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Ospel JM, Zerna C, Harrison E, Kleinig TJ, Puetz V, Kaiser DPO, Graham B, Yu AYX, van Adel B, Shankar JJ, McTaggart RA, Pereira V, Frei DF, Kunz WG, Goyal M, Hill MD. Cost-Effectiveness of Late Endovascular Thrombectomy vs. Best Medical Management in a Clinical Trial Setting and Real-World Setting. Can J Neurol Sci 2024:1-8. [PMID: 38403588 DOI: 10.1017/cjn.2024.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
BACKGROUND AND PURPOSE To assess cost-effectiveness of late time-window endovascular treatment (EVT) in a clinical trial setting and a "real-world" setting. METHODS Data are from the randomized ESCAPE trial and a prospective cohort study (ESCAPE-LATE). Anterior circulation large vessel occlusion patients presenting > 6 hours from last-known-well were included, whereby collateral status was an inclusion criterion for ESCAPE but not ESCAPE-LATE. A Markov state transition model was built to estimate lifetime costs and quality-adjusted life-years (QALYs) for EVT in addition to best medical care vs. best medical care only in a clinical trial setting (comparing ESCAPE-EVT to ESCAPE control arm patients) and a "real-world" setting (comparing ESCAPE-LATE to ESCAPE control arm patients). We performed an unadjusted analysis, using 90-day modified Rankin Scale(mRS) scores as model input and analysis adjusted for baseline factors. Acceptability of EVT was calculated using upper/lower willingness-to-pay thresholds of 100,000 USD/50,000 USD/QALY. RESULTS Two-hundred and forty-nine patients were included (ESCAPE-LATE:n = 200, ESCAPE EVT-arm:n = 29, ESCAPE control-arm:n = 20). Late EVT in addition to best medical care was cost effective in the unadjusted analysis both in the clinical trial and real-world setting, with acceptability 96.6%-99.0%. After adjusting for differences in baseline variables between the groups, late EVT was marginally cost effective in the clinical trial setting (acceptability:49.9%-61.6%), but not the "real-world" setting (acceptability:32.9%-42.6%). CONCLUSION EVT for LVO-patients presenting beyond 6 hours was cost effective in the clinical trial setting and "real-world" setting, although this was largely related to baseline patient differences favoring the "real-world" EVT group. After adjusting for these, EVT benefit was reduced in the trial setting, and absent in the real-world setting.
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Affiliation(s)
- Johanna Maria Ospel
- Department of Diagnostic Imaging, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
| | - Charlotte Zerna
- Department of Neurology, Städtisches Klinikum Dresden, Dresden, Germany
| | - Emma Harrison
- Department of Neurology, Princess Alexandra Hospital, Brisbane, QL, Australia
| | - Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, Australia
| | - Volker Puetz
- Department of Neurology, Technical University Dresden, Dresden, Germany
| | - Daniel P O Kaiser
- Department of Neurology, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Brett Graham
- Department of Neurology, Royal University Hospital of Saskatchewan, Saskatoon, Canada
| | - Amy Y X Yu
- Department of Neurology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Canada
| | - Brian van Adel
- Division of Neurology, Neurosurgery and Diagnostic Imaging, Hamilton General Hospital, McMaster University, Hamilton, Canada
| | - Jai J Shankar
- Department of Neurology, University of Manitoba, Winnipeg, Canada
| | - Ryan A McTaggart
- Department of Radiology, Rhode Island Hospital, Providence, RI, USA
| | - Vitor Pereira
- Department of Neurosurgery, St Michaels Hospital, University of Toronto, Toronto, Canada
| | | | - Wolfgang G Kunz
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Mayank Goyal
- Department of Diagnostic Imaging, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
| | - Michael D Hill
- Department of Diagnostic Imaging, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
