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | - Amunpreet Boyal
- Department of Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Sheila Greenfield
- Department of Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Sue Jowett
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | - Jonathan Mant
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Tom Quinn
- Faculty of Health and Medical Sciences, School of Health and Social Care, University of Surrey, Guildford, UK
| | - Satinder Singh
- Department of Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Richard J McManus
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Holloway RG, Ringel SP. Getting to value in neurological care: a roadmap for academic neurology. Ann Neurol 2011; 69:909-18. [PMID: 21681794 DOI: 10.1002/ana.22439] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Academic neurology is undergoing transformational changes. The public investment in biomedical research and clinical care is enormous and there is a growing perception that the return on this huge investment is insufficient. Hospitals, departments, and individual neurologists should expect more scrutiny as information about their quality of care and financial relationships with industry are increasingly reported to the public. There are unprecedented changes occurring in the financing and delivery of health care and research that will have profound impact on the mission and operation of academic departments of neurology. With the passage of the Patient Protection and Affordable Care Act (PPACA) there will be increasing emphasis on research that demonstrates value and includes the patient's perspective. Here we review neurological investigations of our clinical and research enterprises that focus on quality of care and comparative effectiveness, including cost-effectiveness. By highlighting progress made and the challenges that lie ahead, we hope to create a clinical, educational, and research roadmap for academic departments of neurology to thrive in today's increasingly regulated environment.
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Affiliation(s)
- Robert G Holloway
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA.
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Tung CE, Win SS, Lansberg MG. Cost-effectiveness of tissue-type plasminogen activator in the 3- to 4.5-hour time window for acute ischemic stroke. Stroke 2011; 42:2257-62. [PMID: 21719767 DOI: 10.1161/strokeaha.111.615682] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The aim of this study was to determine the cost-effectiveness of tissue-type plasminogen activator (tPA) treatment in the 3- to 4.5-hour time window after ischemic stroke. METHODS Decision-analytic and Markov state-transition models were created to determine the cost-effectiveness of treatment of ischemic stroke patients with intravenous tPA administered in the 3- to 4.5-hour time window compared with medical therapy without tPA. Health benefits were measured in quality-adjusted life-years (QALYs). The economic outcome measure of the model was the difference in estimated healthcare costs between the 2 treatment alternatives. The incremental cost-effectiveness ratio was calculated by dividing the cost difference by the difference in QALYs. One-way sensitivity and probabilistic analyses were performed to test the robustness of the model. RESULTS The administration of tPA compared with standard medical therapy resulted in a lifetime gain of 0.28 QALYs for an additional cost of $6050, yielding an incremental cost-effectiveness ratio of $21 978 per QALY. One-way sensitivity analyses demonstrated that the incremental cost-effectiveness ratio was most sensitive to the cost of hospitalization for patients who received tPA. Based on probabilistic analysis, there is an 88% probability that tPA is the preferred treatment at a willingness-to-pay threshold of $50 000 per QALY. CONCLUSIONS The balance of costs and benefits favors treatment with intravenous tPA in the 3- to 4.5-hour time window. This supports, from a societal perspective, the use of tPA therapy in this treatment time window for acute ischemic stroke.
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Affiliation(s)
- Christie E Tung
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, California 94305-5235, USA.
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Benbassat J, Baumal R, Herishanu Y. Treatment of acute ischemic stroke in patients with cerebral microbleeds: a decision analysis. QJM 2011; 104:73-82. [PMID: 20630905 DOI: 10.1093/qjmed/hcq119] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- J Benbassat
- Myers-JDC-Brookdale Institute, PO Box 3886, Jerusalem 91037, Israel.
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Jung KT, Shin DW, Lee KJ, Oh M. Cost-effectiveness of recombinant tissue plasminogen activator in the management of acute ischemic stroke: a systematic review. J Clin Neurol 2010; 6:117-26. [PMID: 20944812 PMCID: PMC2950916 DOI: 10.3988/jcn.2010.6.3.117] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2009] [Revised: 01/18/2010] [Accepted: 01/18/2010] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND AND PURPOSE This work was undertaken to review the current cost-effectiveness analysis data on thrombolysis by intravenous (IV) therapy with recombinant tissue plasminogen activator (rtPA) for acute ischemic stroke. METHODS PubMed was searched for articles published between 1995 and 2008. The cost-effectiveness analysis data from eight eligible studies were reviewed, paying particular attention to their modeling assumptions and the quality of the source data. RESULTS THE REVIEWED STUDIES WERE FROM SIX COUNTRIES: USA (n=2), UK (n=2), Canada (n=1), Australia (n=1), Spain (n=1), and Denmark (n=1); most were performed from the healthcare-system and/or societal perspectives. IV rtPA was associated with an acceptable increase in short-term cost [range: US$ 36-236/patient; US$ 29,148-55,591/quality-adjusted life-years (QALYs)], and a net long-term cost saving that was higher from a societal perspective (range: -US$ 12,043 to -US$ 630/patient; -US$ 207,253 to -US$ 21,938/QALYs) than from a healthcare-system perspective (range: -US$ 5,811 to -US$ 5,415/patient; -US$ 41,137 to -US$ 4,662/QALYs). CONCLUSIONS IV rtPA seems to be a cost-effective strategy for the management of acute ischemic stroke, and might reduce the associated healthcare costs as well as patients' disabilities. Further cost-effectiveness research and the development of a public health strategy are warranted to optimize the use of rtPA in Korea.
