1
|
Wang L, Zeng Y, Zhou L, Xu P, Guo X, Xie Y, Cai J, Pan M, Tang J, Gong Q, Su R, Liu Y, Lou Y. Cost-effectiveness of tirofiban for acute ischemic stroke without large or medium-sized vessel occlusion: A Markov modelling analysis from the Chinese and United States perspectives. PLoS One 2024; 19:e0297939. [PMID: 38363737 PMCID: PMC10871502 DOI: 10.1371/journal.pone.0297939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 01/14/2024] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND The RESCUE BT2 trial recently showcased the efficacy of tirofiban in treating acute ischemic stroke (AIS) without large or medium-sized vessel occlusion. To further assess the value of tirofiban from the perspectives of Chinese and US healthcare system, a study was conducted to evaluate its cost-effectiveness. METHODS A hybrid model, integrating a short-term decision tree with a long-term Markov model, was developed to assess cost-effectiveness between tirofiban and aspirin for stroke patients without large or medium-sized vessel occlusion. Efficacy data for tirofiban was sourced from the RESCUE BT2 trial, while cost information was derived from published papers. Outcomes measured included respective cost, effectiveness, and incremental cost-effectiveness ratio (ICER). We conducted a one-way sensitivity analysis to assess the robustness of the results. Additionally, we performed probabilistic sensitivity analysis (PSA) through 10,000 Monte Carlo simulations to evaluate the uncertainties associated with the results. RESULTS The study revealed that tirofiban treatment in AIS patients without large or medium-sized vessel occlusion led to a considerable reduction of 2141 Chinese Yuan (CNY) in total cost, along with a lifetime gain of 0.14 quality-adjusted life years (QALYs). In the US settings, tirofiban also exhibited a lower cost ($197,055 versus $201,984) and higher effectiveness (4.15 QALYs versus 4.06 QALYs) compared to aspirin. One-way sensitivity analysis revealed that post-stroke care costs and stroke utility had the greatest impact on ICER fluctuation in both Chinese and US settings. However, these variations did not exceed the willingness-to-pay threshold. PSA demonstrated tirofiban's superior acceptability over aspirin in over 95% of potential scenarios. CONCLUSION Tirofiban treatment for AIS without large or medium-sized vessel occlusion appeared dominant compared to aspirin in both China and the US.
Collapse
Affiliation(s)
- Li Wang
- Department of Neurology, Zigong Third People’s Hospital, Zigong, China
| | - Yuhong Zeng
- Department of Epidemiology, College of Preventive Medicine, Army Medical University (Third Military Medical University), Chongqing, People’s Republic of China
- Evidence-based Medicine and Clinical Epidemiology Center, Army Medical University (Third Military Medical University), Chongqing, People’s Republic of China
| | - Limei Zhou
- Department of Neurology, Zigong Third People’s Hospital, Zigong, China
| | - Ping Xu
- Department of Neurology, Zigong Third People’s Hospital, Zigong, China
| | - Xianbin Guo
- Department of Neurology, Zigong Third People’s Hospital, Zigong, China
| | - Yu Xie
- Department of Neurology, Zigong Third People’s Hospital, Zigong, China
| | - Junxiu Cai
- Department of Neurology, Zigong Third People’s Hospital, Zigong, China
| | - Min Pan
- Department of Neurology, Zigong Third People’s Hospital, Zigong, China
| | - Jie Tang
- Department of Neurology, Zigong Third People’s Hospital, Zigong, China
| | - Qingtao Gong
- Department of Neurology, Zigong Third People’s Hospital, Zigong, China
| | - Rong Su
- Department of Neurology, Zigong Third People’s Hospital, Zigong, China
| | - Yan Liu
- Department of Neurology, Zigong Third People’s Hospital, Zigong, China
| | - Yake Lou
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| |
Collapse
|
2
|
Li J, Cao W, Zhao F, Jin P. Cost-effectiveness of edaravone dexborneol versus dl-3-n-butylphthalide for the treatment of acute ischemic stroke: a Chinese health care perspective. BMC Public Health 2024; 24:436. [PMID: 38347500 PMCID: PMC10860239 DOI: 10.1186/s12889-024-17959-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 02/01/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND Edaravone dexborneol and dl-3-n-butylphthalide are two innovative brain cytoprotective drugs from China that have been approved and widely prescribed for acute ischemic stroke, and the cost of the two drugs are partially paid by the Chinese medical insurance system. This study aimed to investigate and compare the cost-effectiveness of edaravone dexborneol versus dl-3-n-butylphthalide for acute ischemic stroke from the Chinese healthcare system's perspective. METHODS A model combining a short-term decision tree model with 90 days and a long-term Markov model with a life-time horizon (40 years) was developed to simulate the cost-effectiveness of edaravone dexborneol versus dl-3-n-butylphthalide for acute ischemic stroke over a lifetime horizon. Since the absence of a head-to-head clinical comparison of two therapies, an unanchored matching-adjusted indirect comparison (MAIC) was conducted by adjusting the patient characteristics using individual patient data from pivotal phase III trial of edaravone dexborneol and published aggregated data of dl-3-n-butylphthalide. Health outcomes were measured in quality-adjusted life years (QALYs). Utilities and costs (Chinese Yuan, CNY) were derived from publications and open-access database. One-way and probabilistic sensitivity analyses were performed to evaluate the robustness of results. RESULTS Compared with patients in dl-3-n-butylphthalide arm, edaravone dexborneol arm was found to be cost-effective in 90 days and highly cost-effective as the study horizons extended. With a similar direct medical cost, patients in edaravone dexborneol arm slightly gained an additional 0.1615 QALYs in life-time. In the long term (40 years), patients in edaravone dexborneol arm and dl-3-n-butylphthalide arm yielded 8.0351 and 7.8736 QALYs with the overall direct medical cost of CNY 29,185.23 and CNY 29,940.28, respectively. The one-way sensitivity analysis suggested that the incremental cost-effectiveness ratio was most sensitive to the price of edaravone dexborneol and dl-3-n-butylphthalide. CONCLUSION Edaravone dexborneol is a cost-effective alternative compared with dl-3-n-butylphthalide for acute ischemic stroke patients in current medical setting of China.
Collapse
Affiliation(s)
- Jianchun Li
- Department of Pharmacy, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine,Chinese Academy of Medical Sciences, Beijing Key Laboratory of Assessment of Clinical Drugs Risk and Individual Application (Beijing Hospital), Beijing, China
- Department of Pharmacy Administration and Clinical Pharmacy, Pharmaceutical Science, Peking University, Beijing, China
| | - Weihan Cao
- Department of Pharmacy, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine,Chinese Academy of Medical Sciences, Beijing Key Laboratory of Assessment of Clinical Drugs Risk and Individual Application (Beijing Hospital), Beijing, China
- Department of Pharmacy Administration and Clinical Pharmacy, Pharmaceutical Science, Peking University, Beijing, China
| | - Fei Zhao
- Department of Pharmacy, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine,Chinese Academy of Medical Sciences, Beijing Key Laboratory of Assessment of Clinical Drugs Risk and Individual Application (Beijing Hospital), Beijing, China
| | - Pengfei Jin
- Department of Pharmacy, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine,Chinese Academy of Medical Sciences, Beijing Key Laboratory of Assessment of Clinical Drugs Risk and Individual Application (Beijing Hospital), Beijing, China.
- , No. 1 Dahua Road, Dongcheng district, Beijing, 100730, P.R. China.
| |
Collapse
|
3
|
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.
Collapse
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
| |
Collapse
|
4
|
Poremba M, Champa K, Reichert E. Evaluating reduction in medical costs associated with pharmacists' presence in the emergency department using a novel cost avoidance framework. Am J Health Syst Pharm 2023; 80:S111-S118. [PMID: 36525567 DOI: 10.1093/ajhp/zxac376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/20/2023] Open
Abstract
PURPOSE The purpose of this study was to evaluate the cost avoidance associated with emergency medicine pharmacist (EMP) presence in the emergency department (ED) using a novel cost avoidance framework. SUMMARY This single-center, retrospective, observational study examined EMP interventions from November 1, 2021, through March 31, 2022. EMPs prospectively selected up to 10 shifts in which to log interventions during the study period. Interventions were categorized into 25 cost avoidance categories, 10 of which incorporated recently proposed probability variables. All categories were organized into 4 broad cost avoidance domains, including resource utilization, individualization of patient care, adverse drug event prevention, and hands-on care. During the study period, 894 interventions were logged, which accounted for $143,132 in cost avoidance (lower probability value of $124,186, upper probability value of $168,858), with a median cost avoidance per shift of $1,671 (interquartile range, $1,025 to $2,451). On the basis of 240 shifts, the estimated annual total cost avoidance per pharmacist was extrapolated to be $401,040. CONCLUSION While the mean cost avoidance of $161.10 per intervention observed in our study was less than that in prior cost avoidance studies due to the conservative and potentially more realistic estimates used, implementation of this cost avoidance framework still showed substantial cost avoidance associated with EMP presence in the ED.
Collapse
Affiliation(s)
- Matthew Poremba
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Kelsey Champa
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Erin Reichert
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| |
Collapse
|
5
|
Chen J, Liang X, Tong X, Han M, Ji L, Zhao S, Hu Z, Liu A. Economic evaluation of intravenous alteplase for stroke with the time of onset between 4.5 and 9 hours. J Neurointerv Surg 2023; 15:46-51. [PMID: 35074896 PMCID: PMC9763196 DOI: 10.1136/neurintsurg-2021-018420] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 12/26/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND A clinical trial proved the clinical effectiveness of perfusion imaging-guided intravenous thrombolysis with alteplase for patients with acute ischemic stroke (AIS) with the time of onset between 4.5 and 9 hours. This study aimed to assess the lifetime cost-effectiveness of alteplase versus placebo from the perspective of Chinese and United States (US) healthcare payers. METHODS A decision-analytic model was built to estimate lifetime costs and quality-adjusted life-years (QALYs) associated with alteplase or placebo. Model inputs were extracted from published sources. Incremental costs, incremental QALYs, and incremental cost-effectiveness ratio (ICER) were calculated to evaluate the base-case scenario. One-way and probabilistic sensitivity analysis were performed to evaluate uncertainty in the results. RESULTS In China, alteplase yielded an additional lifetime QALY of 0.126 with an additional cost of Chinese Yuan (¥) ¥9552 compared with placebo, and the ICER was ¥83 950 (US$12 157)/QALY. In the US, alteplase had a higher QALY (difference: 0.193) with a lower cost (difference: US$-2024) compared with placebo. In probabilistic sensitivity analyses, alteplase had a 42.54% to 78.3% probability of being cost-effective compared with placebo in China when the willingness-to-pay (WTP) threshold ranged from ¥72 447/QALY to ¥217 341/QALY. In the US, alteplase had a 93.47% to 93.57% probability of being cost-effective under the WTP threshold of US$100 000/QALY to US$150 000/QALY. These findings remained robust under one-way sensitivity analysis. CONCLUSION For patients with AIS with a time of onset between 4.5 and 9 hours, perfusion imaging-guided intravenous alteplase was likely to be cost-effective in China and was cost-effective in the US when compared with placebo.
Collapse
Affiliation(s)
- Jigang Chen
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xin Liang
- Beijing Shijitan Hospital, Capital Medical University, Beijing, China
- Department of Neurosurgery, Capital Medical University Affiliated Beijing Shijitan Hospital, Beijing, China
| | - Xin Tong
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Mingyang Han
- Department of Neurosurgery, Central South University Third Xiangya Hospital, Changsha, Hunan, China
| | - Linjin Ji
- Department of Neurosurgery, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Songfeng Zhao
- Department of Neurosurgery, Central South University Third Xiangya Hospital, Changsha, Hunan, China
| | - Zhiqiang Hu
- Beijing Shijitan Hospital, Capital Medical University, Beijing, China
- Department of Neurosurgery, Capital Medical University Affiliated Beijing Shijitan Hospital, Beijing, China
| | - Aihua Liu
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
6
|
Qureshi AI, Akinci Y, Huang W, Ishfaq MF, Hassan AE, Siddiq F, Gomez CR. Cost-effectiveness analysis of endovascular treatment with or without intravenous thrombolysis in acute ischemic stroke. J Neurosurg 2023; 138:223-232. [PMID: 35901768 DOI: 10.3171/2022.4.jns22514] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 04/25/2022] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Intravenous (IV) recombinant tissue plasminogen activator (r-tPA) may not provide additional benefit in terms of functional outcomes in patients with acute ischemic stroke (AIS) who undergo endovascular treatment (EVT). In this context, the cost-effectiveness of EVT alone compared with its application following IV r-tPA has not been evaluated. METHODS The authors determined the average rates of death or disability in each of the two treatment groups from four randomized clinical trials that enrolled patients with AIS within 4.5 hours of symptom onset and randomly assigned patients to EVT alone and IV r-tPA and EVT. By using three sources derived from previous studies, the authors determined the cost of IV r-tPA, cost of staff time for administration, cost of the EVT, cost of hospital stay, costs of supported discharge and community care, and cost of posthospitalization care and disability. They then assessed the cost-effectiveness of EVT alone using a decision tree for the 1st year after AIS and a Markov model with a 10-year horizon, including probabilistic assessment by Monte Carlo simulations. RESULTS The 1-year cost was higher with IV r-tPA and EVT compared with EVT alone (incremental cost ranging between $3554 and $13,788 per patient). The mean incremental cost-effectiveness ratios (ICERs) were -$1589, -$78,327, and -$15,471 per quality-adjusted life-year gained for cost sources 1, 2, and 3, respectively, for EVT alone compared with IV r-tPA and EVT at 10 years. The ceiling ICER (willingness to pay) for a probability of 100% that EVT alone was more cost-effective ranged between $25,000 and $100,000 in the three models. CONCLUSIONS EVT alone appears to be more cost-effective compared with EVT and IV r-tPA for the treatment of AIS patients presenting within 4.5 hours of symptom onset.