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Cras TY, Hunink MMG, Dammers R, van Es ACGM, Volovici V, Burke JF, Kremers FCC, Dippel DWJ, Roozenbeek B. Surveillance of Unruptured Intracranial Aneurysms: Cost-Effectiveness Analysis for 3 Countries. Neurology 2022; 99:e890-e903. [PMID: 35654593 DOI: 10.1212/wnl.0000000000200785] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 04/11/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES No consensus exists on adequate surveillance of conservatively managed unruptured intracranial aneurysms (UIAs). We aimed to determine optimal MRI surveillance strategies for the growth of UIAs using cost-effectiveness analysis. A secondary aim was to develop a clinical tool for personalizing UIA surveillance. METHODS We designed a microsimulation model from a health care perspective simulating 100,000 55-year-old women to estimate costs and quality-adjusted life years (QALYs) over a lifetime horizon in the United States, the United Kingdom, and the Netherlands, using literature-derived model parameters. Country-specific costs and willingness-to-pay thresholds ($100,000/QALY for the United States, £30,000/QALY for the United Kingdom, and €80,000/QALY for the Netherlands) were used. Lifetime costs and QALYs were annually discounted at 3% for the United States, 3.5% for the United Kingdom, or 4% (costs) and 1.5% (QALYs) for the Netherlands. Strategies were no follow-up surveillance, follow-up with MRI in the first and fifth year after UIA discovery, every 5 years, every 2 years, or annually, or immediate intervention (i.e., clipping or coiling). Using the microsimulation model, we developed a tool for personalizing UIA surveillance for men and women, with different ages and varying aneurysm characteristics. Uncertainty in the input parameters was modeled with probabilistic sensitivity analysis. RESULTS Among 55-year-old women, 2,222 individuals in the United States, 1,910 in the United Kingdom, and 2,040 in the Netherlands needed to undergo an annual MRI scan to prevent 1 case of subarachnoid hemorrhage per year. No surveillance MRI was most cost-effective in the United States (in 47% of the simulations) and United Kingdom (in 54% of simulations), whereas annual MRI was most cost-effective in the Netherlands (in 53% of simulations). In the United States and United Kingdom, annual surveillance or surveillance in the first and fifth year after discovery was cost-effective in patients <60 years and at increased risk of aneurysm growth. The optimal, personalized, surveillance strategies were summarized in a look-up table for use in clinical practice. DISCUSSION Generally, the US and UK physicians should refrain from assigning patients, particularly older patients and those with few risk factors for aneurysm growth or rupture, to frequent MRI surveillance. In the Netherlands, annual follow-up is generally most cost-effective.
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Affiliation(s)
- Tim Yannick Cras
- From the Departments of Neurology (T.Y.C., F.C.C.K., D.W.J.D., B.R.), Epidemiology (M.M.G.H.), Radiology & Nuclear Medicine (M.M.G.H., B.R.), Neurosurgery (R.D., V.V.), and Erasmus MC University Medical Center (T.Y.C., F.C.C.K., D.W.J.D., B.R., R.D.), Rotterdam, the Netherlands; Centre for Health Decision Sciences (M.M.G.H.), Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA; Department of Radiology (A.C.G.M.v.E.), Leiden University Medical Center, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Myriam M G Hunink
- From the Departments of Neurology (T.Y.C., F.C.C.K., D.W.J.D., B.R.), Epidemiology (M.M.G.H.), Radiology & Nuclear Medicine (M.M.G.H., B.R.), Neurosurgery (R.D., V.V.), and Erasmus MC University Medical Center (T.Y.C., F.C.C.K., D.W.J.D., B.R., R.D.), Rotterdam, the Netherlands; Centre for Health Decision Sciences (M.M.G.H.), Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA; Department of Radiology (A.C.G.M.v.E.), Leiden University Medical Center, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Ruben Dammers
- From the Departments of Neurology (T.Y.C., F.C.C.K., D.W.J.D., B.R.), Epidemiology (M.M.G.H.), Radiology & Nuclear Medicine (M.M.G.H., B.R.), Neurosurgery (R.D., V.V.), and Erasmus MC University Medical Center (T.Y.C., F.C.C.K., D.W.J.D., B.R., R.D.), Rotterdam, the Netherlands; Centre for Health Decision Sciences (M.M.G.H.), Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA; Department of Radiology (A.C.G.M.v.E.), Leiden University Medical Center, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Adriaan C G M van Es
- From the Departments of Neurology (T.Y.C., F.C.C.K., D.W.J.D., B.R.), Epidemiology (M.M.G.H.), Radiology & Nuclear Medicine (M.M.G.H., B.R.), Neurosurgery (R.D., V.V.), and Erasmus MC University Medical Center (T.Y.C., F.C.C.K., D.W.J.D., B.R., R.D.), Rotterdam, the Netherlands; Centre for Health Decision Sciences (M.M.G.H.), Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA; Department of Radiology (A.C.G.M.v.E.), Leiden University Medical Center, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Victor Volovici