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Affiliation(s)
- Kee-Taig Jung
- Department of Health Services Management, School of Management, Kyung Hee University, Seoul, Korea
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Guilhaume C, Saragoussi D, Cochran J, François C, Toumi M. Modeling stroke management: a qualitative review of cost-effectiveness analyses. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2010; 11:419-426. [PMID: 20238137 DOI: 10.1007/s10198-010-0228-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2009] [Accepted: 02/15/2010] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To review recent economic analyses and determine if means of improving methodology used in modeling stroke management may exist. STUDY DESIGN AND SETTING The Medline database was searched for pharmacoeconomic models of treatments or interventions in acute, non-transitory ischemic stroke. Search terms were: stroke, cost, cost-effectiveness, cost analysis, stroke management, model, modeling, and economic. All English-language articles published from January 1997 to January 2008 were reviewed. RESULTS Ten Markov models and three decision analytical models were identified. All models had a societal perspective and all but one had lifetime horizons. They were all based on common patient states of disability, mortality and recurrence of stroke. Inputs used in the models were transparent and valid. Intracranial hemorrhage, cardiovascular events and data closely related to local settings were not systematically considered. One-way sensitivity analyses were the most common, but few parameters were tested and these varied between models. Consensus key drivers were therefore difficult to determine. CONCLUSION The overall structure of the models reviewed was sound. However, they should include more systematically cardiovascular events and intracranial hemorrhage, as well as local epidemiological data. Further multi-way sensitivity analyses would help to identify key cost drivers with greater precision and robustness.
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Affiliation(s)
- Chantal Guilhaume
- Global Outcomes Research Division, H. Lundbeck A/S, 37-45 Quai du Président Roosevelt, 92445, Issy-les-Moulineaux Cedex, France
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Earnshaw SR, Wilson M, Mauskopf J, Joshi AV. Model-based cost-effectiveness analyses for the treatment of acute stroke events: a review and summary of challenges. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2009; 12:507-520. [PMID: 19900253 DOI: 10.1111/j.1524-4733.2008.00467.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To summarize the methodological approaches used in published decision-analytic models evaluating interventions for acute stroke treatment, to highlight key components of decision-analytic models of stroke treatment, and to discuss challenges for developing stroke decision models. METHODS A review of the published literature was performed using Medline, to identify studies involving mathematical decision models to evaluate interventions for acute stroke treatment. Articles were analyzed to determine key components of a stroke model and to note areas in which data are lacking. RESULTS We identified 13 published models of acute stroke treatment. These models typically possessed a short-term treatment module and a long-term post-treatment module. The following aspects of economic modeling were found to be relevant for developing a stroke model: modeling approach and health state; health state transition probabilities; estimation of short-term, long-term, and indirect costs; health state utilities; poststroke mortality; time horizon; model validation; and estimation of parameter uncertainty. CONCLUSIONS Data gaps have limited the development of economic models in stroke to date. In order to more accurately assess the long-term incremental impact of a new treatment of stroke, future research is needed to address these data gaps. We recommend that the complexity of models for examining the cost-effectiveness of an acute stroke treatment be kept to a minimum such that it can incorporate the currently available data without making a large number of assumptions around the data.