Collapse
Affiliation(s)
- Adnan I Qureshi
- 1Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri
| | - Yasemin Akinci
- 1Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri
| | - Wei Huang
- 1Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri
| | - Muhammad F Ishfaq
- 1Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri
| | - Ameer E Hassan
- 2Department of Neuroscience, Valley Baptist Medical Center, Harlingen, Texas.,3Department of Neurology, University of Texas Rio Grande Valley School of Medicine, Harlingen, Texas; and
| | - Farhan Siddiq
- 4Division of Neurosurgery, University of Missouri, Columbia, Missouri
| | - Camilo R Gomez
- 1Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri
| |
Collapse
|
7
|
Zhao S, Cheng Y, Tong X, Han M, Ji L, Che Y, Hu W, Liu A. Cost-effectiveness of recombinant tissue-type plasminogen activator for acute ischaemic stroke with unknown time of onset: a Markov modelling analysis from the Chinese and US perspectives. BMJ Open 2022; 12:e065133. [PMID: 36375982 PMCID: PMC9664282 DOI: 10.1136/bmjopen-2022-065133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE The effectiveness of MRI-guided intravenous recombinant tissue-type plasminogen activator (r-tPA) for acute ischaemic stroke (AIS) with an unknown time of onset has been demonstrated by the WAKE-UP Trial. We aim to evaluate its long-term cost-effectiveness from the perspective of Chinese and US healthcare payers. METHODS A combination of decision tree and Markov model was built to project lifetime costs and quality-adjusted life-years (QALYs) associated with intravenous r-tPA or placebo treatment. Model inputs including the transition probabilities, costs and utilities were derived from the WAKE-UP Trial, similar cost-effectiveness studies and other published sources. To compare intravenous r-tPA to placebo, we calculated incremental costs, incremental QALYs and incremental cost-effectiveness ratio (ICER). One-way sensitivity, probabilistic sensitivity and subgroup analyses were performed to evaluate uncertainty in the results. RESULTS In China, intravenous r-tPA gained an additional lifetime QALY of 0.293 with an additional cost of the Chinese Yuan (¥) of 7871 when compared with placebo, resulting in an ICER of ¥26 870 (US$3894)/QALY. In the USA, intravenous r-tPA yielded a higher QALY (difference: 0.430) and lower cost (difference: ¥-4563) when compared with placebo. In probabilistic sensitivity analyses, intravenous r-tPA had a 97.8% and 99.8% probability of being cost-effective or cost-saving in China and the USA, respectively. These findings remained robust under one-way sensitivity and subgroup analysis except for patients with a National Institute of Health Stroke Scale Score of less than 4, between 11 and 16, and over 16. CONCLUSIONS MRI-guided intravenous r-tPA for patients with AIS with an unknown time of onset is cost-effective in China and cost-saving in the USA.
Collapse
Affiliation(s)
- Songfeng Zhao
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurosurgery, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Yuhong Cheng
- Department of Neurosurgery, Linfen Central Hospital, Linfen, China
| | - Xin Tong
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Mingyang Han
- Department of Neurosurgery, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Linjin Ji
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yuxiong Che
- Department of Neurology, Changde First Hospital of Traditional Chinese Medicine, Changde, China
| | - Weiwu Hu
- Department of Neurology, Changde First Hospital of Traditional Chinese Medicine, Changde, China
| | - Aihua Liu
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurosurgery, The Third Xiangya Hospital, Central South University, Changsha, China
| |
Collapse
|
8
|
Hornby TG, Rafferty MR, Pinto D, French D, Jordan N. Cost-Effectiveness of High-intensity Training vs Conventional Therapy for Individuals With Subacute Stroke. Arch Phys Med Rehabil 2021; 103:S197-S204. [PMID: 34228956 DOI: 10.1016/j.apmr.2021.05.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 04/28/2021] [Accepted: 05/06/2021] [Indexed: 12/30/2022]
Abstract
OBJECTIVE This investigation estimated the incremental cost-effectiveness of high-intensity training (HIT) compared with conventional physical therapy in individuals with subacute stroke, based on the additional personnel required to deliver the therapy. DESIGN Secondary analysis from a pilot study and subsequent randomized controlled trial. SETTING Outpatient laboratory setting. PARTICIPANTS Data were collected from individuals with locomotor impairments 1-6 months poststroke (N=44) who participated in HIT (n=27) or conventional physical therapy (n=17). INTERVENTIONS Individuals performing HIT practiced walking tasks in variable contexts (stairs, overground, treadmill) while targeting up to 80% maximum heart rate reserve. Individuals performing conventional therapy practiced impairment-based and functional tasks at lower intensities (<40% heart rate reserve). MAIN OUTCOME MEASURES Costs were assessed based on personnel use with availability of similar equipment. Incremental cost-effectiveness ratios (ICERs) and cost-effectiveness acceptability curves were calculated for quality-adjusted life years (QALYs) derived from the Medical Outcomes Short Form-36 questionnaire and gains in self-selected speeds (SSSs). RESULTS Personnel costs were higher after HIT (mean, $1420±234) vs conventional therapy (mean, $1111±219), although between-group differences in QALYs (0.05 QALYs; 95% confidence interval [CI], 0.0-0.10 QALYs) and SSS (0.20 m/s; 95% CI, 0.05-0.35 m/s) favored HIT. ICERs were $6180 (95% CI, -$96,364 to $123,211) per QALY and $155 (95% CI, 38-242) for a 0.1 m/s gain in SSS. CONCLUSIONS Additional personnel to support HIT are relatively inexpensive but can add substantial effectiveness to subacute rehabilitation. Future research should evaluate patient factors that increase the likelihood of improvement to maximize the cost-effectiveness of treatment post stroke.
Collapse
Affiliation(s)
- T George Hornby
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, IN; Rehabilitation Hospital of Indiana, Indianapolis, IN; Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, IL.
| | - Miriam R Rafferty
- Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, IL; Shirley Ryan AbilityLab, Chicago, IL
| | - Daniel Pinto
- Department of Physical Therapy, Marquette University, Milwaukee, WI
| | - Dustin French
- Department of Psychiatry and Behavioral Science, Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Ophthalmology, Northwestern University Feinberg School of Medicine; Chicago, IL; Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr Veterans Administration Hospital, Hines, IL
| | - Neil Jordan
- Department of Psychiatry and Behavioral Science, Northwestern University Feinberg School of Medicine, Chicago, IL; Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr Veterans Administration Hospital, Hines, IL
| |
Collapse
|
9
|
Dusanovic Pjevic M, Jekic B, Beslac Bumbasirevic L, Vojvodic L, Damnjanovic T, Grk M, Maksimovic N, Pesic M, Gulic M, Trickovic J, Kacar K. TT genotype of the MMP-9-1562C/T polymorphism may be a risk factor for thrombolytic therapy-induced hemorrhagic complications after acute ischemic stroke. Pharmacotherapy 2021; 41:562-571. [PMID: 33942334 DOI: 10.1002/phar.2532] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 04/10/2021] [Accepted: 04/10/2021] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Levels of matrix metalloproteinases (MMPs) and their tissue inhibitors (TIMPs) influence recombinant tissue plasminogen activator (rtPA) therapy response in patients with acute ischemic stroke (AIS). Serum levels of MMPs and TIMPs along with the expression of genes coding these proteins are related to the recovery and appearance of adverse effects (AE) after AIS. Consequently, it is important to explore whether polymorphisms in regulatory sequences of MMPs and TIMPs are associated with rtPA response in AIS patients. OBJECTIVES To determine whether selected polymorphic variants within MMP-2, MMP-9, and TIMP-2 genes may influence rtPA therapy response with regard to outcomes in patients with AIS and the occurrence of AE. METHODS Our study included 166 patients suffering AIS, treated with rtPA. Patients' recovery was estimated using the Modified Rankin Scale (mRS) 3 months after the AIS occurred. Favorable outcome was defined with scores 0-1 and poor outcome with scores 2-6. Genotyping was performed using real-time PCR (rs243866, rs243865, rs243864, rs2277698, and rs8179090) and PCR-RFLP (rs2285053, rs3918242) methods. Additionally, rtPA AE were followed during the hospitalization. RESULTS There was no significant association between genotypes and alleles of selected polymorphisms and rtPA therapy response measured through the decrease of the mRS score in patients with AIS. Intracranial hemorrhage, as well as parenchymal hematoma type 2, was significantly more frequent in patients with TT genotype of the MMP-9-1562C/T polymorphism (p = 0.047, p = 0.011, respectively). Patients with intracranial hemorrhages after rtPA were significantly more likely to have the TT genotype of TIMP-2-303C/T polymorphism and the TT genotype of MMP-9-1562C/T polymorphism (p < 0.001). CONCLUSION TT genotype of the MMP-9-1562C/T polymorphism may be a risk factor for rtPA-induced hemorrhagic complications after AIS.
Collapse
Affiliation(s)
| | - Biljana Jekic
- Faculty of Medicine, Institute of Human Genetics, University of Belgrade, Belgrade, Serbia
| | - Ljiljana Beslac Bumbasirevic
- Neurology Clinic, Clinical Center of Serbia, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | | | - Tatjana Damnjanovic
- Faculty of Medicine, Institute of Human Genetics, University of Belgrade, Belgrade, Serbia
| | - Milka Grk
- Faculty of Medicine, Institute of Human Genetics, University of Belgrade, Belgrade, Serbia
| | - Nela Maksimovic
- Faculty of Medicine, Institute of Human Genetics, University of Belgrade, Belgrade, Serbia
| | - Milica Pesic
- Faculty of Medicine, Institute of Human Genetics, University of Belgrade, Belgrade, Serbia
| | - Milica Gulic
- Faculty of Medicine, Institute of Human Genetics, University of Belgrade, Belgrade, Serbia
| | | | | |
Collapse
|
10
|
Peultier AC, Pandya A, Sharma R, Severens JL, Redekop WK. Cost-effectiveness of Mechanical Thrombectomy More Than 6 Hours After Symptom Onset Among Patients With Acute Ischemic Stroke. JAMA Netw Open 2020; 3:e2012476. [PMID: 32840620 PMCID: PMC7448828 DOI: 10.1001/jamanetworkopen.2020.12476] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
IMPORTANCE Two 2018 randomized controlled trials (DAWN and DEFUSE 3) demonstrated the clinical benefit of mechanical thrombectomy (MT) more than 6 hours after onset in acute ischemic stroke (AIS). Health-economic evidence is needed to determine whether the short-term health benefits of late MT translate to a cost-effective option during a lifetime in the United States. OBJECTIVE To compare the cost-effectiveness of 2 strategies (MT added to standard medical care [SMC] vs SMC alone) for various subgroups of patients with AIS receiving care more than 6 hours after symptom onset. DESIGN, SETTING, AND PARTICIPANTS This economic evaluation study used the results of the DAWN and DEFUSE 3 trials to populate a cost-effectiveness model from a US health care perspective combining a decision tree and Markov trace. The DAWN and DEFUSE 3 trials enrolled 206 international patients from 2014 to 2017 and 182 US patients from 2016 to 2017, respectively. Patients were followed until 3 months after stroke. The clinical outcome at 3 months was available for 29 subgroups of patients with AIS and anterior circulation large vessel occlusions. Data analysis was conducted from July 2018 to October 2019. EXPOSURES MT with SMC in the extended treatment window vs SMC alone. MAIN OUTCOMES AND MEASURES Expected costs and quality-adjusted life-years (QALYs) during lifetime were estimated. Deterministic results (incremental costs and effectiveness, incremental cost-effectiveness ratios, and net monetary benefit) were presented, and probabilistic analyses were performed for the total populations and 27 patient subgroups. RESULTS In the DAWN study, the MT group had a mean (SD) age of 69.4 (14.1) years and 42 of 107 (39.3%) were men, and the control group had a mean (SD) age of 70.7 (13.2) years and 51 of 99 (51.5%) were men. In the DEFUSE 3 study, the MT group had a median (interquartile range) age of 70 (59-79) years, and 46 of 92 (50.0%) were men, and the control group had a median (interquartile range) age of 71 (59-80) years, and 44 of 90 (48.9%) were men. For the total trial population, incremental cost-effectiveness ratios were $662/QALY and $13 877/QALY based on the DAWN and DEFUSE 3 trials, respectively. MT with SMC beyond 6 hours had a probability greater than 99.9% of being cost-effective vs SMC alone at a willingness-to-pay threshold of $100 000/QALY. Subgroup analyses showed a wide range of probabilities for MT with SMC to be cost-effective at a willingness-to-pay threshold of $50 000/QALY, with the greatest uncertainty observed for patients with a National Institute of Health Stroke Scale score of at least 16 and for those aged 80 years or older. CONCLUSIONS AND RELEVANCE The results of this study suggest that late MT added to SMC is cost-effective in all subgroups evaluated in the DAWN and DEFUSE 3 trials, with most results being robust in probabilistic sensitivity analyses. Future MT evidence-gathering could focus on older patients and those with National Institute of Health Stroke Scale scores of 16 and greater.
