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Morsi RZ, Zhang Y, Zhu M, Xie S, Carrión-Penagos J, Desai H, Tannous E, Kothari SA, Khamis A, Darzi AJ, Tarabichi A, Bastin R, Hneiny L, Thind S, Siegler JE, Coleman ER, Mendelson SJ, Mansour A, Prabhakaran S, Kass-Hout T. Endovascular Thrombectomy with or without Bridging Thrombolysis in Acute Ischemic Stroke: A Cost-Effectiveness Analysis. Neuroepidemiology 2023; 58:47-56. [PMID: 38128500 PMCID: PMC10857025 DOI: 10.1159/000535796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 12/03/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND There is unclear added benefit of intravenous thrombolysis (IVT) with endovascular thrombectomy (EVT). We performed a cost-effectiveness analysis to assess the cost-effectiveness of comparing EVT with IVT versus EVT alone. METHODS We used a decision tree to examine the short-term costs and outcomes at 90 days after the occurrence of index stroke to compare the cost-effectiveness of EVT alone with EVT plus IVT for patients with stroke. Subsequently, we developed a Markov state transition model to assess the costs and outcomes over 1-year, 5-year, and 20-year time horizons. We estimated total and incremental cost, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio. RESULTS The average costs per patient were estimated to be $47,304, $49,510, $59,770, and $76,561 for EVT-only strategy and $55,482, $57,751, $68,314, and $85,611 for EVT with IVT over 90 days, 1 year, 5 years, and 20 years, respectively. The cost saving of EVT-only strategy was driven by the avoided medication costs of IVT (ranging from $8,178 to $9,050). The additional IVT led to a slight decrease in QALY estimate during the 90-day time horizon (loss of 0.002 QALY), but a small gain over 1-year and 5-year time horizons (0.011 and 0.0636 QALY). At a willingness-to-pay threshold of $50,000 per QALY gained, the probabilities of EVT only being cost-effective were 100%, 100%, and 99.3% over 90-day, 1-year, and 5-year time horizons. CONCLUSION Our cost-effectiveness model suggested that EVT only may be cost-effective for patients with acute ischemic stroke secondary to large vessel occlusion.
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Affiliation(s)
- Rami Z Morsi
- Department of Neurology, University of Chicago, Chicago, Illinois, USA,
| | - Yuan Zhang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Meng Zhu
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Shitong Xie
- School of Pharmaceutical Science and Technology, Tianjin University, Tianjin, China
| | | | - Harsh Desai
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Elie Tannous
- Department of Pathology, Albany Medical Center, Albany, New York, USA
| | - Sachin A Kothari
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Assem Khamis
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Andrea J Darzi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Ammar Tarabichi
- DENT Neuroimaging Center, DENT Neurologic Institute, Amherst, New York, USA
| | - Reena Bastin
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Layal Hneiny
- Wegner Health Sciences Information Center, University of South Dakota, Sioux Falls, South Dakota, USA
| | - Sonam Thind
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - James E Siegler
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | | | - Scott J Mendelson
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Ali Mansour
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Shyam Prabhakaran
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Tareq Kass-Hout
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
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Pouget AM, Costa N, Mounié M, Gombault-Datzenko E, Derumeaux H, Pagès A, Rouzaud-Laborde C, Molinier L. Mechanical Thrombectomy with Intravenous Thrombolysis versus Thrombolysis Alone for the Treatment of Stroke: A Systematic Review of Economic Evaluations. J Vasc Interv Radiol 2023; 34:1749-1759.e2. [PMID: 37331591 DOI: 10.1016/j.jvir.2023.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 05/25/2023] [Accepted: 06/08/2023] [Indexed: 06/20/2023] Open
Abstract
Mechanical thrombectomy has revolutionized the management of stroke by improving the recanalization rates and reducing deleterious consequences. It is now the standard of care despite the high financial cost. A considerable number of studies have evaluated its cost effectiveness. Therefore, this study aimed to identify economic evaluations of mechanical thrombectomy with thrombolysis compared with thrombolysis alone to provide an update of existing evidence, focusing on the period after proof of effectiveness of mechanical thrombectomy. Twenty-one studies were included in the review: 18 were model-based economic evaluations to simulate long-term outcomes and costs, and 19 were conducted in high-income countries. Incremental cost-effectiveness ratios ranged from -$5,670 to $74,216 per quality-adjusted life year. Mechanical thrombectomy is cost-effective in high-income countries and in the populations selected for clinical trials. However, most of the studies used the same data. There is a lack of real-world and long-term data to analyze the cost effectiveness of mechanical thrombectomy in treating the global burden of stroke.