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Earnshaw SR, Jackson D, Farkouh R, Schwamm L. Cost-effectiveness of patient selection using penumbral-based MRI for intravenous thrombolysis. Stroke 2009; 40:1710-20. [PMID: 19286581 DOI: 10.1161/strokeaha.108.540138] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Better selection of patients for intravenous recombinant tissue plasminogen activator (IV tPA) treatment may improve clinical outcomes. We examined the cost-effectiveness of adding penumbral-based MRI to usual computed tomography (CT)-based methods to identify patients for IV tPA treatment. METHODS A decision-analytic model estimated the lifetime costs and outcomes associated with penumbral-based MRI selection in a patient population similar to that enrolled in the IV tPA clinical trials. Inputs were obtained from published literature, clinical trial data, claims databases, and expert opinion. Outcomes included cost per life-year saved and cost per quality-adjusted life-year (QALY) gained. Costs and outcomes were discounted at 3% annually. Sensitivity analyses were conducted. RESULTS The addition of penumbral-based MRI selection increased total cost by $103 over the patient's remaining lifetime. Penumbral-based MRI selection resulted in favorable outcomes (modified Rankin Scale <or=1) more often than CT-based selection (36.66% versus 35.06%) with an incremental cost per life year of $1840 and an incremental cost per QALY of $1004. Multivariate sensitivity analysis predicted cost-effectiveness (<or=$50,000 per QALY) in 99.7% of simulation runs. CONCLUSIONS Selecting ischemic stroke patients for IV tPA treatment using penumbral-based MRI after routine CT may increase overall acute care costs, but the benefit is large enough to make this highly cost-effective. This economic analysis lends further support to the consideration of a paradigm shift in acute stroke evaluation.
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Dirks M, Niessen LW, Huijsman R, van Wijngaarden J, Minkman MMN, Franke CL, van Oostenbrugge RJ, Koudstaal PJ, Dippel DWJ. Promoting Acute Thrombolysis for Ischaemic Stroke (PRACTISE). Int J Stroke 2008; 2:151-9. [PMID: 18705977 DOI: 10.1111/j.1747-4949.2007.00119.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
RATIONALE Thrombolysis with intravenous rtPA is an effective treatment for patients with ischaemic stroke if given within 3 h from onset. Generally, more than 20% of stroke patients arrive in time to be treated with thrombolysis. Nevertheless, in most hospitals, only 1-8% of all stroke patients are actually treated. Interorganisational, intraorganisational, medical and psychological barriers are hampering broad implementation of thrombolysis for acute ischaemic stroke. AIMS To evaluate the effect of a high-intensity implementation strategy for intravenous thrombolysis in acute ischaemic stroke, compared with regular implementation; to identify success factors and obstacles for implementation and to assess its cost-effectiveness, taking into account the costs of implementation. DESIGN The PRACTISE study is a national cluster-randomised-controlled trial. Twelve hospitals have been assigned to the regular or high-intensity intervention by random allocation after pair-wise matching. The high-intensity implementation consists of training sessions in conformity with the Breakthrough model, and a tool kit. All patients who are admitted with acute stroke and onset of symptoms not longer than 24 h are registered. STUDY OUTCOMES The primary outcome measure is treatment with thrombolysis. Secondary outcomes are admission within 4 h after onset of symptoms, death or disability at 3 months, the rate of haemorrhagic complications in patients treated with thrombolysis, and costs of implementation and stroke care in the acute setting. Tertiary outcomes are derived from detailed criteria for the organisational characteristics, such as door-to-needle time and protocol violations. These can be used to monitor the implementation process and study the effectiveness of specific interventions. DISCUSSION This study will provide important information on the effectiveness and cost-effectiveness of actively implementing an established treatment for acute ischaemic stroke. The multifaceted aspect of the intervention will make it difficult to attribute a difference in the primary outcome measure to a specific aspect of the intervention. However, careful monitoring of intermediate parameters as well as monitoring of accomplished SMART tasks can be expected to provide useful insights into the nature and role of factors associated with implementation of thrombolysis for acute ischaemic stroke, and of effective acute interventions in general.
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Affiliation(s)
- Maaike Dirks
- Department of Neurology, Erasmus MC University Hospital Rotterdam, Rotterdam, The Netherlands.
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Abstract
The administration of intravenous thrombolytic therapy to appropriate patients and the provision of care in a dedicated stroke unit setting form the pillars of evidence-based acute stroke care. Yet, the availability of these interventions remains variable around the world. Many challenges exist for physicians attempting to set up an acute stroke service for the first time. Based upon their experience in three countries, the authors propose 12 key steps in setting up a successful acute stroke service: identify the building blocks understand local funding mechanisms forge partnerships engage senior managers obtain training be inclusive adapt to local surroundings maintain a clinical focus be incremental capitalise on the enthusiasm of others lead from the front; and provide feedback. The authors then examine some of the specific barriers that may be encountered and offer three historical examples of evidence-based interventions that were slow to be adopted. An acute stroke service is evidence-based and cost effective, yet the ability of patients to access such a service is variable, even in the developed world. By considering 12 common-sense steps, physicians and managers can maximise their chances of setting up a sustainable and successful acute stroke service.