Collapse
Affiliation(s)
- Anne-Claire Peultier
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Ankur Pandya
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Richa Sharma
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut
| | - Johan L. Severens
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - W. Ken Redekop
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, the Netherlands
| |
Collapse
|
11
|
Hong KS, Kim SE, Bae HJ. Five-Year Cumulative Cost Saving with Thrombolysis in Korea: 3-Month Disability-Based Estimation. J Stroke 2020; 22:262-265. [PMID: 32635691 PMCID: PMC7341012 DOI: 10.5853/jos.2020.00556] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 05/08/2020] [Indexed: 11/11/2022] Open
Affiliation(s)
- Keun-Sik Hong
- Department of Neurology, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Seong-Eun Kim
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Hee-Joon Bae
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| |
Collapse
|
12
|
Yang Y, Li T, Li Z, Liu N, Yan Y, Liu B. Role of Mitophagy in Cardiovascular Disease. Aging Dis 2020; 11:419-437. [PMID: 32257551 PMCID: PMC7069452 DOI: 10.14336/ad.2019.0518] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 05/18/2019] [Indexed: 12/17/2022] Open
Abstract
Cardiovascular disease is the leading cause of mortality worldwide, and mitochondrial dysfunction is the primary contributor to these disorders. Recent studies have elaborated on selective autophagy-mitophagy, which eliminates damaged and dysfunctional mitochondria, stabilizes mitochondrial structure and function, and maintains cell survival and growth. Numerous recent studies have reported that mitophagy plays an important role in the pathogenesis of various cardiovascular diseases. This review summarizes the mechanisms underlying mitophagy and advancements in studies on the role of mitophagy in cardiovascular disease.
Collapse
Affiliation(s)
- Yibo Yang
- Department of Cardiology, The Second Hospital of Jilin University, Changchun 130041, China
| | - Tianyi Li
- Department of Cardiology, The Second Hospital of Jilin University, Changchun 130041, China
| | - Zhibo Li
- Department of Cardiology, The Second Hospital of Jilin University, Changchun 130041, China
| | - Ning Liu
- Department of Cardiology, The Second Hospital of Jilin University, Changchun 130041, China
| | - Youyou Yan
- Department of Cardiology, The Second Hospital of Jilin University, Changchun 130041, China
| | - Bin Liu
- Department of Cardiology, The Second Hospital of Jilin University, Changchun 130041, China
| |
Collapse
|
13
|
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.
Collapse
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.)
| |
Collapse
|
14
|
Propagating Relationship of Cerebral Oximetric Volume and the Clinical Outcome of Recombinant Tissue Plasminogen Activator (r-TPA) Therapy on Acute Cerebral Ischemic Stroke Patients. ADVANCED JOURNAL OF EMERGENCY MEDICINE 2020; 4:e7. [PMID: 31938776 PMCID: PMC6955029 DOI: 10.22114/ajem.v0i0.174] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Introduction: Currently, the most available treatment for acute ischemic stroke (AIS) is thrombolytic therapy with recombinant tissue plasminogen activator (r-TPA). A challenge in r-TPA therapy is the prediction of recovery in each case. Objective: The aim was to find a possible relationship between the cerebral oximetry indexes and the clinical outcome of r-TPA therapy to assess the cerebral oximetry as a non-invasive monitoring agent for therapy. Methods: The inclusion criteria were all patients with AIS who received r-TPA. The neurologic status was evaluated based on the national institutes of health stroke scale (NIHSS) score at arrival, and after a period of 24 hours. In addition, the levels of brain oxygenation in both hemispheres were measured before and continuously over the first 24 hours after r-TPA injection, using an oximetric sensor in the frontal lobes. The clinical success was defined as a 4-point improvement from the baseline NIHSS. Results: Total 44 patients with the mean age of 58.2 ± 2.18 years were enrolled, of whom 68.18% were male. Twenty-eight patients remained clinically unimproved and 16 patients were improved. A significant difference was found in the mean surface area under the brain oximetric curve in the 24 hour, in the affected hemisphere in the improved group, compared to the unimproved group (P = 0.007). There was a significant difference between the mean increase in brain oxygenation within 24 hours in the improved and unimproved groups (P = 0.002). Conclusion: It is likely that, The cerebral oximetry could contribute to predict the likelihood of r-TPA prognosis in patients with AIS.
Collapse
|
15
|
Stevens ER, Roberts E, Kuczynski HC, Boden-Albala B. Stroke Warning Information and Faster Treatment (SWIFT): Cost-Effectiveness of a Stroke Preparedness Intervention. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2019; 22:1240-1247. [PMID: 31708060 PMCID: PMC6857539 DOI: 10.1016/j.jval.2019.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 05/09/2019] [Accepted: 06/10/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Less than 25% of stroke patients arrive to an emergency department within the 3-hour treatment window. OBJECTIVE We evaluated the cost-effectiveness of a stroke preparedness behavioral intervention study (Stroke Warning Information and Faster Treatment [SWIFT]), a stroke intervention demonstrating capacity to decrease race-ethnic disparities in ED arrival times. METHODS Using the literature and SWIFT outcomes for 2 interventions, enhanced educational (EE) materials, and interactive intervention (II), we assess the cost-effectiveness of SWIFT in 2 ways: (1) Markov model, and (2) cost-to-outcome ratio. The Markov model primary outcome was the cost per quality-adjusted life-year (QALY) gained using the cost-effectiveness threshold of $100 000/QALY. The primary cost-to-outcome endpoint was cost per additional patient with ED arrival <3 hours, stroke knowledge, and preparedness capacity. We assessed the ICER of II and EE versus standard care (SC) from a health sector and societal perspective using 2015 USD, a time horizon of 5 years, and a discount rate of 3%. RESULTS The cost-effectiveness of the II and EE programs was, respectively, $227.35 and $74.63 per additional arrival <3 hours, $440.72 and $334.09 per additional person with stroke knowledge proficiency, and $655.70 and $811.77 per additional person with preparedness capacity. Using a societal perspective, the ICER for EE versus SC was $84 643 per QALY gained and the ICER for II versus EE was $59 058 per QALY gained. Incorporating fixed costs, EE and II would need to administered to 507 and 1693 or more patients, respectively, to achieve an ICER of $100 000/QALY. CONCLUSION II was a cost-effective strategy compared with both EE and SC. Nevertheless, high initial fixed costs associated with II may limit its cost-effectiveness in settings with smaller patient populations.
Collapse
Affiliation(s)
- Elizabeth R Stevens
- Department of Epidemiology, New York University College of Global Public Health, New York, NY, USA; Department of Population Health, New York University School of Medicine, New York, NY, USA.
| | - Eric Roberts
- Department of Epidemiology, New York University College of Global Public Health, New York, NY, USA
| | - Heather Carman Kuczynski
- Department of Epidemiology, New York University College of Global Public Health, New York, NY, USA
| | - Bernadette Boden-Albala
- Department of Epidemiology, New York University College of Global Public Health, New York, NY, USA
| |
Collapse
|
16
|
Peultier AC, Redekop WK, Allen M, Peters J, Eker OF, Severens JL. Exploring the Cost-Effectiveness of Mechanical Thrombectomy Beyond 6 Hours Following Advanced Imaging in the United Kingdom. Stroke 2019; 50:3220-3227. [PMID: 31637975 PMCID: PMC6824506 DOI: 10.1161/strokeaha.119.026816] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Supplemental Digital Content is available in the text. In the United Kingdom, mechanical thrombectomy (MT) for acute ischemic stroke patients assessed beyond 6 hours from symptom onset will be commissioned up to 12 hours provided that advanced imaging (AdvImg) demonstrates salvageable brain tissue. While the accuracy of AdvImg differs across technologies, evidence is limited regarding the proportion of patients who would benefit from late MT. We compared the cost-effectiveness of 2 care pathways: (1) MT within and beyond 6 hours based on AdvImg selection versus (2) MT only within 6 hours based on conventional imaging selection. The impact of varying AdvImg accuracy and prior probability for acute ischemic stroke patients to benefit from late MT was assessed.
Collapse
Affiliation(s)
- Anne-Claire Peultier
- From Erasmus School of Health Policy and Management (A.-C.P., W.K.R., J.L.S.), Erasmus University Rotterdam, the Netherlands
| | - William K Redekop
- From Erasmus School of Health Policy and Management (A.-C.P., W.K.R., J.L.S.), Erasmus University Rotterdam, the Netherlands.,Institute for Medical Technology Assessment (W.K.R., J.L.S.), Erasmus University Rotterdam, the Netherlands
| | - Michael Allen
- University of Exeter Medical School, United Kingdom (M.A.).,National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South West Peninsula, United Kingdom (M.A.)
| | - Jaime Peters
- Exeter Test Group, University of Exeter Medical School, United Kingdom (J.P.)
| | - Omer Faruk Eker
- Department of Neuroradiology, Lyon University Hospital, France (O.F.E.)
| | - Johan L Severens
- From Erasmus School of Health Policy and Management (A.-C.P., W.K.R., J.L.S.), Erasmus University Rotterdam, the Netherlands.,Institute for Medical Technology Assessment (W.K.R., J.L.S.), Erasmus University Rotterdam, the Netherlands
| |
Collapse
|
17
|
Liberman AL, Choi HJ, French DD, Prabhakaran S. Is the Cost-Effectiveness of Stroke Thrombolysis Affected by Proportion of Stroke Mimics? Stroke 2019; 50:463-468. [PMID: 30572813 DOI: 10.1161/strokeaha.118.022857] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Differentiating ischemic stroke patients from stroke mimics (SM), nonvascular conditions which simulate stroke, can be challenging in the acute setting. We sought to model the cost-effectiveness of treating suspected acute ischemic stroke patients before a definitive diagnosis could be made. We hypothesized that we would identify threshold proportions of SM among suspected stroke patients arriving to an emergency department above which administration of intravenous thrombolysis was no longer cost-effective. Methods- We constructed a decision-analytic model to examine various emergency department thrombolytic treatment scenarios. The main variables were proportion of SM to true stroke patients, time from symptom onset to treatment, and complication rates. Costs, reimbursement rates, and expected clinical outcomes of ischemic stroke and SM patients were estimated from published data. We report the 90-day incremental cost-effectiveness ratio of administering intravenous thrombolysis compared with no acute treatment from a healthcare sector perspective, as well as the cost-reimbursement ratio from a hospital-level perspective. Cost-effectiveness was defined as a willingness to pay <$100 000 USD per quality adjusted life year gained and high cost-reimbursement ratio was defined as >1.5. Results- There was an increase in incremental cost-effectiveness ratios as the proportion of SM cases increased in the 3-hour time window. The threshold proportion of SM above which the decision to administer thrombolysis was no longer cost-effective was 30%. The threshold proportion of SM above which the decision to administer thrombolysis resulted in high cost-reimbursement ratio was 75%. Results were similar for patients arriving within 0 to 90 minutes of symptom onset as compared with 91 to 180 minutes but were significantly affected by cost of alteplase in sensitivity analyses. Conclusions- We identified thresholds of SM above which thrombolysis was no longer cost-effective from 2 analytic perspectives. Hospitals should monitor SM rates and establish performance metrics to prevent rising acute stroke care costs and avoid potential patient harms.