- From the Departments of Neurology (T.Y.C., F.C.C.K., D.W.J.D., B.R.), Epidemiology (M.M.G.H.), Radiology & Nuclear Medicine (M.M.G.H., B.R.), Neurosurgery (R.D., V.V.), and Erasmus MC University Medical Center (T.Y.C., F.C.C.K., D.W.J.D., B.R., R.D.), Rotterdam, the Netherlands; Centre for Health Decision Sciences (M.M.G.H.), Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA; Department of Radiology (A.C.G.M.v.E.), Leiden University Medical Center, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - James F Burke
- From the Departments of Neurology (T.Y.C., F.C.C.K., D.W.J.D., B.R.), Epidemiology (M.M.G.H.), Radiology & Nuclear Medicine (M.M.G.H., B.R.), Neurosurgery (R.D., V.V.), and Erasmus MC University Medical Center (T.Y.C., F.C.C.K., D.W.J.D., B.R., R.D.), Rotterdam, the Netherlands; Centre for Health Decision Sciences (M.M.G.H.), Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA; Department of Radiology (A.C.G.M.v.E.), Leiden University Medical Center, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Femke C C Kremers
- From the Departments of Neurology (T.Y.C., F.C.C.K., D.W.J.D., B.R.), Epidemiology (M.M.G.H.), Radiology & Nuclear Medicine (M.M.G.H., B.R.), Neurosurgery (R.D., V.V.), and Erasmus MC University Medical Center (T.Y.C., F.C.C.K., D.W.J.D., B.R., R.D.), Rotterdam, the Netherlands; Centre for Health Decision Sciences (M.M.G.H.), Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA; Department of Radiology (A.C.G.M.v.E.), Leiden University Medical Center, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Diederik W J Dippel
- From the Departments of Neurology (T.Y.C., F.C.C.K., D.W.J.D., B.R.), Epidemiology (M.M.G.H.), Radiology & Nuclear Medicine (M.M.G.H., B.R.), Neurosurgery (R.D., V.V.), and Erasmus MC University Medical Center (T.Y.C., F.C.C.K., D.W.J.D., B.R., R.D.), Rotterdam, the Netherlands; Centre for Health Decision Sciences (M.M.G.H.), Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA; Department of Radiology (A.C.G.M.v.E.), Leiden University Medical Center, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Bob Roozenbeek
- From the Departments of Neurology (T.Y.C., F.C.C.K., D.W.J.D., B.R.), Epidemiology (M.M.G.H.), Radiology & Nuclear Medicine (M.M.G.H., B.R.), Neurosurgery (R.D., V.V.), and Erasmus MC University Medical Center (T.Y.C., F.C.C.K., D.W.J.D., B.R., R.D.), Rotterdam, the Netherlands; Centre for Health Decision Sciences (M.M.G.H.), Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA; Department of Radiology (A.C.G.M.v.E.), Leiden University Medical Center, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor.
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Crinnion W, Jackson B, Sood A, Lynch J, Bergeles C, Liu H, Rhode K, Mendes Pereira V, Booth TC. Robotics in neurointerventional surgery: a systematic review of the literature. J Neurointerv Surg 2022; 14:539-545. [PMID: 34799439 PMCID: PMC9120401 DOI: 10.1136/neurintsurg-2021-018096] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 10/24/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Robotically performed neurointerventional surgery has the potential to reduce occupational hazards to staff, perform intervention with greater precision, and could be a viable solution for teleoperated neurointerventional procedures. OBJECTIVE To determine the indication, robotic systems used, efficacy, safety, and the degree of manual assistance required for robotically performed neurointervention. METHODS We conducted a systematic review of the literature up to, and including, articles published on April 12, 2021. Medline, PubMed, Embase, and Cochrane register databases were searched using medical subject heading terms to identify reports of robotically performed neurointervention, including diagnostic cerebral angiography and carotid artery intervention. RESULTS A total of 8 articles treating 81 patients were included. Only one case report used a robotic system for intracranial intervention, the remaining indications being cerebral angiography and carotid artery intervention. Only one study performed a comparison of robotic and manual procedures. Across all studies, the technical success rate was 96% and the clinical success rate was 100%. All cases required a degree of manual assistance. No studies had clearly defined patient selection criteria, reference standards, or index tests, preventing meaningful statistical analysis. CONCLUSIONS Given the clinical success, it is plausible that robotically performed neurointerventional procedures will eventually benefit patients and reduce occupational hazards for staff; however, there is no high-level efficacy and safety evidence to support this assertion. Limitations of current robotic systems and the challenges that must be overcome to realize the potential for remote teleoperated neurointervention require further investigation.