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Affiliation(s)
- Alix Marie Pouget
- Health Economic Unit, Toulouse University Hospital, Toulouse, France; Department of Pharmacy, Toulouse University Hospital, Toulouse, France; French National Institute for Health and Medical Research (INSERM), Mixed Research Unit 1297 (UMR), Institute of Metabolic and Cardiac Diseases (I2MC), Toulouse III University, Toulouse, France.
| | - Nadège Costa
- Health Economic Unit, Toulouse University Hospital, Toulouse, France; French National Institute for Health and Medical Research (INSERM), Mixed Research Unit 1297 (UMR), Centre for Epidemiology and Population Health Research (for CERPOP), Toulouse III University, Toulouse, France
| | - Michael Mounié
- Health Economic Unit, Toulouse University Hospital, Toulouse, France; French National Institute for Health and Medical Research (INSERM), Mixed Research Unit 1297 (UMR), Centre for Epidemiology and Population Health Research (for CERPOP), Toulouse III University, Toulouse, France
| | - Eugénie Gombault-Datzenko
- Health Economic Unit, Toulouse University Hospital, Toulouse, France; French National Institute for Health and Medical Research (INSERM), Mixed Research Unit 1297 (UMR), Centre for Epidemiology and Population Health Research (for CERPOP), Toulouse III University, Toulouse, France
| | - Hélène Derumeaux
- Health Economic Unit, Toulouse University Hospital, Toulouse, France; French National Institute for Health and Medical Research (INSERM), Mixed Research Unit 1297 (UMR), Centre for Epidemiology and Population Health Research (for CERPOP), Toulouse III University, Toulouse, France
| | - Arnaud Pagès
- Health Economic Unit, Toulouse University Hospital, Toulouse, France
| | - Charlotte Rouzaud-Laborde
- Department of Pharmacy, Toulouse University Hospital, Toulouse, France; French National Institute for Health and Medical Research (INSERM), Mixed Research Unit 1297 (UMR), Institute of Metabolic and Cardiac Diseases (I2MC), Toulouse III University, Toulouse, France
| | - Laurent Molinier
- Health Economic Unit, Toulouse University Hospital, Toulouse, France; French National Institute for Health and Medical Research (INSERM), Mixed Research Unit 1297 (UMR), Centre for Epidemiology and Population Health Research (for CERPOP), Toulouse III University, Toulouse, France
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Ye Z, Zhou T, Zhang M, Zhou J, Xie F, Hill MD, Smith EE, Busse JW, Zhang Y, Liu Y, Wang X, Ma Z, An Z. Cost-effectiveness of endovascular thrombectomy with alteplase versus endovascular thrombectomy alone for acute ischemic stroke secondary to large vessel occlusion. CMAJ Open 2023; 11:E443-E450. [PMID: 37192770 DOI: 10.9778/cmajo.20220096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2023] Open
Abstract
BACKGROUND Recent randomized trials have suggested that endovascular thrombectomy (EVT) alone may provide similar functional outcomes as the current standard of care, EVT combined with intravenous alteplase treatment, for acute ischemic stroke secondary to large vessel occlusion. We conducted an economic evaluation of these 2 therapeutic options. METHODS We constructed a decision analytic model with a hypothetical cohort of 1000 patients to assess the cost-effectiveness of EVT with intravenous alteplase treatment versus EVT alone for acute ischemic stroke secondary to large vessel occlusion from both the societal and public health care payer perspectives. We used studies and data published in 2009-2021 for model inputs, and acquired cost data for Canada and China, representing high- and middle-income countries, respectively. We calculated incremental cost-effectiveness ratios (ICERs) using a lifetime horizon and accounted for uncertainty using 1-way and probabilistic sensitivity analyses. All costs are reported in 2021 Canadian dollars. RESULTS In Canada, the difference in quality-adjusted life-years (QALYs) gained between EVT with alteplase and EVT alone was 0.10 from both the societal and health care payer perspectives. The difference in cost was $2847 from a societal perspective and $2767 from the payer perspective. In China, the difference in QALYs gained was 0.07 from both perspectives, and the difference in cost was $1550 from the societal perspective and $1607 from the payer perspective. One-way sensitivity analyses showed that the distributions of modified Rankin Scale scores at 90 days after stroke were the most influential factor on ICERs. For Canada, compared to EVT alone, the probability that EVT with alteplase would be cost-effective at a willingness-to-pay threshold of $50 000 per QALY gained was 58.7% from a societal perspective and 58.4% from a payer perspective. The corresponding values for at a willingness-to-pay threshold of $47 185 (3 times the Chinese gross domestic product per capita in 2021) were 65.2% and 67.4%. INTERPRETATION For patients with acute ischemic stroke due to large vessel occlusion eligible for immediate treatment with both EVT alone and EVT with intravenous alteplase treatment, it is uncertain whether EVT with alteplase is cost-effective compared to EVT alone in Canada and China.
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Affiliation(s)
- Zhikang Ye
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Ting Zhou
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Mengmeng Zhang
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Junwen Zhou
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Feng Xie
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Michael D Hill
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Eric E Smith
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Jason W Busse
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Yi Zhang
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Ying Liu
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Xin Wang
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Zhuo Ma
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Zhuoling An
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont.