Collapse
Affiliation(s)
- Ava L Liberman
- From the Department of Neurology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY (A.L.L.)
| | - Ho-Jun Choi
- McCormick School of Engineering and Applied Science, Northwestern University. Evanston, IL (H.-J.C.)
| | - Dustin D French
- Department of Ophthalmology and Center for Healthcare Studies (D.D.F.), Feinberg School of Medicine, Northwestern University, Chicago, IL.,Veterans Affairs Health Services Research and Development Service, Chicago, Illinois (D.D.F.)
| | - Shyam Prabhakaran
- Department of Neurology (S.P.), Feinberg School of Medicine, Northwestern University, Chicago, IL
| |
Collapse
|
18
|
Affiliation(s)
- Raul G. Nogueira
- From the Department of Neurology, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA (R.G.N.)
| | - Marc Ribó
- Department of Neurology, Hospital Vall d’Hebron, Barcelona, Spain (M.R.)
| |
Collapse
|
19
|
Damani RH, Anand S, Asgarisabet P, Bissell C, Savitz S, Suarez JI. Regional Intervention of Stroke Care to Increase Thrombolytic Therapy for Acute Ischemic Stroke. Stroke 2019; 49:2008-2010. [PMID: 29991653 DOI: 10.1161/strokeaha.118.021109] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background and Purpose- The aims of this study were to investigate the effect of an intervention to unblind data on r-tPA (recombinant tissue-type plasminogen activator) administration and sharing data with chief executive officers of participating hospitals, on r-tPA administration rates postintervention and on potential healthcare cost savings implemented at 26 Southeast Texas Regional Advisory Council hospitals. Methods- Retrospective analysis of prospective data on thrombolytic therapy from 26 Southeast Texas Regional Advisory Council hospitals, collected between April 2014 and June 2016. The control (blinded) period (Q2-2014 to Q2-2015) was followed by unblinding (Q3-2015). Results- Intervention was associated with 21.1% increase in r-tPA administration rates, with 38.5% increase in r-tPA administration with door-to-needle time ≤60 minutes. An absolute increase in r-tPA administration of 2.1% was seen with an average lifetime cost savings of $3.6 million. Conclusions- Transparent regional data sharing was associated with improved r-tPA administration and healthcare cost savings.
Collapse
Affiliation(s)
- Rahul H Damani
- From the Division of Vascular Neurology and Neurocritical Care, Department of Neurology, Baylor College of Medicine, Houston, TX (R.H.D., S.A.)
| | - Samyuktha Anand
- From the Division of Vascular Neurology and Neurocritical Care, Department of Neurology, Baylor College of Medicine, Houston, TX (R.H.D., S.A.)
| | - Parisa Asgarisabet
- University of Texas Health Science Center at Houston School of Public Health (P.A.)
| | | | - Sean Savitz
- Department of Neurology, McGovern School of Medicine, Houston, TX (S.S.)
| | - Jose I Suarez
- Division of Neurosciences Critical Care, Department of Anesthesiology and Critical Care Medicine (J.I.S.).,Department of Neurology (J.I.S.).,Department of Neurosurgery (J.I.S.), Johns Hopkins University School of Medicine, Baltimore, MD
| |
Collapse
|
20
|
McDermott M, Skolarus LE, Burke JF. A systematic review and meta-analysis of interventions to increase stroke thrombolysis. BMC Neurol 2019; 19:86. [PMID: 31053101 PMCID: PMC6500041 DOI: 10.1186/s12883-019-1298-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 04/11/2019] [Indexed: 12/22/2022] Open
Abstract
Background Although the efficacy of tissue plasminogen activator (tPA) for acute ischemic stroke is well established, rates of tPA use remain low. For clinicians, advocates, and policy-makers seeking to increase tPA treatment rates, it is important to understand what interventions exist and their relative effectiveness. Methods We searched PubMed and EMBASE to identify all studies published between 1995 and January 8, 2015 documenting interventions to increase the use of tPA with broadly inclusive criteria. The principal summary measure was the percentage change in rate of tPA administration. Random effects meta-analytic models were built to summarize the effect of intervention compared to control overall and for intervention characteristics. Results The search yielded 1457 results of which 25 met eligibility criteria. We identified 14 pre-post studies, ten randomized controlled trials, and one quasi-experiment. Included studies targeted their interventions at emergency medical services (EMS) (n = 14), telemedicine (n = 6), and public education (n = 6). In a random effects model, tPA administration was significantly higher in the intervention arm across all studies limiting enrollment to ischemic stroke patients (n = 16) with a risk ratio (RR) of 1.80 (95% confidence interval [CI], 1.45–2.22). A trend towards increased tPA administration was observed for all intervention approaches: risk ratio of 1.73 (95% CI, 1.44–2.09) for EMS, 1.58 (95% CI, 0.72–3.47) for telemedicine, and 1.89 (95% CI, 0.77–4.65) for public education, the latter not restricted to ischemic stroke patients. Conclusions Interventions to increase tPA use appear to have considerable effectiveness. Our findings support the use of such interventions to improve stroke outcomes.
Collapse
Affiliation(s)
- Mollie McDermott
- Neurology Department, University of Michigan, Cardiovascular Center, 1500 East Medical Center Drive - SPC #5855, Ann Arbor, MI, 48109-5855, USA.
| | - Lesli E Skolarus
- Neurology Department, University of Michigan, Cardiovascular Center, 1500 East Medical Center Drive - SPC #5855, Ann Arbor, MI, 48109-5855, USA
| | - James F Burke
- Neurology Department, University of Michigan, Cardiovascular Center, 1500 East Medical Center Drive - SPC #5855, Ann Arbor, MI, 48109-5855, USA
| |
Collapse
|
21
|
Baby P, Srijithesh PR, Ashraf J, Kannan D. Emergency nurses' knowledge about tissue plasminogen activator therapy and their perception about barriers for thrombolysis in acute stroke care. INTERNATIONAL JOURNAL OF NONCOMMUNICABLE DISEASES 2019. [DOI: 10.4103/jncd.jncd_16_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
22
|
Bazargani YT, Ugurlu M, de Boer A, Leufkens HGM, Mantel-Teeuwisse AK. Selection of essential medicines for the prevention and treatment of cardiovascular diseases in low and middle income countries. BMC Cardiovasc Disord 2018; 18:126. [PMID: 29940880 PMCID: PMC6019804 DOI: 10.1186/s12872-018-0858-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 06/10/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The incidence and mortality of cardiovascular diseases (CVDs) in low and middle income countries (LMICs) have been increasing, while access to CVDs medicines is suboptimal. We assessed selection of essential medicines for the prevention and treatment of CVDs on national essential medicines lists (NEMLs) of LMICs and potential determinants for selection. METHODS Only operational NEMLs were considered eligible for this study. A selection of medicines listed under "cardiovascular medicines" or "blood products and plasma substitutes" in the NEMLs were included if they were present on international guidelines for the prevention and treatment of CVDs (hyperlipidemia, hypertension, platelet inhibition, ischemic stroke, stable ischemic heart disease, acute coronary syndromes, heart failure, atrial fibrillation, peripheral arterial disease and acute limb ischemia). The number and diversity of essential medicines selected for CVDs were studied. Moreover, determinants of selection of essential medicines for CVDs at a national level were explored. Data analysis was done using univariate linear regression and non-parametric tests. RESULTS All medicine groups listed by the international guidelines were selected by the majority of the 34 countries studied with the exception of adenosine diphosphate receptor inhibitors which appeared on less than half of the NEMLs studied (41% of countries). The total number of essential medicines for the prevention and treatment of cardiovascular diseases (median 24 (range 16-50)) differed significantly across income levels (median range: 19.5-25, p = 0.014) and across regions (median range: 20-32, p = 0.049). When recommendations of the international guidelines were considered, over 75% of the NEMLs contained essential medicines for the majority of CVDs. CONCLUSION The main medicine classes for the management of CVDs were represented on NEMLs. Consequently, for the majority of CVDs, evidence-based guideline-recommended treatment is possible as far as selection of essential medicines is concerned. Selection will therefore not be the limiting step in access to medicines for cardiovascular diseases.
Collapse
Affiliation(s)
- Y. T. Bazargani
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, PO Box 80082, 3508 TB Utrecht, The Netherlands
| | - M. Ugurlu
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, PO Box 80082, 3508 TB Utrecht, The Netherlands
| | - A. de Boer
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, PO Box 80082, 3508 TB Utrecht, The Netherlands
| | - H. G. M. Leufkens
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, PO Box 80082, 3508 TB Utrecht, The Netherlands
| | - A. K. Mantel-Teeuwisse
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, PO Box 80082, 3508 TB Utrecht, The Netherlands
| |
Collapse
|
23
|
Sun T, Xu Z, Diao SS, Zhang LL, Fang Q, Cai XY, Kong Y. Safety and cost-effectiveness thrombolysis by diffusion-weighted imaging and fluid attenuated inversion recovery mismatch for wake-up stroke. Clin Neurol Neurosurg 2018; 170:47-52. [PMID: 29729542 DOI: 10.1016/j.clineuro.2018.04.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 04/13/2018] [Accepted: 04/22/2018] [Indexed: 01/16/2023]
Abstract
Wake-up stroke, defined as patients who wake up with stroke symptoms which were not present prior to falling asleep, accounted for 14%-25% of acute ischemic stroke. Due to the unknown time of symptom onset, wake-up stoke was not in including criteria of intravenous thrombolysis. Several large randomized stroke trials using diffusion-weighted imaging(DWI)and fluid attenuated inversion recovery(FLAIR)mismatch patient selection may identify a subset of patients with wake-up stroke that can safely and effectively benefit from intravenous thrombolysis. In addition, economic factor was another important limitation to generalize thrombolysis treatment. Fortunately, MRI-based thrombolysis was a cost-effective treatment for wake-up stroke compared to these patients with no thrombolysis.
Collapse
Affiliation(s)
- Tong Sun
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Zhuan Xu
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Shan-Shan Diao
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Lu-Lu Zhang
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Qi Fang
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Xiu-Ying Cai
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China.
| | - Yan Kong
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China.
| |
Collapse
|
24
|
Shiue HJ, Albright KC, Sands KA. Relevance of the Updated Food and Drug Administration Alteplase Label for Acute Ischemic Stroke: The Estimated Impact and Current Guidelines. Ann Pharmacother 2018; 52:388-391. [DOI: 10.1177/1060028017751175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
|
25
|
Amiri A, Goudarzi R, Amiresmaili M, Iranmanesh F. Cost-effectiveness analysis of tissue plasminogen activator in acute ischemic stroke in Iran. J Med Econ 2018; 21:282-287. [PMID: 29105528 DOI: 10.1080/13696998.2017.1401545] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
AIMS Tissue plasminogen activator (tPA) is used to treat acute ischemic stroke up to 4.5 h after symptom onset. Its cost-effectiveness in developing countries is not specified yet. This study aimed to study cost-effectiveness of tPA in Iran. METHODS This is a cost-effectiveness analysis from the perspective of the third party payer to compare IV tPA with no tPA of ischemic stroke. A Markov model with a lifetime horizon was used to analyze the costs and outcomes. Cost data were extracted from the 94 patients admitted in two hospitals in Iran. All costs were calculated based on US dollars in 2016. Quality-adjusted life years (QALY) were extracted from previously published literature. Cost-effectiveness was determined by calculating ICER by TreeAge Pro 2011 software. RESULTS Lifetime costs of no tPA strategy were higher than tPA ($10,718 in the no tPA group compared with $8,796 in the tPA group). The tPA arm gained 0.20 QALY compared with no tPA. ICER was $8,471 per QALY. ICER value suggests that tPA is cost-effective compared with no tPA. LIMITATIONS The limitations of the present study are the reliance on calculated QALY value of other countries and difficulty in accessing patients treated with tPA. CONCLUSIONS The balance of hospitalization and rehabilitation costs and QALYs support the conclusion that treatment with intravenous tPA in the 4.5-h time window is cost-effective from the perspectives of the third party payer and inclusion of tPA in the insurance benefit package being reasonable.
Collapse
Affiliation(s)
- Asrin Amiri
- a Faculty of Management and Medical Informatics , Kerman University of Medical Sciences , Kerman , Iran
| | - Reza Goudarzi
- b Modeling in Health Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences , Kerman , Iran
| | - Mohammadreza Amiresmaili
- a Faculty of Management and Medical Informatics , Kerman University of Medical Sciences , Kerman , Iran
| | - Farhad Iranmanesh
- c Neurology Research Center, Kerman University of Medical Sciences , Kerman , Iran
| |
Collapse
|
26
|
|
27
|
Abstract
Purpose
Stroke is a leading cause of death and disability in the USA and worldwide. While stroke care has evolved dramatically, many new acute approaches to therapy focus only on the first 3-12 hours. Significant treatment opportunities beyond the first 12 hours can play a major role in improving outcomes for stroke patients. The purpose of this paper is to highlight the issues that affect stroke care delivery for patients and caregivers and describe an integrated care model that can improve care across the continuum.
Design/methodology/approach
This paper details evidence-based research that documents current stroke care and efforts to improve care delivery. Further, an innovative integrated care model is described, and its novel application to stroke care is highlighted.
Findings
Stroke patients and caregivers face fragmented and poorly coordinated care systems as they move through specific stroke nodes of care, from acute emergency and in-hospital stay through recovery post-discharge at a care facility or at home, and can be addressed by applying a comprehensive, technology-enabled Integrated Stroke Practice Unit (ISPU) Model of Care.