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Affiliation(s)
- William Crinnion
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
- NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Ben Jackson
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Avnish Sood
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Jeremy Lynch
- Department of Neuroradiology, King's College Hospital NHS Foundation Trust, London, UK
| | - Christos Bergeles
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Hongbin Liu
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Kawal Rhode
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Vitor Mendes Pereira
- Division of Neuroradiology, Department of Medical Imaging and Division of Neurosurgery, Department of Surgery, University Health Network - Toronto Western Hospital, Toronto, Ontario, Canada
| | - Thomas C Booth
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
- Department of Neuroradiology, King's College Hospital NHS Foundation Trust, London, UK
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Han M, Qin Y, Tong X, Ji L, Zhao S, Liu L, Chen J, Liu A. Cost-effective analysis of mechanical thrombectomy alone in the treatment of acute ischaemic stroke: a Markov modelling study. BMJ Open 2022; 12:e059098. [PMID: 35387833 PMCID: PMC8987747 DOI: 10.1136/bmjopen-2021-059098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Recently, a randomised controlled trial (DIRECT-MT) demonstrated that mechanical thrombectomy (MT) was non-inferior to MT with intravenous alteplase as to the functional outcomes. This study aims to investigate whether MT alone is cost-effective compared with MT with alteplase in China. METHODS A Markov decision analytic model was built from the Chinese healthcare perspective using a lifetime horizon. Probabilities, costs and outcomes data were obtained from the DIRECT-MT trial and other most recent/comprehensive literature. Base case calculation was conducted to compare the costs and effectiveness between MT alone and MT with alteplase. One-way and probabilistic sensitivity analyses were performed to evaluate the robustness of the results. RESULTS MT alone had a lower cost and higher effectiveness compared with MT with alteplase. The probabilistic sensitivity analysis demonstrated that, over a lifetime horizon, MT alone had a 99.5% probability of being cost-effective under the willingness-to-pay threshold of 1× gross domestic product per capita in China based on data obtained from the DIRECT-MT trial. These results remained robust under one-way sensitivity analysis. CONCLUSIONS MT alone was cost-effective compared with MT with alteplase in China. However, cautions are needed to extend this conclusion to regions outside of China.
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Affiliation(s)
- Mingyang Han
- Department of Neurosurgery, Central South University Third Xiangya Hospital, Changsha, Hunan, China
| | - Yongkai Qin
- Department of Neurosurgery, Central South University Third Xiangya Hospital, Changsha, Hunan, China
| | - Xin Tong
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, 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
| | - Lang Liu
- Department of Neurosurgery, Central South University Third Xiangya Hospital, Changsha, Hunan, China
| | - Jigang Chen
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Aihua Liu
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
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Haranhalli N, Fortunel A, Javed K, Zampolin R, Brook A, Liberman A, Lee SK, Altschul D, Schechter C. Cost-effective analysis of mechanical thrombectomy (MT) in patients with poor baseline modified Rankin Score (mRS). J Clin Neurosci 2022; 99:94-98. [PMID: 35278935 DOI: 10.1016/j.jocn.2022.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 02/11/2022] [Accepted: 03/02/2022] [Indexed: 11/25/2022]
Abstract
Mechanical thrombectomy (MT) has been established as a standard of care for patients with acute ischemic stroke for the past five years. However, the direct benefits of this treatment in patients with baseline disability remains unclear. This study aims to elucidate the cost impact of performing MT on patients with moderate-to-severe baseline disability to work towards an optimized system of care for acute ischemic stroke. We developed a Markov economic model with a life-time horizon analysis of costs associated with mechanical thrombectomy in patients grouped on baseline disability as defined by modified Rankin Score. Our clinical and economic data is based on an American payer perspective. Our results identified a marginal cost-effective ratio (mCER) of $18,835.00 per quality-adjusted life year (QALY) when mechanical thrombectomy is reserved as a treatment only for patients with no-to-minimal baseline disability as compared to those with any level of baseline disability. Our results provide a framework for these future studies and highlight key sectors that drive cost in the surgical treatment and life-long care of patients with acute ischemic stroke.