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Affiliation(s)
- Ian Reckless
- Acute Stroke Programme, Oxford Comprehensive Biomedical Research Centre, Oxford, UK
| | - Simon Nagel
- Acute Stroke Programme, Oxford Comprehensive Biomedical Research Centre, Oxford, UK
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Alastair Buchan
- Acute Stroke Programme, Oxford Comprehensive Biomedical Research Centre, Oxford, UK
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Flynn RWV, MacWalter RSM, Doney ASF. The cost of cerebral ischaemia. Neuropharmacology 2008; 55:250-6. [PMID: 18573263 DOI: 10.1016/j.neuropharm.2008.05.031] [Citation(s) in RCA: 161] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2007] [Revised: 05/23/2008] [Accepted: 05/27/2008] [Indexed: 11/30/2022]
Abstract
Cerebral ischaemia is a major cause of disability and death globally and has a profoundly negative impact on the individuals it affects, those that care for them and society as a whole. The most common and familiar manifestation is stroke, 85% of which are ischaemic and which is the second leading cause of death and most common cause of complex chronic disability worldwide. Stroke survivors often suffer from long-term neurological disabilities significantly reducing their ability to integrate effectively in society with all the financial and social consequences that this implies. These difficulties cascade to their next of kin who often become caregivers and are thus indirectly burdened. A more insidious consequence of cerebral ischaemia is progressive cognitive impairment causing dementia which although less abrupt is also associated with a significant long-term disability. Globally cerebrovascular diseases are responsible for 5.4 million deaths every year (1 in 10 of total). Approximately 3% of total healthcare expenditure is attributable to cerebral ischaemia with cerebrovascular diseases costing EU healthcare systems 21 billion euro in 2003. The cost to the wider economy (including informal care and lost productivity) is even greater with stroke costing the UK 7-8 billion pound in 2005 and the US $62.7 billion in 2007. Cerebrovascular disease cost the EU 34 billion euro in 2003. From 2005 to 2050 the anticipated cost of stroke to the US economy is estimated at $2.2 trillion. Given the global scale of the problem and the enormous associated costs it is clear that there is an urgent need for advances in the prevention of cerebral ischaemia and its consequences. Such developments would result in profound benefits for both individuals and their wider societies and address one of the world's most pre-eminent public health issues.
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Affiliation(s)
- R W V Flynn
- Stroke Studies Centre, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland, UK
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Angquist L, Hössjer O, Groop L. Strategies for conditional two-locus nonparametric linkage analysis. Hum Hered 2008; 66:138-56. [PMID: 18418001 DOI: 10.1159/000126049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2007] [Accepted: 09/06/2007] [Indexed: 01/17/2023] Open
Abstract
In this article we deal with two-locus nonparametric linkage (NPL) analysis, mainly in the context of conditional analysis. This means that one incorporates single-locus analysis information through conditioning when performing a two-locus analysis. Here we describe different strategies for using this approach. Cox et al. [Nat Genet 1999;21:213-215] implemented this as follows: (i) Calculate the one-locus NPL process over the included genome region(s). (ii) Weight the individual pedigree NPL scores using a weighting function depending on the NPL scores for the corresponding pedigrees at speci fi c conditioning loci. We generalize this by conditioning with respect to the inheritance vector rather than the NPL score and by separating between the case of known (prede fi ned) and unknown (estimated) conditioning loci. In the latter case we choose conditioning locus, or loci, according to prede fi ned criteria. The most general approach results in a random number of selected loci, depending on the results from the previous one-locus analysis. Major topics in this article include discussions on optimal score functions with respect to the noncentrality parameter (NCP), and how to calculate adequate p values and perform power calculations. We also discuss issues related to multiple tests which arise from the two-step procedure with several conditioning loci as well as from the genome-wide tests.
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Affiliation(s)
- Lars Angquist
- Centre for Mathematical Sciences, Department of Mathematical Statistics, Lund University, Lund, Sweden.