Originality/value
This paper documents specific issues that impact stroke care and the utilization of integrated care delivery models to address them. Evidence-based research results document difficulties of current care delivery methods for stroke and the impact of that care delivery on patients and caregivers across each node of care. It offers an innovative ISPU model and highlights specific tenets of that model for readers.
Collapse
|
28
|
Wu W, Zhong W, Lang B, Hu Z, He J, Tang X. Thrombopoietin could protect cerebral tissue against ischemia-reperfusion injury by suppressing NF-κB and MMP-9 expression in rats. Int J Med Sci 2018; 15:1341-1348. [PMID: 30275761 PMCID: PMC6158660 DOI: 10.7150/ijms.27543] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 07/26/2018] [Indexed: 11/20/2022] Open
Abstract
Objective: To determine the neuroprotective effects and underpinning mechanisms of thrombopoietin (TPO), Matrix Metalloproteinase-9(MMP-9) and Nuclear Factor-κB (NF-κB) after focal cerebral ischemia-reperfusion in rats. Methods: Male rats underwent 2 hours of right middle cerebral artery occlusion (MCAO) followed by 22 hours of reperfusion. PBS or TPO (0.1ug/kg) was administered from caudal vein before reperfusion. Neurologic deficits, brain edema, Evans blue (EB) extravasation, NF-κB and MMP-9 expression were subsequently examined. Results: Ischemia-reperfusion injury produced a large area of edema. TPO significantly reduced edema and alleviated neurologic deficits after ischemia-reperfusion. Ischemia-induced increases of NF-κB, MMP-9 and Evans blue extravasation were reduced by TPO intervention. Conclusion: TPO improved neurological function and ameliorated brain edema after stroke, partly by reducing the ischemia-induced increase of NF-κB and MMP-9.
Collapse
Affiliation(s)
- Wenjuan Wu
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China.,Department of Neurology, The First Affiliated Hospital of Henan University of Science and Technology
| | - Wei Zhong
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Bing Lang
- National Clinical Research Center for Mental Disorders, the Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Zhiping Hu
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Jialin He
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Xiangqi Tang
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| |
Collapse
|
29
|
Joo H, Wang G, George MG. Age-specific Cost Effectiveness of Using Intravenous Recombinant Tissue Plasminogen Activator for Treating Acute Ischemic Stroke. Am J Prev Med 2017; 53:S205-S212. [PMID: 29153122 PMCID: PMC5819005 DOI: 10.1016/j.amepre.2017.06.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 05/09/2017] [Accepted: 06/05/2017] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Studies have demonstrated that intravenous recombinant tissue plasminogen activator (IV rtPA) is a cost-effective treatment for acute ischemic stroke. Age-specific cost effectiveness has not been well examined. This study estimated age-specific incremental cost-effectiveness ratios (ICERs) of IV rtPA treatment versus no IV rtPA. METHODS A Markov model was developed to examine the economic impact of IV rtPA over a 20-year time horizon on four age groups (18-44, 45-64, 65-80, and ≥81 years) from the U.S. healthcare sector perspective. The model used health outcomes from a national stroke registry adjusted by parameters from previous literature and current hospitalization costs in 2013 U.S. dollars. Long-term annual costs and quality-adjusted life years (QALYs) in the years after a stroke were discounted at 3% per year. Incremental costs, incremental QALYs, and ICERs were estimated and sensitivity analyses were conducted between 2015 and 2017. RESULTS Use of IV rtPA gained 0.55 QALYs and cost $3,941 more than no IV rtPA for stroke patients aged ≥18 years over a 20-year time horizon. IV rtPA was a dominant strategy compared to no IV rtPA for patients aged 18-44 and 45-64 years. For patients aged 65-80 years, IV rtPA gained 0.44 QALYs and cost $4,872 more than no IV rtPA (ICER=$11,132/QALY). For patients aged ≥81 years, ICER was estimated at $48,676/QALY. CONCLUSIONS IV rtPA saved costs and improved health outcomes for patients aged 18-64 years and was cost effective for those aged ≥65 years. These findings support the use of IV rtPA.
Collapse
Affiliation(s)
- Heesoo Joo
- IHRC Inc., Atlanta, Georgia; Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia.
| | - Guijing Wang
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Mary G George
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| |
Collapse
|
30
|
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.
Collapse
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
| |
Collapse
|
31
|
Kleindorfer D, Broderick J, Demaerschalk B, Saver J. Cost of Alteplase Has More Than Doubled Over the Past Decade. Stroke 2017; 48:2000-2002. [DOI: 10.1161/strokeaha.116.015822] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 03/27/2017] [Accepted: 04/05/2017] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Intravenous alteplase (tissue-type plasminogen activator) has been shown to be cost-effective because of savings in long-term disability. In October of 2005, an increased DRG payment to hospitals for alteplase-treated stroke patients was introduced. We sought to describe the trends in the cost of alteplase over time, in comparison to trends in hospital reimbursement in the United States.
Methods—
Using publicly available information on the Centers for Medicare and Medicaid Services (CMS) website (
www.cms.gov
), we obtained CMS quarterly payment amounts between January 1, 2005, and October 1, 2014, for alteplase, listed as alteplase recombinant, per mg. CMS payment amounts are the manufacturer’s average sales price+6% until April 2014, when it was lowered to +4.3%. Estimates for DRG base payments were calculated within the Medicare Provider and Analysis Review (MEDPAR) for fiscal years 2006 (DRG 559) and 2013 (MS DRGs 61, 62, and 63) as (DRG relative weights)×(standardized operating and capital amount). The consumer price index was also queried for all prescription drugs, urban areas, during the same study period as reference.
Results—
The CMS payment amount for alteplase per milligram was $30.50 in January 2005 and $64.30 in October 2014. Trends in the CMS payment amounts for alteplase increased by 111% between 2005 and 2014. The consumer price index for all prescription drugs increased by 30.2% in the same time frame. The base payment for alteplase-treated stroke admissions was $11 173 in 2006 and $12 064 in 2013, an 8% increase.
Conclusions—
We found a striking increase in the cost of alteplase over the last decade, with a 100 mg vial now with a CMS payment of ≈$6400, a >100% increase over 10 years. During the same time frame, the DRG base payment to hospitals increased by only 8%, and alteplase cost increased from 27% of the payment in 2006 to 53% in 2013. Researchers and stroke physicians should be aware of these changes in drug costs and their impact on cost-effectiveness analyses.
Collapse
Affiliation(s)
- Dawn Kleindorfer
- From the Department of Neurology, University of Cincinnati, OH (D.K., J.B.); Department of Neurology, Mayo Clinic, Scottsdale, AZ (B.D.); and Department of Neurology, University of California Los Angeles (J.S.)
| | - Joseph Broderick
- From the Department of Neurology, University of Cincinnati, OH (D.K., J.B.); Department of Neurology, Mayo Clinic, Scottsdale, AZ (B.D.); and Department of Neurology, University of California Los Angeles (J.S.)
| | - Bart Demaerschalk
- From the Department of Neurology, University of Cincinnati, OH (D.K., J.B.); Department of Neurology, Mayo Clinic, Scottsdale, AZ (B.D.); and Department of Neurology, University of California Los Angeles (J.S.)
| | - Jeffrey Saver
- From the Department of Neurology, University of Cincinnati, OH (D.K., J.B.); Department of Neurology, Mayo Clinic, Scottsdale, AZ (B.D.); and Department of Neurology, University of California Los Angeles (J.S.)
| |
Collapse
|
32
|
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.
Collapse
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
| |
Collapse
|
33
|
Brzica H, Abdullahi W, Ibbotson K, Ronaldson PT. Role of Transporters in Central Nervous System Drug Delivery and Blood-Brain Barrier Protection: Relevance to Treatment of Stroke. J Cent Nerv Syst Dis 2017; 9:1179573517693802. [PMID: 28469523 PMCID: PMC5392046 DOI: 10.1177/1179573517693802] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 01/22/2017] [Indexed: 01/01/2023] Open
Abstract
Ischemic stroke is a leading cause of morbidity and mortality in the United States. The only approved pharmacologic treatment for ischemic stroke is thrombolysis via recombinant tissue plasminogen activator (r-tPA). A short therapeutic window and serious adverse events (ie, hemorrhage, excitotoxicity) greatly limit r-tPA therapy, which indicates an essential need to develop novel stroke treatment paradigms. Transporters expressed at the blood-brain barrier (BBB) provide a significant opportunity to advance stroke therapy via central nervous system delivery of drugs that have neuroprotective properties. Examples of such transporters include organic anion–transporting polypeptides (Oatps) and organic cation transporters (Octs). In addition, multidrug resistance proteins (Mrps) are transporter targets in brain microvascular endothelial cells that can be exploited to preserve BBB integrity in the setting of stroke. Here, we review current knowledge on stroke pharmacotherapy and demonstrate how endogenous BBB transporters can be targeted for improvement of ischemic stroke treatment.
Collapse
Affiliation(s)
- Hrvoje Brzica
- Department of Pharmacology, College of Medicine, The University of Arizona, Tucson, AZ, USA
| | - Wazir Abdullahi
- Department of Pharmacology, College of Medicine, The University of Arizona, Tucson, AZ, USA
| | - Kathryn Ibbotson
- Department of Pharmacology and Toxicology, College of Pharmacy, The University of Arizona, Tucson, AZ, USA
| | - Patrick T Ronaldson
- Department of Pharmacology, College of Medicine, The University of Arizona, Tucson, AZ, USA
| |
Collapse
|
34
|
Abstract
In Germany dedicated neurological-neurosurgical critical care (NCC) is the fastest growing specialty and one of the five big disciplines integrated within the German critical care society (Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin; DIVI). High-quality investigations based on resilient evidence have underlined the need for technical advances, timely optimization of therapeutic procedures, and multidisciplinary team-work to treat those critically ill patients. This evolution has repeatedly raised questions, whether NCC-units should be run independently or better be incorporated within multidisciplinary critical care units, whether treatment variations exist that impact clinical outcome, and whether nowadays NCC-units can operate cost-efficiently? Stroke is the most frequent disease entity treated on NCC-units, one of the most common causes of death in Germany leading to a great socio-economic burden due to long-term disabled patients. The main aim of NCC employs surveillance of structural and functional integrity of the central nervous system as well as the avoidance of secondary brain damage. However, clinical evaluation of these severely injured commonly sedated and mechanically ventilated patients is challenging and highlights the importance of neuromonitoring to detect secondary damaging mechanisms. This multimodal strategy not only requires medical expertise but also enforces the need for specialized teams consisting of qualified nurses, technical assistants and medical therapists. The present article reviews most recent data and tries to answer the aforementioned questions.
Collapse
|
35
|
Mu F, Hurley D, Betts KA, Messali AJ, Paschoalin M, Kelley C, Wu EQ. Real-world costs of ischemic stroke by discharge status. Curr Med Res Opin 2017; 33:371-378. [PMID: 27826997 DOI: 10.1080/03007995.2016.1257979] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The objective of this study was to estimate the acute healthcare costs of ischemic stroke during hospitalization and the quarterly all-cause healthcare costs for the first year after discharge by discharge status. METHODS Adult patients with a hospitalization with a diagnosis of ischemic stroke (ICD-9-CM: 434.xx or 436.xx) between 1 January 2006 and 31 March 2015 were identified from a large US commercial claims database. Patients were classified into three cohorts based on their discharge status from the first stroke hospitalization, i.e. dead at discharge, discharged with disability, or discharged without disability. Third-party (medical and pharmacy) and out-of-pocket costs were adjusted to 2015 USD. RESULTS A total of 7919 patients dead at discharge, 45,695 patients discharged with disability, and 153,778 patients discharged without disability were included in this analysis. The overall average age was 59.7 years and 52.3% were male. During hospitalization, mean total costs (third-party and out-of-pocket) were $68,370 for patients dead at discharge, $73,903 for patients discharged with disability, and $24,448 for patients discharged without disability (p < .001 for each pairwise comparison); mean third-party costs were $63,605 for patients dead at discharge, $67,861 for patients discharged with disability and $19,267 for patients discharged without disability (p < .001 for each pairwise comparison). During the first year after discharge, mean total costs for patients discharged with disability vs. without disability were $46,850 vs. $30,132 (p < .001). Mean third-party costs for patients discharged with disability vs. without disability were $19,116 vs. $10,976 during the first quarter after discharge, $10,236 vs. $6926 during the second quarter, $8241 vs. $5810 during the third quarter, and $6875 vs. $5292 during the fourth quarter (p < .001 for each quarter). CONCLUSION The results demonstrated the high economic burden of ischemic stroke, especially among patients discharged with disability with the highest costs incurred during the inpatient stays.