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Affiliation(s)
- Neil Haranhalli
- Department of Neurosurgery, Montefiore Medical Center, Bronx, NY, USA.
| | - Adisson Fortunel
- Department of Neurosurgery, Montefiore Medical Center, Bronx, NY, USA
| | - Kainaat Javed
- Department of Neurosurgery, Montefiore Medical Center, Bronx, NY, USA
| | - Richard Zampolin
- Department of Radiology, Montefiore Medical Center, Bronx, NY, USA
| | - Allan Brook
- Department of Radiology, Montefiore Medical Center, Bronx, NY, USA
| | - Ava Liberman
- Department of Neurology, Montefiore Medical Center, Bronx, NY, USA
| | - Seon-Kyu Lee
- Department of Radiology, Montefiore Medical Center, Bronx, NY, USA
| | - David Altschul
- Department of Radiology, Montefiore Medical Center, Bronx, NY, USA
| | - Clyde Schechter
- Departments of Family and Social Medicine and Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
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Gao L, Bivard A, Parsons M, Spratt NJ, Levi C, Butcher K, Kleinig T, Yan B, Dong Q, Cheng X, Lou M, Yin C, Chen C, Wang P, Lin L, Choi P, Miteff F, Moodie M. Real-World Cost-Effectiveness of Late Time Window Thrombectomy for Patients With Ischemic Stroke. Front Neurol 2022; 12:780894. [PMID: 34970213 PMCID: PMC8712752 DOI: 10.3389/fneur.2021.780894] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 10/26/2021] [Indexed: 11/13/2022] Open
Abstract
Background: To compare the cost-effectiveness of providing endovascular thrombectomy (EVT) for patients with ischemic stroke in the >4.5 h time window between patient groups who met and did not meet the perfusion imaging trial criteria. Methods: A discrete event simulation (DES) model was developed to simulate the long-term outcome post EVT in patients meeting or not meeting the extended time window clinical trial perfusion imaging criteria at presentation, vs. medical treatment alone (including intravenous thrombolysis). The effectiveness of thrombectomy in patients meeting the landmark trial criteria (DEFUSE 3 and DAWN) was derived from a prospective cohort study of Australian patients who received EVT for ischemic stroke, between 2015 and 2019, in the extended time window (>4.5 h). Results: Endovascular thrombectomy was shown to be a cost-effective treatment for patients satisfying the clinical trial criteria in our prospective cohort [incremental cost-effectiveness ratio (ICER) of $11,608/quality-adjusted life year (QALY) for DEFUSE 3-postive or $34,416/QALY for DAWN-positive]. However, offering EVT to patients outside of clinical trial criteria was associated with reduced benefit (−1.02 QALY for DEFUSE 3; −1.43 QALY for DAWN) and higher long-term patient costs ($8,955 for DEFUSE 3; $9,271 for DAWN), thereby making it unlikely to be cost-effective in Australia. Conclusions: Treating patients not meeting the DAWN or DEFUSE 3 clinical trial criteria in the extended time window for EVT was associated with less gain in QALYs and higher cost. Caution should be exercised when considering this procedure for patients not satisfying the trial perfusion imaging criteria for EVT.