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Ehlers L, Müskens WM, Jensen LG, Kjølby M, Andersen G. National use of thrombolysis with alteplase for acute ischaemic stroke via telemedicine in Denmark: a model of budgetary impact and cost effectiveness. CNS Drugs 2008; 22:73-81. [PMID: 18072816 DOI: 10.2165/00023210-200822010-00006] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
AIM The purpose of this analysis was to assess the budgetary impact and cost effectiveness of the national use of thrombolysis with alteplase (recombinant tissue plasminogen activator; rt-PA) for acute ischaemic stroke via telemedicine in Denmark. METHODS Computations were based on a Danish health economic model of thrombolysis treatment of acute ischaemic stroke via telemedicine. Cost data for stroke units and satellite clinics were taken from the first practical experiences in Denmark with implementing thrombolysis via telemedical linkage to the Stroke Department at Aarhus University Hospital. Effectiveness data were taken from a published pooled analysis of results from randomized controlled trials of alteplase. RESULTS The calculations showed that the additional total costs to the hospitals of implementing thrombolysis with alteplase for acute ischaemic stroke via telemedicine were approximately $US3.0 (range 2.0-5.8) million per year in the case of five centres and five satellite clinics, or $US3.6 (range 2.4-7.0) million per year based on seven centres and seven satellite clinics. The incremental cost-effectiveness ratio was calculated to be approximately $US50,000 when taking a short time perspective (1 year), but thrombolysis was dominant (both cheaper and more effective) after as little as 2 years and cost effectiveness improved over longer time scales. CONCLUSION The budgetary impact of using thrombolysis with alteplase for acute ischaemic stroke via telemedicine depends on the existing capacity and organizational conditions at the local hospitals. The health economic model computations suggest that the macroeconomic costs may balance with savings in care and rehabilitation after as little as 2 years, and that potentially large long-term savings are associated with thrombolysis with alteplase delivered by telemedicine, although the long-term calculations are uncertain.
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Affiliation(s)
- Lars Ehlers
- HTA Unit, Aarhus University Hospital, Aarhus, Denmark.
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Lo W, Zamel K, Ponnappa K, Allen A, Chisolm D, Tang M, Kerlin B, Yeates KO. The Cost of Pediatric Stroke Care and Rehabilitation. Stroke 2008; 39:161-5. [DOI: 10.1161/strokeaha.107.497420] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Warren Lo
- From the Departments of Pediatrics and Psychology, The Ohio State University and Children’s Hospital, Columbus, Ohio
| | - Khaled Zamel
- From the Departments of Pediatrics and Psychology, The Ohio State University and Children’s Hospital, Columbus, Ohio
| | - Kavita Ponnappa
- From the Departments of Pediatrics and Psychology, The Ohio State University and Children’s Hospital, Columbus, Ohio
| | - Antoni Allen
- From the Departments of Pediatrics and Psychology, The Ohio State University and Children’s Hospital, Columbus, Ohio
| | - Deena Chisolm
- From the Departments of Pediatrics and Psychology, The Ohio State University and Children’s Hospital, Columbus, Ohio
| | - Monica Tang
- From the Departments of Pediatrics and Psychology, The Ohio State University and Children’s Hospital, Columbus, Ohio
| | - Bryce Kerlin
- From the Departments of Pediatrics and Psychology, The Ohio State University and Children’s Hospital, Columbus, Ohio
| | - Keith O. Yeates
- From the Departments of Pediatrics and Psychology, The Ohio State University and Children’s Hospital, Columbus, Ohio
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Ehlers L, Jensen LG, Bech MA, Andersen G, Kjølby M. Organisational barriers to thrombolysis treatment of acute ischaemic stroke. Curr Med Res Opin 2007; 23:2833-9. [PMID: 17910781 DOI: 10.1185/030079907x242557] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Intravenous thrombolysis with fibrinolytic drugs such as alteplase is not implemented widely in any country although the treatment is both effective and cost-effective in selected patients within a 3-h window after acute ischaemic stroke. The purpose of the present study was to describe the organisational barriers to delivery of thrombolysis for acute ischaemic stroke with special regard to the Danish healthcare system. METHOD Systematic and unsystematic searches of medical, economic and grey literature on organisational barriers to thrombolysis treatment were performed in Cochrane, PubMed, EMBASE, Cinahl, Econlit, NHS EED, SvedMed+ and the Health Technology Assessment (HTA) database. The search periods were 1996-2006. FINDINGS Three main types of literature on organisational barriers were found: medical literature including HTA reports on barriers related to the 3-h window, economic literature on barriers related to the lack of capacity to provide the treatment on a 24-h basis, and grey literature/policy papers on standards and demands to the hospitals and healthcare systems who implements the treatment. CONCLUSION Information on organisational barriers can be extracted from different types of literature (medical, economic and grey literature/policy papers), but organisational barriers are most often not the primary study objective in the relevant literature. This review showed a broad spectrum of possible organisational barriers to the delivery of thrombolysis treatment of acute ischaemic stroke.
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Affiliation(s)
- Lars Ehlers
- HTA Unit, Aarhus University Hospital, Denmark.
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