Collapse
Affiliation(s)
- F Mu
- a Analysis Group Inc. , Boston , MA , USA
| | - D Hurley
- b HUTH Global LLC , Seattle , WA , USA
| | - K A Betts
- a Analysis Group Inc. , Boston , MA , USA
| | | | - M Paschoalin
- c Genentech Inc. , South San Francisco , CA , USA
| | - C Kelley
- a Analysis Group Inc. , Boston , MA , USA
| | - E Q Wu
- a Analysis Group Inc. , Boston , MA , USA
| |
Collapse
|
36
|
Lapchak PA, Zhang JH. The High Cost of Stroke and Stroke Cytoprotection Research. Transl Stroke Res 2016; 8:307-317. [PMID: 28039575 DOI: 10.1007/s12975-016-0518-y] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 12/18/2016] [Accepted: 12/21/2016] [Indexed: 10/20/2022]
Abstract
Acute ischemic stroke is inadequately treated in the USA and worldwide due to a lengthy history of neuroprotective drug failures in clinical trials. The majority of victims must endure life-long disabilities that not only affect their livelihood, but also have an enormous societal economic impact. The rapid development of a neuroprotective or cytoprotective compound would allow future stroke victims to receive a treatment to reduce disabilities and further promote recovery of function. This opinion article reviews in detail the enormous costs associated with developing a small molecule to treat stroke, as well as providing a timely overview of the cell-death time-course and relationship to the ischemic cascade. Distinct temporal patterns of cell-death of neurovascular unit components provide opportunities to intervene and optimize new cytoprotective strategies. However, adequate research funding is mandatory to allow stroke researchers to develop and test their novel therapeutic approach to treat stroke victims.
Collapse
Affiliation(s)
- Paul A Lapchak
- Director of Translational Research, Department of Neurology & Neurosurgery, Advanced Health Sciences Pavilion, Suite 8305, Cedars-Sinai Medical Center, 127 S. San Vicente Blvd, Los Angeles, CA, 90048, USA.
| | - John H Zhang
- Director, Center for Neuroscience Research, Loma Linda University School of Medicine, 11175 Campus St, Loma Linda, CA, 92350, USA
| |
Collapse
|
37
|
Dong W, Xian Y, Yuan W, Huifeng Z, Tao W, Zhiqiang L, Shan F, Ya F, Hongli W, Jinghuan W, Lei Q, Li Z, Hongyi Q. Catalpol stimulates VEGF production via the JAK2/STAT3 pathway to improve angiogenesis in rats' stroke model. JOURNAL OF ETHNOPHARMACOLOGY 2016; 191:169-179. [PMID: 27301615 DOI: 10.1016/j.jep.2016.06.030] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Revised: 06/05/2016] [Accepted: 06/08/2016] [Indexed: 05/25/2023]
Abstract
ETHNOBOTANICAL RELEVANCE Catalpol is the main active component of the radix from Rehmannia glutinosa Libosch, which has pleiotropic protective effects in neurodegenerative diseases, ischemic stroke, metabolic disorders and others AIM Catalpol has been shown to have neuroprotective, neurorepair, and angiogenesis effects following ischemic brain injury. However, its molecular mechanisms are still poorly understood. In previous studies, the JAK2/STAT3 signaling pathway was found to play a role in neuroprotection and angiogenesis. This study investigated the role of catalpol in stimulating angiogenesis via the JAK2/STAT3 pathway after permanent focal cerebral ischemia (pMCAO). METHODS Rats were subjected to right middle cerebral artery occlusion through electrocoagulation and were treated with catalpol (5mg/kg), AG490 was also used to inhibit STAT3 phosphorylation (pSTAT3). RESULTS Following stroke, Catalpol improved the neuroethology deficit, increased the cerebral blood flow (CBF) of infarcted brain and upregulated EPO and EPOR. AG490 suppressed the phosphorylation of signal transducer and activator of transcription 3 (STAT3), ultimately inhibited VEGF mRNA expression, which reduced VEGF protein expression and inhibited stroke-induced angiogenesis. However, Catalpol enhanced stroke-induced STAT3 activation and subsequently restored STAT3 activity through the recovery of STAT3 binding to VEGF. Moreover, Catalpol reversed the effect of AG490 on STAT3 activation and nuclear translocation, restored the transcriptional activity of the VEGF promoter by recruiting STAT3 to the VEGF promoter, improved VEGF mRNA and protein expression, increased angiogenesis, reduced the difference in CBF between the infarcted and intact brain and ameliorated the neuroethology behaviors after stroke. CONCLUSION Catalpol affects neuroprotection and angiogenesis via the JAK2/STAT3 signaling pathway, which is mediated by STAT3 activation and VEGF expression. Catalpol may be used as a potential therapeutic drug for stroke.
Collapse
MESH Headings
- Angiogenesis Inducing Agents/pharmacology
- Animals
- Brain/drug effects
- Brain/enzymology
- Brain/pathology
- Brain/physiopathology
- Cerebral Arteries/drug effects
- Cerebral Arteries/enzymology
- Cerebral Arteries/pathology
- Cerebral Arteries/physiopathology
- Cerebrovascular Circulation/drug effects
- Disease Models, Animal
- Erythropoietin/metabolism
- Infarction, Middle Cerebral Artery/drug therapy
- Infarction, Middle Cerebral Artery/enzymology
- Infarction, Middle Cerebral Artery/pathology
- Infarction, Middle Cerebral Artery/physiopathology
- Iridoid Glucosides/pharmacology
- Janus Kinase 2/metabolism
- Male
- Neovascularization, Physiologic/drug effects
- Neuroprotective Agents/pharmacology
- Phosphorylation
- Promoter Regions, Genetic
- Protein Binding
- RNA, Messenger/genetics
- RNA, Messenger/metabolism
- Rats, Sprague-Dawley
- Receptors, Erythropoietin/metabolism
- STAT3 Transcription Factor/metabolism
- Signal Transduction/drug effects
- Time Factors
- Transcriptional Activation
- Up-Regulation
- Vascular Endothelial Growth Factor A/genetics
- Vascular Endothelial Growth Factor A/metabolism
Collapse
Affiliation(s)
- Wan Dong
- Department of Emergency, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Yang Xian
- Department of Pharmacy, The Seventh People's Hospital of Chengdu, Chengdu 610041, China
| | - Wang Yuan
- College of Pharmaceutical Sciences and Traditional Chinese Medicine, Southwest University, Chongqing 400715, China; Chongqing Engineering Research Center for Pharmacological Evaluation, Chongqing 400715, China; Engineering Research Center for Chongqing Pharmaceutical Process and Quality Control, Chongqing 400715, China
| | - Zhu Huifeng
- College of Pharmaceutical Sciences and Traditional Chinese Medicine, Southwest University, Chongqing 400715, China; Chongqing Engineering Research Center for Pharmacological Evaluation, Chongqing 400715, China; Engineering Research Center for Chongqing Pharmaceutical Process and Quality Control, Chongqing 400715, China.
| | - Wang Tao
- College of Pharmaceutical Sciences and Traditional Chinese Medicine, Southwest University, Chongqing 400715, China; Chongqing Engineering Research Center for Pharmacological Evaluation, Chongqing 400715, China; Engineering Research Center for Chongqing Pharmaceutical Process and Quality Control, Chongqing 400715, China
| | - Liu Zhiqiang
- Department of Pharmacy, The First People's Hospital of Neijiang, Neijiang 641000, China
| | - Feng Shan
- College of Pharmaceutical Sciences and Traditional Chinese Medicine, Southwest University, Chongqing 400715, China; Chongqing Engineering Research Center for Pharmacological Evaluation, Chongqing 400715, China; Engineering Research Center for Chongqing Pharmaceutical Process and Quality Control, Chongqing 400715, China
| | - Fu Ya
- College of Chemistry and Chemical Engineering, Chongqing University of Science & Technology, Chongqing 401331, China
| | - Wang Hongli
- College of Pharmaceutical Sciences and Traditional Chinese Medicine, Southwest University, Chongqing 400715, China; Chongqing Engineering Research Center for Pharmacological Evaluation, Chongqing 400715, China; Engineering Research Center for Chongqing Pharmaceutical Process and Quality Control, Chongqing 400715, China
| | - Wang Jinghuan
- College of Pharmaceutical Sciences and Traditional Chinese Medicine, Southwest University, Chongqing 400715, China; Chongqing Engineering Research Center for Pharmacological Evaluation, Chongqing 400715, China; Engineering Research Center for Chongqing Pharmaceutical Process and Quality Control, Chongqing 400715, China
| | - Qin Lei
- College of Pharmaceutical Sciences and Traditional Chinese Medicine, Southwest University, Chongqing 400715, China; Chongqing Engineering Research Center for Pharmacological Evaluation, Chongqing 400715, China; Engineering Research Center for Chongqing Pharmaceutical Process and Quality Control, Chongqing 400715, China
| | - Zou Li
- College of Pharmaceutical Sciences and Traditional Chinese Medicine, Southwest University, Chongqing 400715, China; Chongqing Engineering Research Center for Pharmacological Evaluation, Chongqing 400715, China; Engineering Research Center for Chongqing Pharmaceutical Process and Quality Control, Chongqing 400715, China
| | - Qi Hongyi
- College of Pharmaceutical Sciences and Traditional Chinese Medicine, Southwest University, Chongqing 400715, China; Chongqing Engineering Research Center for Pharmacological Evaluation, Chongqing 400715, China; Engineering Research Center for Chongqing Pharmaceutical Process and Quality Control, Chongqing 400715, China
| |
Collapse
|
38
|
The pros and cons of intravenous thrombolysis in stroke. Lancet Neurol 2016; 15:997-8. [DOI: 10.1016/s1474-4422(16)30159-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 06/29/2016] [Indexed: 11/19/2022]
|
39
|
Moloczij N, Mosley I, Moss KM, Bagot KL, Bladin CF, Cadilhac DA. Is telemedicine helping or hindering the delivery of stroke thrombolysis in rural areas? A qualitative analysis. Intern Med J 2016; 45:957-64. [PMID: 25904209 DOI: 10.1111/imj.12793] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 04/15/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Fast diagnosis and delivery of treatment to patients experiencing acute stroke can reduce subsequent disability. While telemedicine can improve rural community access to specialists and facilitate timely diagnosis and treatment decisions, it is not widely used for stroke in Australia. AIM Identifying the barriers and facilitators to clinician engagement with, and utilisation of, telemedicine consultations could expedite implementation in rural and remote locations. METHODS Purposive sampling was used to identify and recruit medical and nursing staff varying in telemedicine experience across one hospital department. Twenty-four in-depth, face-to-face interviews were conducted examining aspects surrounding stroke telemedicine uptake. Inductive qualitative thematic analysis was undertaken, and two further researchers verified coding. RESULTS The main barriers identified were contrasting opinions about the utility of thrombolysis for treating acute stroke, lack of confidence in the telemedicine system, perceived limited need for specialist advice and concerns about receiving advice from an unfamiliar doctor. Facilitators included assistance with diagnosis and treatment, the need for a user-friendly system and access to specialists for complex cases. CONCLUSIONS Acceptability of telemedicine for acute stroke was multifaceted and closely aligned with regional clinician beliefs about the value of thrombolysis for stroke, highlighting an important area for education. Addressing beliefs about treatment efficacy and other perceived barriers is important for establishing a stroke telemedicine programme.
Collapse
Affiliation(s)
- N Moloczij
- Medical and Cognitive Research Unit, Austin Health, Heidelberg, Victoria, Australia
| | - I Mosley
- National Trauma Research Institute, Alfred Health, Melbourne, Victoria, Australia
| | - K M Moss
- Stroke Division, The Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia
| | - K L Bagot
- Stroke Division, The Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia
| | - C F Bladin
- Stroke Division, The Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia.,Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - D A Cadilhac
- Stroke Division, The Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia.,Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| |
Collapse
|
40
|
Asadi H, Williams D, Thornton J. Changing Management of Acute Ischaemic Stroke: the New Treatments and Emerging Role of Endovascular Therapy. Curr Treat Options Neurol 2016; 18:20. [PMID: 27017832 DOI: 10.1007/s11940-016-0403-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OPINION STATEMENT Urgent reperfusion of the ischaemic brain is the aim of stroke treatment, and the last two decades have seen a rapid advancement in the medical and endovascular treatment of acute ischaemic stroke. Intravenous tissue plasminogen activator (tPA) was first introduced as a safe and effective thrombolytic agent followed by the introduction of newer thrombolytic agents as well as anticoagulant and antiplatelet agents, proposed as potentially safer drugs with more favourable interaction profiles. In addition to chemo-thrombolysis, other techniques including transcranial sonothrombolysis and microbubble cavitation have been introduced which are showing promising results, but await large-scale clinical trials. These developments in medical therapies which are undoubtedly of great importance due to their potential widespread and immediate availability are paralleled with gradual but steady improvements in endovascular recanalisation techniques which were initiated by the introduction of the MERCI (Mechanical Embolus Removal in Cerebral Ischemia) and Penumbra systems. The introduction of the Solitaire device was a significant achievement in reliable and safe endovascular recanalisation and was followed by further innovative stent retrievers. Initial trials failed to show a solid benefit in endovascular intervention compared with IV-tPA alone. These counterintuitive results did not last long, however, when a series of very well-designed randomised controlled trials, pioneered by MR-CLEAN, EXTEND-IA and ESCAPE, emerged, confirming the well-believed daily anecdotal evidence. There have now been seven positive trials of endovascular treatment for acute ischaemic stroke. Now that level I evidence regarding the superiority of endovascular recanalisation is abundantly available, the clinical challenge is how to select patients suitable for intervention and to familiarise and educate stroke care providers with this recent development in stroke care. It is important for the interventional services to be provided only in comprehensive stroke centres and endovascular interventions attempted by experienced well-trained operators, at this stage as an adjunct to the established medical treatment of IV-tPA, if there are no contraindications.