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Affiliation(s)
- Lan Gao
- Deakin Health Economics, Institute for Health Transformation, Deakin University, Geelong, VIC, Australia
| | - Andrew Bivard
- Melbourne Brain Centre, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Mark Parsons
- Melbourne Brain Centre, Royal Melbourne Hospital, Parkville, VIC, Australia.,Departments of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, NSW, Australia.,Department of Neurology, UNSW South Western Clinical School, Liverpool Hospital, University of New South Wales, Kensington, NSW, Australia
| | - Neil J Spratt
- Departments of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, NSW, Australia
| | - Christopher Levi
- Departments of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, NSW, Australia
| | - Kenneth Butcher
- Department of Neurology, Prince of Wales Hospital, University of New South Wales, Sydney, NSW, Australia
| | - Timothy Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Bernard Yan
- Melbourne Brain Centre, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Qiang Dong
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xin Cheng
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Min Lou
- Department of Neurology, Second Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Congguo Yin
- Department of Neurology, Hangzhou First Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chushuang Chen
- Departments of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, NSW, Australia
| | - Peng Wang
- Zhejiang Provincial People's Hospital, Zhejiang, China
| | - Longting Lin
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
| | - Philip Choi
- Department of Neurology, Box Hill Hospital, Eastern Health, Box Hill, VIC, Australia
| | - Ferdinand Miteff
- Departments of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, NSW, Australia
| | - Marj Moodie
- Deakin Health Economics, Institute for Health Transformation, Deakin University, Geelong, VIC, Australia
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7
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Hendrix P, Chaudhary D, Avula V, Abedi V, Zand R, Noto A, Melamed I, Goren O, Schirmer CM, Griessenauer CJ. Outcomes of Mechanical Thrombectomy in the Early (<6-hour) and Extended (≥6-hour) Time Window Based Solely on Noncontrast CT and CT Angiography: A Propensity Score-Matched Cohort Study. AJNR Am J Neuroradiol 2021; 42:1979-1985. [PMID: 34556475 DOI: 10.3174/ajnr.a7271] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 06/29/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Current stroke care recommendations for patient selection for mechanical thrombectomy in the extended time window demand advanced imaging to determine the stroke core volume and hypoperfusion mismatch, which may not be available at every center. We aimed to determine outcomes in patients selected for mechanical thrombectomy solely on the basis of noncontrast CT and CTA in the early (<6-hour) and extended (≥6-hour) time windows. MATERIALS AND METHODS Consecutive mechanical thrombectomies performed for acute large-vessel occlusion ischemic (ICA, M1, M2) stroke between February 2016 and August 2020 were retrospectively reviewed. Eligibility was based solely on demographics and noncontrast CT (ASPECTS) and CTA, due to the limited availability of perfusion imaging during the study period. Propensity score matching was performed to compare outcomes between time windows. RESULTS Of 417 mechanical thrombectomies performed, 337 met the inclusion criteria, resulting in 205 (60.8%) and 132 (39.2%) patients in the 0- to 6- and 6- to 24-hour time windows, respectively. The ASPECTS was higher in the early time window (9; interquartile range = 8-10) than the extended time window (9; interquartile range = 7-10; P = .005). Propensity score matching yielded 112 well-matched pairs. Equal rates of TICI 2b/3 revascularization and symptomatic intracranial hemorrhage were observed. A favorable functional outcome (mRS 0-2) at 90 days was numerically more frequent in the early window (45.5% versus 33.9%, P = .091). Mortality was numerically more frequent in the early window (25.9% versus 17.0%, P = .096). CONCLUSIONS Patients selected for mechanical thrombectomy in the extended time window solely on the basis of noncontrast CT and CTA still achieved decent rates of favorable 90-day functional outcomes, not statistically different from patients in the early time window.
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Affiliation(s)
- P Hendrix
- From the Department of Neurosurgery (P.H., I.M., O.G., C.M.S., C.J.G.).,Department of Neurosurgery (P.H.), Saarland University Hospital, Homburg, Germany
| | - D Chaudhary
- Department of Neurology (D.C., R.Z., A.N.), Geisinger Neuroscience Institute
| | - V Avula
- Department of Molecular and Functional Genomics (V. Avula, V. Abedi), Geisinger Health System, Danville, Pennsylvania
| | - V Abedi
- Department of Molecular and Functional Genomics (V. Avula, V. Abedi), Geisinger Health System, Danville, Pennsylvania.,Biocomplexity Institute (V. Abedi), Virginia Polytechnic Institute and State University, Blacksburg, Virginia
| | - R Zand
- Department of Neurology (D.C., R.Z., A.N.), Geisinger Neuroscience Institute
| | - A Noto
- Department of Neurology (D.C., R.Z., A.N.), Geisinger Neuroscience Institute
| | - I Melamed
- From the Department of Neurosurgery (P.H., I.M., O.G., C.M.S., C.J.G.)
