Cost-effectiveness of targeted thrombolytic therapy for stroke patients using multi-modal CT compared to usual practice

Cost-Effectiveness of Constraint-Induced Movement Therapy Implementation in Neurorehabilitation: The ACTIveARM Project

BACKGROUND

Constraint-induced movement therapy (CIMT) is a recommended intervention for improving arm recovery following stroke and traumatic brain injury; however, delivery in practice remains rare.

PURPOSE

The aim of this study was to investigate the costs and cost effectiveness of CIMT delivery, and the use of a CIMT implementation package designed to improve CIMT uptake and delivery by therapists in Sydney, Australia.

METHODS

This economic evaluation was conducted with a subset of CIMT programmes (n = 20) delivered by neurological rehabilitation teams at five varied hospitals within a mixed methods implementation study (ACTIveARM). The costs of delivering the CIMT implementation package and publicly funded CIMT were calculated using a bottom-up approach. A cost-effectiveness analysis was conducted, using decision analytic modelling. We compared the uptake and outcomes of people who received CIMT from health services that had received a CIMT implementation package, with those receiving standard upper limb therapy. An Australian health care system perspective was used in the model, over a 3-week time horizon (the average timeframe of a CIMT programme). All costs were calculated in Australian dollars (AUD). Inputs were derived from the ACTIveARM study and relevant literature. The Action Research Arm Test was used to measure arm outcomes. Sensitivity analyses assessed the impact of improving CIMT uptake, scale-up of the implementation package and resource adjustment, including a 'best-case' scenario analysis.

RESULTS

The total cost of delivering the implementation package to nine teams across five hospitals was $110,336.43 AUD over 18 months. The mean cost of delivering an individual CIMT programme was $1233.38 AUD per participant, and $936.03 AUD per participant for group-based programmes. The incremental cost-effectiveness ratio (ICER) of individual CIMT programmes was $8052 AUD per additional person achieving meaningful improvement in arm function, and $6045 AUD for group-based CIMT. The ICER was most sensitive to reductions in staffing costs. In the 'best-case' scenario, the ICER for both individual and group-based CIMT was $245 AUD per additional person gaining a meaningful change in function.

CONCLUSION

Therapists improved CIMT uptake and delivery with the support of an implementation package, however cost effectiveness was unclear.

CLINICAL TRIAL REGISTRATION

https://anzctr.org.au/Trial ID: ACTRN12617001147370.

Collateral status evaluation coupled with time window by dynamic axial computed tomographic angiography with a focus on the middle cerebral artery for mechanical thrombectomy

Background

Dynamic axial computed tomographic angiography (dynax–CTA), covering a thin width, with a focus on the bilateral middle cerebral artery (MCA), can quickly visualize the internal carotid artery (ICA) or MCA occlusion. We aimed to investigate whether dynax–CTA appropriately evaluated the collateral status coupled with the upper limit of the onset-to-reperfusion (OtR) time to achieve a major neurological improvement (MNI) at a 24-h follow-up examination after mechanical thrombectomy (MT).

Methods

We included acute ischemic stroke patients admitted from 2018 to 2020 who underwent dynax–CTA on admission and emergent MT for ICA or MCA occlusion. We performed dynax–CTA using an 80-row CT scanner and acquired 25 volume scans, consisting of 40 images of 1-mm thickness and 4-cm width. We classified the collateral status as good, intermediate, and poor based on MCA branch opacification. We evaluated the collateral status and the upper OtR time limit to achieve MNI.

Results

Forty-eight patients met our inclusion criteria. Dynax–CTA findings demonstrated MCA and ICA occlusion in 30 and 18 patients, respectively. The collateral status was good, intermediate, and poor in four, 25, and 19 patients, respectively. The upper limits of the OtR time for MNI were 3.63, 8.08, and 8.67 h in patients with poor, intermediate, and intermediate or good collateral status, respectively.

Conclusions

Dynax–CTA appropriately evaluated the collateral status coupled with the upper limit of the OtR time before performing MT.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-021-02284-8.