Collapse
Affiliation(s)
- Hamed Asadi
- Neuroradiology and Neurointerventional Service, Department of Radiology, Beaumont Hospital, Beaumont Rd, Beaumont, Dublin, Ireland. .,School of Medicine, Faculty of Health, Deakin University, Pigdons Road, Waurn Ponds, VIC, 3216, Australia. .,Interventional Radiology Service, Department of Radiology, Beaumont Hospital, Beaumont Rd, Beaumont, Dublin, Ireland.
| | - David Williams
- Department of Geriatric and Stroke Medicine, Royal College of Surgeons in Ireland and Beaumont Hospital, Beaumont Rd, Beaumont, Dublin, Ireland
| | - John Thornton
- Neuroradiology and Neurointerventional Service, Department of Radiology, Beaumont Hospital, Beaumont Rd, Beaumont, Dublin, Ireland
| |
Collapse
|
41
|
Commiskey P, Afshinnik A, Cothren E, Gropen T, Iwuchukwu I, Jennings B, McGrade HC, Mora-Guillot J, Sabharwal V, Vidal GA, Zweifler RM, Gaines K. Description of a novel telemedicine-enabled comprehensive system of care: drip and ship plus drip and keep within a system of stroke care delivery. J Telemed Telecare 2016; 23:428-436. [DOI: 10.1177/1357633x16637967] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
United States (US) and worldwide telestroke programs frequently focus only on emergency room hyper-acute stroke management. This article describes a comprehensive, telemedicine-enabled, stroke care delivery system that combines “drip and ship” and “drip and keep” models with a comprehensive stroke center primary hub at Ochsner Medical Center in New Orleans, advanced stroke-capable regional hubs, and geographically-aligned, “stroke-ready” spokes. The primary hub provides vascular neurology expertise via telemedicine and monitors care for patients remaining at regional hubs and spokes using a multidisciplinary team approach. By 2014, primary hub telestroke consults grew to ≈1000/year with 16 min average door to consult initiation and 20 min to completion, and 29% of ischemic stroke patients received recombinant tissue-type plasminogen activator (rtPA), increasing 275%. Most patients remained in hospitals close to home, but neurointensive care and interventional procedures were common reasons for primary hub transfer. Given the time sensitivity and expert consultation needed for complex acute stroke care delivery paradigms, telestroke programs are effective for fulfilling unmet care needs. Combining drip and ship and drip and keep management allows more patients to stay “local,” limiting primary hub transfer unless more advanced services are required. Post admission telestroke management at spokes increases personnel efficiency and can positively impact stroke outcomes.
Collapse
Affiliation(s)
| | | | | | - Toby Gropen
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
42
|
Joo H, Wang G, George MG. Use of intravenous tissue plasminogen activator and hospital costs for patients with acute ischaemic stroke aged 18-64 years in the USA. Stroke Vasc Neurol 2016; 1:8-15. [PMID: 27547449 PMCID: PMC4990217 DOI: 10.1136/svn-2015-000002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Introduction Intravenous tissue plasminogen activator (IV tPA) is a globally recommended treatment for patients with acute ischaemic stroke. We examined IV tPA use among patients aged 18–64 years with a primary diagnosis of acute ischaemic stroke in the USA and inpatient costs per hospitalisation by IV tPA use status among these patients. Methods Using the 2010–2013 MarketScan Commercial Claims and Encounters Inpatient Data, we identified 39 149 hospitalisations with a primary diagnosis of acute ischaemic stroke. We verified those with and without IV tPA by ICD-9 procedure code 99.10. We estimated trends in IV tPA use by applying logistic regression. The average inpatient costs per acute ischaemic stroke hospitalisation were assessed for subpopulations. We examined costs per acute ischaemic stroke hospitalisation using multivariate regression models controlling for IV tPA status, age, gender, urbanisation, geographic region, Charlson comorbidity index, length of hospital stays (LOS) and discharge status. Results 2546 hospitalisations (6.5%) used IV tPA. IV tPA use increased over time (2010 vs 2013; OR 1.50). Average inpatient costs per acute ischaemic stroke hospitalisation were $20 331 ($31 369 for the IV tPA group, $19 563 for the non-tPA group). From multivariate analyses, higher costs per acute ischaemic stroke hospitalisation were associated with longer LOS, non-home discharge destination, and IV tPA use, which might be correlated with severity of stroke. Conclusions Findings suggest that IV tPA use has increased in recent years while the inpatient costs per acute ischaemic stroke hospitalisation using IV tPA are substantial. Those findings are useful in better understanding the overall economic burden of stroke, short-term cost implications of using IV tPA, and for estimating the accurate cost-effectiveness of stroke treatments.
Collapse
Affiliation(s)
| | - Guijing Wang
- Division for Heart Disease and Stroke Prevention, US Centers for Disease Control and Prevention (US CDC), Atlanta, GA, USA
| | - Mary G George
- Division for Heart Disease and Stroke Prevention, US Centers for Disease Control and Prevention (US CDC), Atlanta, GA, USA
| |
Collapse
|
43
|
Torabi E, Froehle CM, Lindsell CJ, Moomaw CJ, Kanter D, Kleindorfer D, Adeoye O. Monte Carlo Simulation Modeling of a Regional Stroke Team's Use of Telemedicine. Acad Emerg Med 2016; 23:55-62. [PMID: 26720746 DOI: 10.1111/acem.12839] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 07/27/2015] [Accepted: 08/05/2015] [Indexed: 01/08/2023]
Abstract
OBJECTIVES The objective of this study was to evaluate operational policies that may improve the proportion of eligible stroke patients within a population who would receive intravenous recombinant tissue plasminogen activator (rt-PA) and minimize time to treatment in eligible patients. METHODS In the context of a regional stroke team, the authors examined the effects of staff location and telemedicine deployment policies on the timeliness of thrombolytic treatment, and estimated the efficacy and cost-effectiveness of six different policies. A process map comprising the steps from recognition of stroke symptoms to intravenous administration of rt-PA was constructed using data from published literature combined with expert opinion. Six scenarios were investigated: telemedicine deployment (none, all, or outer-ring hospitals only) and staff location (center of region or anywhere in region). Physician locations were randomly generated based on their zip codes of residence and work. The outcomes of interest were onset-to-treatment (OTT) time, door-to-needle (DTN) time, and the proportion of patients treated within 3 hours. A Monte Carlo simulation of the stroke team care-delivery system was constructed based on a primary data set of 121 ischemic stroke patients who were potentially eligible for treatment with rt-PA. RESULTS With the physician located randomly in the region, deploying telemedicine at all hospitals in the region (compared with partial or no telemedicine) would result in the highest rates of treatment within 3 hours (80% vs. 75% vs. 70%) and the shortest OTT (148 vs. 164 vs. 176 minutes) and DTN (45 vs. 61 vs. 73 minutes) times. However, locating the on-call physician centrally coupled with partial telemedicine deployment (five of the 17 hospitals) would be most cost-effective with comparable eligibility and treatment times. CONCLUSIONS Given the potential societal benefits, continued efforts to deploy telemedicine appear warranted. Aligning the incentives between those who would have to fund the up-front technology investments and those who will benefit over time from reduced ongoing health care expenses will be necessary to fully realize the benefits of telemedicine for stroke care.
Collapse
Affiliation(s)
- Elham Torabi
- Lindner College of Business; University of Cincinnati; Cincinnati OH
- Department of Emergency Medicine; University of Cincinnati; Cincinnati OH
| | - Craig M. Froehle
- Lindner College of Business; University of Cincinnati; Cincinnati OH
- Department of Emergency Medicine; University of Cincinnati; Cincinnati OH
- Cincinnati Children's Hospital Medical Center; Cincinnati OH
| | | | - Charles J. Moomaw
- Department of Neurology and Rehabilitation Medicine; University of Cincinnati; Cincinnati OH
| | - Daniel Kanter
- Department of Neurology and Rehabilitation Medicine; University of Cincinnati; Cincinnati OH
- University of Cincinnati Neuroscience Institute; Cincinnati OH
| | - Dawn Kleindorfer
- Department of Neurology and Rehabilitation Medicine; University of Cincinnati; Cincinnati OH
- University of Cincinnati Neuroscience Institute; Cincinnati OH
| | - Opeolu Adeoye
- Department of Emergency Medicine; University of Cincinnati; Cincinnati OH
- Department of Neurosurgery; University of Cincinnati; Cincinnati OH
- University of Cincinnati Neuroscience Institute; Cincinnati OH
| |
Collapse
|
44
|
Lapchak PA. Critical early thrombolytic and endovascular reperfusion therapy for acute ischemic stroke victims: a call for adjunct neuroprotection. Transl Stroke Res 2015; 6:345-54. [PMID: 26314402 PMCID: PMC4568436 DOI: 10.1007/s12975-015-0419-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Accepted: 08/06/2015] [Indexed: 12/28/2022]
Abstract
Today, there is an enormous amount of excitement in the field of stroke victim care due to the recent success of MR. CLEAN, SWIFT PRIME, ESCAPE, EXTEND-IA, and REVASCAT endovascular trials. Successful intravenous (IV) recombinant tissue plasminogen activator (rt-PA) clinical trials [i.e., National Institute of Neurological Disorders and Stroke (NINDS) rt-PA trial, Third European Cooperative Acute Stroke Study (ECASSIII), and Third International Stroke study (IST-3)] also need to be emphasized. In the recent endovascular and thrombolytic trials, there is statistically significant improvement using both the National Institutes of Health Stroke Scale (NIHSS) and the modified Rankin Score (mRS) scale, but neither approach promotes complete recovery in patients enrolled within any particular NIHSS or mRS score tier. Absolute improvement (mRS 0-2 at 90 days) with endovascular therapy is 13.5-31 %, whereas thrombolytics alone also significantly improve patient functional independence, but to a lesser degree (NINDS rt-PA trial 13 %). This article has 3 main goals: (1) first to emphasize the utility and cost-effectiveness of rt-PA to treat stroke; (2) second to review the recent endovascular trials with respect to efficacy, safety, and cost-effectiveness as a stroke treatment; and (3) to further consider and evaluate strategies to develop novel neuroprotective drugs. A thesis will be put forth so that future stroke trials and therapy development can optimally promote recovery so that stroke victims can return to "normal" life.
Collapse
Affiliation(s)
- Paul A Lapchak
- Department of Neurology & Neurosurgery, Cedars-Sinai Medical Center Advanced Healthcare Science Pavilion, 127 S. San Vicente Blvd., Suite 8305, Los Angeles, CA, 90048, USA,
| |
Collapse
|
45
|
Moretti A, Ferrari F, Villa RF. Pharmacological therapy of acute ischaemic stroke: Achievements and problems. Pharmacol Ther 2015; 153:79-89. [DOI: 10.1016/j.pharmthera.2015.06.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 06/03/2015] [Indexed: 01/04/2023]
|
46
|
Beyer SE, Hunink MG, Schöberl F, von Baumgarten L, Petersen SE, Dichgans M, Janssen H, Ertl-Wagner B, Reiser MF, Sommer WH. Different Imaging Strategies in Patients With Possible Basilar Artery Occlusion: Cost-Effectiveness Analysis. Stroke 2015; 46:1840-9. [PMID: 26022634 PMCID: PMC4476845 DOI: 10.1161/strokeaha.115.008841] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 04/02/2015] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND PURPOSE This study evaluated the cost-effectiveness of different noninvasive imaging strategies in patients with possible basilar artery occlusion. METHODS A Markov decision analytic model was used to evaluate long-term outcomes resulting from strategies using computed tomographic angiography (CTA), magnetic resonance imaging, nonenhanced CT, or duplex ultrasound with intravenous (IV) thrombolysis being administered after positive findings. The analysis was performed from the societal perspective based on US recommendations. Input parameters were derived from the literature. Costs were obtained from United States costing sources and published literature. Outcomes were lifetime costs, quality-adjusted life-years (QALYs), incremental cost-effectiveness ratios, and net monetary benefits, with a willingness-to-pay threshold of $80,000 per QALY. The strategy with the highest net monetary benefit was considered the most cost-effective. Extensive deterministic and probabilistic sensitivity analyses were performed to explore the effect of varying parameter values. RESULTS In the reference case analysis, CTA dominated all other imaging strategies. CTA yielded 0.02 QALYs more than magnetic resonance imaging and 0.04 QALYs more than duplex ultrasound followed by CTA. At a willingness-to-pay threshold of $80,000 per QALY, CTA yielded the highest net monetary benefits. The probability that CTA is cost-effective was 96% at a willingness-to-pay threshold of $80,000/QALY. Sensitivity analyses showed that duplex ultrasound was cost-effective only for a prior probability of ≤0.02 and that these results were only minimally influenced by duplex ultrasound sensitivity and specificity. Nonenhanced CT and magnetic resonance imaging never became the most cost-effective strategy. CONCLUSIONS Our results suggest that CTA in patients with possible basilar artery occlusion is cost-effective.