| | - O Goren
- From the Department of Neurosurgery (P.H., I.M., O.G., C.M.S., C.J.G.)
| | - C M Schirmer
- From the Department of Neurosurgery (P.H., I.M., O.G., C.M.S., C.J.G.).,Research Institute of Neurointervention (C.M.S., C.J.G.)
| | - C J Griessenauer
- From the Department of Neurosurgery (P.H., I.M., O.G., C.M.S., C.J.G.) .,Research Institute of Neurointervention (C.M.S., C.J.G.).,Department of Neurosurgery (C.J.G.), Christian Doppler University Hospital, Paracelsus Medical University, Salzburg, Austria
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8
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Adapting Clinical Practice of Thrombolysis for Acute Ischemic Stroke Beyond 4.5 Hours: A Review of the Literature. J Stroke Cerebrovasc Dis 2021; 30:106059. [PMID: 34464927 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106059] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 07/23/2021] [Accepted: 08/11/2021] [Indexed: 12/16/2022] Open
Abstract
Several clinical trials have demonstrated that advanced neuroimaging can select patients for recanalization therapy in an extended time window. The favorable functional outcomes and safety profile of these studies have led to the incorporation of neuroimaging in endovascular treatment guidelines, and most recently, also extended to decision making on thrombolysis. Two randomized clinical trials have demonstrated that patients who are not amenable to endovascular thrombectomy within 4.5 hours from symptoms discovery or beyond 4.5 hours from the last-known-well time may also be safely treated with intravenous thrombolysis and have a clinical benefit above the risk of safety concerns. With the growing aging population, increased stroke incidence in the young, and the impact of evolving medical practice, healthcare and stroke systems of care need to adapt continuously to provide evidence-based care efficiently. Therefore, understanding and incorporating appropriate screening strategies is critical for the prompt recognition of potentially eligible patients for extended-window intravenous thrombolysis. Here we review the clinical trial evidence for thrombolysis for acute ischemic stroke in the extended time window and provide a review of new enrolling clinical trials that include thrombolysis intervention beyond the 4.5 hour window.
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9
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Waqas M, Gong AD, Levy BR, Dossani RH, Vakharia K, Cappuzzo JM, Becker A, Sonig A, Tutino VM, Almayman F, Davies JM, Snyder KV, Siddiqui AH, Levy EI. Is Endovascular Therapy for Stroke Cost-Effective Globally? A Systematic Review of the Literature. J Stroke Cerebrovasc Dis 2021; 30:105557. [PMID: 33556672 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105557] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 12/11/2020] [Accepted: 12/13/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Cost-effectiveness of endovascular therapy (EVT) is a key consideration for broad use of this approach for emergent large vessel occlusion stroke. We evaluated the evidence on cost-effectiveness of EVT in comparison with best medical management from a global perspective. MATERIALS AND METHODS This systematic review of studies published between January 2010 and May 2020 evaluated the cost effectiveness of EVT for patients with large vessel occlusion acute ischemic stroke. The gain in quality adjusted life year (QALY) and incremental cost-effectiveness ratio (ICER), expressed as cost per QALY resulting from EVT, were recorded. The study setting (country, economic perspective), decision model, and data sources used in economic models of EVT cost-effectiveness were recorded. RESULTS Twenty-five original studies from 12 different countries were included in our review. Five of these studies were reported from a societal perspective; 18 were reported from a healthcare system perspective. Two studies used real-world data. The time horizon varied from 1 year to a lifetime; however, 18 studies reported a time horizon of >10 years. Twenty studies reported using outcome data from randomized, controlled clinical trials for their models. Nineteen studies reported using a Markov model. Incremental QALYs ranged from 0.09-3.5. All studies but 1 reported that EVT was cost-effective. CONCLUSIONS Evidence from different countries and economic perspectives suggests that EVT for stroke treatment is cost-effective. Most cost-effectiveness studies are based on outcome data from randomized clinical trials. However, there is a need to study the cost-effectiveness of EVT based solely on real-world outcome data.
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Affiliation(s)
- Muhammad Waqas
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA.
| | - Andrew D Gong
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA.
| | - Bennett R Levy
- George Washington School of Medicine and Health Sciences, Washington, DC, USA.
| | - Rimal H Dossani
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA
| | - Kunal Vakharia
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA.
| | - Justin M Cappuzzo
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA.
| | - Alexander Becker
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA.
| | - Ashish Sonig
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA.
| | - Vincent M Tutino
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Biomedical Engineering, University at Buffalo, Buffalo, NY, USA; Department of Pathology and Anatomical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY USA.
| | - Faisal Almayman
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA.
| | - Jason M Davies
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY USA; Department of Bioinformatics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Kenneth V Snyder
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY USA.
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY USA; Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA.
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY USA; Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA.
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10
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Peultier AC, Pandya A, Sharma R, Severens JL, Redekop WK. Cost-effectiveness of Mechanical Thrombectomy More Than 6 Hours After Symptom Onset Among Patients With Acute Ischemic Stroke. JAMA Netw Open 2020; 3:e2012476. [PMID: 32840620 PMCID: PMC7448828 DOI: 10.1001/jamanetworkopen.2020.12476] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
IMPORTANCE Two 2018 randomized controlled trials (DAWN and DEFUSE 3) demonstrated the clinical benefit of mechanical thrombectomy (MT) more than 6 hours after onset in acute ischemic stroke (AIS). Health-economic evidence is needed to determine whether the short-term health benefits of late MT translate to a cost-effective option during a lifetime in the United States. OBJECTIVE To compare the cost-effectiveness of 2 strategies (MT added to standard medical care [SMC] vs SMC alone) for various subgroups of patients with AIS receiving care more than 6 hours after symptom onset. DESIGN, SETTING, AND PARTICIPANTS This economic evaluation study used the results of the DAWN and DEFUSE 3 trials to populate a cost-effectiveness model from a US health care perspective combining a decision tree and Markov trace. The DAWN and DEFUSE 3 trials enrolled 206 international patients from 2014 to 2017 and 182 US patients from 2016 to 2017, respectively. Patients were followed until 3 months after stroke. The clinical outcome at 3 months was available for 29 subgroups of patients with AIS and anterior circulation large vessel occlusions. Data analysis was conducted from July 2018 to October 2019. EXPOSURES MT with SMC in the extended treatment window vs SMC alone. MAIN OUTCOMES AND MEASURES Expected costs and quality-adjusted life-years (QALYs) during lifetime were estimated. Deterministic results (incremental costs and effectiveness, incremental cost-effectiveness ratios, and net monetary benefit) were presented, and probabilistic analyses were performed for the total populations and 27 patient subgroups. RESULTS In the DAWN study, the MT group had a mean (SD) age of 69.4 (14.1) years and 42 of 107 (39.3%) were men, and the control group had a mean (SD) age of 70.7 (13.2) years and 51 of 99 (51.5%) were men. In the DEFUSE 3 study, the MT group had a median (interquartile range) age of 70 (59-79) years, and 46 of 92 (50.0%) were men, and the control group had a median (interquartile range) age of 71 (59-80) years, and 44 of 90 (48.9%) were men. For the total trial population, incremental cost-effectiveness ratios were $662/QALY and $13 877/QALY based on the DAWN and DEFUSE 3 trials, respectively. MT with SMC beyond 6 hours had a probability greater than 99.9% of being cost-effective vs SMC alone at a willingness-to-pay threshold of $100 000/QALY. Subgroup analyses showed a wide range of probabilities for MT with SMC to be cost-effective at a willingness-to-pay threshold of $50 000/QALY, with the greatest uncertainty observed for patients with a National Institute of Health Stroke Scale score of at least 16 and for those aged 80 years or older. CONCLUSIONS AND RELEVANCE The results of this study suggest that late MT added to SMC is cost-effective in all subgroups evaluated in the DAWN and DEFUSE 3 trials, with most results being robust in probabilistic sensitivity analyses. Future MT evidence-gathering could focus on older patients and those with National Institute of Health Stroke Scale scores of 16 and greater.
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Affiliation(s)
- Anne-Claire Peultier
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Ankur Pandya
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Richa Sharma
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut
| | - Johan L. Severens
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - W. Ken Redekop
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, the Netherlands
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