Collapse
Affiliation(s)
- Sebastian E Beyer
- From the Institute of Clinical Radiology (S.E.B., B.E.-W., M.F.R., W.H.S.), Department of Neurology (F.S., L.B.), Institute for Stroke and Dementia Research (M.D.), and Department of Neuroradiology (H.J.), Ludwig-Maximilian University of Munich Hospitals, Munich, Germany; Advanced Cardiovascular Imaging, William Harvey Research Institute, National Institute for Health Research, Cardiovascular Biomedical Research Unit at Barts, The London Chest Hospital, London, United Kingdom (S.E.P.); Department of Radiology (M.G.H.) and Department of Epidemiology (M.G.H.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Department of Health Policy and Management, Harvard School of Public Health, Harvard University, Boston, MA (M.G.H.)
| | - Myriam G Hunink
- From the Institute of Clinical Radiology (S.E.B., B.E.-W., M.F.R., W.H.S.), Department of Neurology (F.S., L.B.), Institute for Stroke and Dementia Research (M.D.), and Department of Neuroradiology (H.J.), Ludwig-Maximilian University of Munich Hospitals, Munich, Germany; Advanced Cardiovascular Imaging, William Harvey Research Institute, National Institute for Health Research, Cardiovascular Biomedical Research Unit at Barts, The London Chest Hospital, London, United Kingdom (S.E.P.); Department of Radiology (M.G.H.) and Department of Epidemiology (M.G.H.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Department of Health Policy and Management, Harvard School of Public Health, Harvard University, Boston, MA (M.G.H.)
| | - Florian Schöberl
- From the Institute of Clinical Radiology (S.E.B., B.E.-W., M.F.R., W.H.S.), Department of Neurology (F.S., L.B.), Institute for Stroke and Dementia Research (M.D.), and Department of Neuroradiology (H.J.), Ludwig-Maximilian University of Munich Hospitals, Munich, Germany; Advanced Cardiovascular Imaging, William Harvey Research Institute, National Institute for Health Research, Cardiovascular Biomedical Research Unit at Barts, The London Chest Hospital, London, United Kingdom (S.E.P.); Department of Radiology (M.G.H.) and Department of Epidemiology (M.G.H.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Department of Health Policy and Management, Harvard School of Public Health, Harvard University, Boston, MA (M.G.H.)
| | - Louisa von Baumgarten
- From the Institute of Clinical Radiology (S.E.B., B.E.-W., M.F.R., W.H.S.), Department of Neurology (F.S., L.B.), Institute for Stroke and Dementia Research (M.D.), and Department of Neuroradiology (H.J.), Ludwig-Maximilian University of Munich Hospitals, Munich, Germany; Advanced Cardiovascular Imaging, William Harvey Research Institute, National Institute for Health Research, Cardiovascular Biomedical Research Unit at Barts, The London Chest Hospital, London, United Kingdom (S.E.P.); Department of Radiology (M.G.H.) and Department of Epidemiology (M.G.H.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Department of Health Policy and Management, Harvard School of Public Health, Harvard University, Boston, MA (M.G.H.)
| | - Steffen E Petersen
- From the Institute of Clinical Radiology (S.E.B., B.E.-W., M.F.R., W.H.S.), Department of Neurology (F.S., L.B.), Institute for Stroke and Dementia Research (M.D.), and Department of Neuroradiology (H.J.), Ludwig-Maximilian University of Munich Hospitals, Munich, Germany; Advanced Cardiovascular Imaging, William Harvey Research Institute, National Institute for Health Research, Cardiovascular Biomedical Research Unit at Barts, The London Chest Hospital, London, United Kingdom (S.E.P.); Department of Radiology (M.G.H.) and Department of Epidemiology (M.G.H.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Department of Health Policy and Management, Harvard School of Public Health, Harvard University, Boston, MA (M.G.H.)
| | - Martin Dichgans
- From the Institute of Clinical Radiology (S.E.B., B.E.-W., M.F.R., W.H.S.), Department of Neurology (F.S., L.B.), Institute for Stroke and Dementia Research (M.D.), and Department of Neuroradiology (H.J.), Ludwig-Maximilian University of Munich Hospitals, Munich, Germany; Advanced Cardiovascular Imaging, William Harvey Research Institute, National Institute for Health Research, Cardiovascular Biomedical Research Unit at Barts, The London Chest Hospital, London, United Kingdom (S.E.P.); Department of Radiology (M.G.H.) and Department of Epidemiology (M.G.H.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Department of Health Policy and Management, Harvard School of Public Health, Harvard University, Boston, MA (M.G.H.)
| | - Hendrik Janssen
- From the Institute of Clinical Radiology (S.E.B., B.E.-W., M.F.R., W.H.S.), Department of Neurology (F.S., L.B.), Institute for Stroke and Dementia Research (M.D.), and Department of Neuroradiology (H.J.), Ludwig-Maximilian University of Munich Hospitals, Munich, Germany; Advanced Cardiovascular Imaging, William Harvey Research Institute, National Institute for Health Research, Cardiovascular Biomedical Research Unit at Barts, The London Chest Hospital, London, United Kingdom (S.E.P.); Department of Radiology (M.G.H.) and Department of Epidemiology (M.G.H.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Department of Health Policy and Management, Harvard School of Public Health, Harvard University, Boston, MA (M.G.H.)
| | - Birgit Ertl-Wagner
- From the Institute of Clinical Radiology (S.E.B., B.E.-W., M.F.R., W.H.S.), Department of Neurology (F.S., L.B.), Institute for Stroke and Dementia Research (M.D.), and Department of Neuroradiology (H.J.), Ludwig-Maximilian University of Munich Hospitals, Munich, Germany; Advanced Cardiovascular Imaging, William Harvey Research Institute, National Institute for Health Research, Cardiovascular Biomedical Research Unit at Barts, The London Chest Hospital, London, United Kingdom (S.E.P.); Department of Radiology (M.G.H.) and Department of Epidemiology (M.G.H.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Department of Health Policy and Management, Harvard School of Public Health, Harvard University, Boston, MA (M.G.H.)
| | - Maximilian F Reiser
- From the Institute of Clinical Radiology (S.E.B., B.E.-W., M.F.R., W.H.S.), Department of Neurology (F.S., L.B.), Institute for Stroke and Dementia Research (M.D.), and Department of Neuroradiology (H.J.), Ludwig-Maximilian University of Munich Hospitals, Munich, Germany; Advanced Cardiovascular Imaging, William Harvey Research Institute, National Institute for Health Research, Cardiovascular Biomedical Research Unit at Barts, The London Chest Hospital, London, United Kingdom (S.E.P.); Department of Radiology (M.G.H.) and Department of Epidemiology (M.G.H.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Department of Health Policy and Management, Harvard School of Public Health, Harvard University, Boston, MA (M.G.H.)
| | - Wieland H Sommer
- From the Institute of Clinical Radiology (S.E.B., B.E.-W., M.F.R., W.H.S.), Department of Neurology (F.S., L.B.), Institute for Stroke and Dementia Research (M.D.), and Department of Neuroradiology (H.J.), Ludwig-Maximilian University of Munich Hospitals, Munich, Germany; Advanced Cardiovascular Imaging, William Harvey Research Institute, National Institute for Health Research, Cardiovascular Biomedical Research Unit at Barts, The London Chest Hospital, London, United Kingdom (S.E.P.); Department of Radiology (M.G.H.) and Department of Epidemiology (M.G.H.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Department of Health Policy and Management, Harvard School of Public Health, Harvard University, Boston, MA (M.G.H.).
| |
Collapse
|
47
|
Leppert MH, Campbell JD, Simpson JR, Burke JF. Cost-Effectiveness of Intra-Arterial Treatment as an Adjunct to Intravenous Tissue-Type Plasminogen Activator for Acute Ischemic Stroke. Stroke 2015; 46:1870-6. [PMID: 26012639 DOI: 10.1161/strokeaha.115.009779] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 04/24/2015] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND PURPOSE The objective of this study was to determine the cost-effectiveness of intra-arterial treatment within the 0- to 6-hour window after intravenous tissue-type plasminogen activator within 0- to 4.5-hour compared with intravenous tissue-type plasminogen activator alone, in the US setting and from a social perspective. METHODS A decision analytic model estimated the lifetime costs and outcomes associated with the additional benefit of intra-arterial therapy compared with standard treatment with intravenous tissue-type plasminogen activator alone. Model inputs were obtained from published literature, the Multicenter Randomized Clinical Trial of Endovascular Therapy for Acute Ischemic Stroke in the Netherlands (MR CLEAN) study, and claims databases in the United States. Health outcomes were measured in quality-adjusted life years (QALYs). Treatment benefit was assessed by calculating the cost per QALY gained. One-way and probabilistic sensitivity analyses were performed to estimate the overall uncertainty of model results. RESULTS The addition of intra-arterial therapy compared with standard treatment alone yielded a lifetime gain of 0.7 QALY for an additional cost of $9911, which resulted in a cost of $14 137 per QALY. Multivariable sensitivity analysis predicted cost-effectiveness (≤$50 000 per QALY) in 97.6% of simulation runs. CONCLUSIONS Intra-arterial treatment after intravenous tissue-type plasminogen activator for patients with anterior circulation strokes within the 6-hour window is likely cost-effective. From a societal perspective, increased investment in access to intra-arterial treatment for acute stroke may be justified.
Collapse
Affiliation(s)
- Michelle H Leppert
- From the Departments of Neurology (M.H.L., J.R.S.) and Pharmacy (J.D.C.), University of Colorado, Aurora; and Stroke Program, University of Michigan, Ann Arbor (J.F.B.).
| | - Jonathan D Campbell
- From the Departments of Neurology (M.H.L., J.R.S.) and Pharmacy (J.D.C.), University of Colorado, Aurora; and Stroke Program, University of Michigan, Ann Arbor (J.F.B.)
| | - Jennifer R Simpson
- From the Departments of Neurology (M.H.L., J.R.S.) and Pharmacy (J.D.C.), University of Colorado, Aurora; and Stroke Program, University of Michigan, Ann Arbor (J.F.B.)
| | - James F Burke
- From the Departments of Neurology (M.H.L., J.R.S.) and Pharmacy (J.D.C.), University of Colorado, Aurora; and Stroke Program, University of Michigan, Ann Arbor (J.F.B.)
| |
Collapse
|
48
|
Lapchak PA. A cost-effective rabbit embolic stroke bioassay: insight into the development of acute ischemic stroke therapy. Transl Stroke Res 2015; 6:99-103. [PMID: 25637174 PMCID: PMC4359071 DOI: 10.1007/s12975-015-0386-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2015] [Accepted: 01/06/2015] [Indexed: 12/25/2022]
Affiliation(s)
- Paul A Lapchak
- Departments of Neurology and Neurosurgery, Cedars-Sinai Medical Center, Advanced Health Sciences Pavilion Suite 8305, 127 S. San Vicente Blvd., Los Angeles, CA, 90048, USA,
| |
Collapse
|
49
|
Lan X, Wang W, Li Q, Wang J. The Natural Flavonoid Pinocembrin: Molecular Targets and Potential Therapeutic Applications. Mol Neurobiol 2015; 53:1794-1801. [PMID: 25744566 DOI: 10.1007/s12035-015-9125-2] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2014] [Accepted: 02/22/2015] [Indexed: 12/29/2022]
Abstract
Pinocembrin is a natural flavonoid compound extracted from honey, propolis, ginger roots, wild marjoram, and other plants. In preclinical studies, it has shown anti-inflammatory and neuroprotective effects as well as the ability to reduce reactive oxygen species, protect the blood-brain barrier, modulate mitochondrial function, and regulate apoptosis. Considering these pharmaceutical characteristics, pinocembrin has potential as a drug to treat ischemic stroke and other clinical conditions. In this review, we summarize its pharmacologic characteristics and discuss its mechanisms of action and potential therapeutic applications.
Collapse
Affiliation(s)
- Xi Lan
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, 720 Rutland Ave, Ross Bldg 370B, Baltimore, MD, 21205, USA
| | - Wenzhu Wang
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, 720 Rutland Ave, Ross Bldg 370B, Baltimore, MD, 21205, USA
| | - Qiang Li
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, 720 Rutland Ave, Ross Bldg 370B, Baltimore, MD, 21205, USA
| | - Jian Wang
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, 720 Rutland Ave, Ross Bldg 370B, Baltimore, MD, 21205, USA.
| |
Collapse
|