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Morii Y, Abiko K, Osanai T, Takami J, Tanikawa T, Fujiwara K, Houkin K, Ogasawara K. Cost-effectiveness of seven-days-per-week rehabilitation schedule for acute stroke patients. Cost Eff Resour Alloc 2023; 21:12. [PMID: 36726117 PMCID: PMC9893661 DOI: 10.1186/s12962-023-00421-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 01/23/2023] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Rehabilitation is an essential medical service for patients who have suffered acute stroke. Although the effectiveness of 7-days-per-week rehabilitation schedule has been studied in comparison with 5- or 6-days-per-week rehabilitation schedule, its cost-effectiveness has not been analyzed. In this research, to help formulate more cost-effective medical treatments for acute stroke patients, we analyzed the cost-effectiveness of 7-days-per-week rehabilitation for acute stroke from public health payer's perspective, and public healthcare and long-term care payer's perspective in Japan. METHODS Cost-effectiveness of 7-days-per-week rehabilitation for acute stroke patients was analyzed based on the result from a previous study using a Japanese database examining the efficacy of 7-days-per-week rehabilitation. Cost utility analysis was conducted by comparing 7-days-per-week rehabilitation with 5- or 6-days-per-week rehabilitation, with its main outcome incremental cost-effectiveness ratio (ICER) calculated by dividing estimated incremental medical and long-term care costs by incremental quality-adjusted life years (QALY). The costs were estimated using the Japanese fee table and from published sources. The time horizon was 5 years, and Markov modeling was used for the analysis. RESULTS The ICER was $6339/QALY from public health payer's perspective, lower than 5,000,000 Yen/QALY (approximately US$37,913), which was the willingness-to-pay used for the cost-effectiveness evaluation in Japan. The 7-day-per-week rehabilitation was dominant from public healthcare and long-term care payer's perspective. The result of sensitivity analysis confirmed the results. CONCLUSION The results indicated that 7-days-per-week rehabilitation for acute stroke rehabilitation was likely to be cost-effective.
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Affiliation(s)
- Yasuhiro Morii
- grid.415776.60000 0001 2037 6433Center for Outcomes Research and Economic Evaluation for Health, National Institute of Public Health, 2-3-6 Minami, Wako, Saitama Japan ,grid.39158.360000 0001 2173 7691Faculty of Health Sciences, Hokkaido University, N12-W5, Kita-Ku, Sapporo, Hokkaido Japan
| | - Kagari Abiko
- grid.415260.40000 0004 1769 060XDepartment of Rehabilitation Medicine, Sapporo Azabu Neurosurgical Hospital, N22-E1, Higashi-Ku, Sapporo, Hokkaido Japan ,grid.412167.70000 0004 0378 6088Department of Rehabilitation Medicine, Hokkaido University Hospital, N15-W7, Kita-Ku, Sapporo, Hokkaido Japan
| | - Toshiya Osanai
- grid.39158.360000 0001 2173 7691Department of Neurosurgery, Graduate School of Medicine, Hokkaido University, N15-W7, Kita-Ku, Sapporo, Hokkaido Japan
| | - Jiro Takami
- Department of Rehabilitation, Nishi Sapporo Hospital, 5-1, Yamanote 3-2, Nishi-Ku, Sapporo, Hokkaido Japan
| | - Takumi Tanikawa
- grid.39158.360000 0001 2173 7691Faculty of Health Sciences, Hokkaido University, N12-W5, Kita-Ku, Sapporo, Hokkaido Japan ,grid.444700.30000 0001 2176 3638Faculty of Health Sciences, Hokkaido University of Science, 4-1, Maeda 7-15, Teine-Ku, Sapporo, Hokkaido Japan
| | - Kensuke Fujiwara
- grid.39158.360000 0001 2173 7691Faculty of Health Sciences, Hokkaido University, N12-W5, Kita-Ku, Sapporo, Hokkaido Japan ,grid.444620.00000 0001 0666 3591Graduate School of Commerce, Otaru University of Commerce, 5-21, Midori 3, Otaru, Hokkaido Japan
| | - Kiyohiro Houkin
- grid.39158.360000 0001 2173 7691Department of Neurosurgery, Graduate School of Medicine, Hokkaido University, N15-W7, Kita-Ku, Sapporo, Hokkaido Japan
| | - Katsuhiko Ogasawara
- grid.39158.360000 0001 2173 7691Faculty of Health Sciences, Hokkaido University, N12-W5, Kita-Ku, Sapporo, Hokkaido Japan
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Oliveira AJF, Viana SMN, Santos AS. Mechanical thromb ectomy for acute ischemic stroke: systematic review and meta-analysis. einstein (São Paulo) 2022; 20:eRW6642. [PMID: 35946742 PMCID: PMC9345509 DOI: 10.31744/einstein_journal/2022rw6642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 08/26/2021] [Indexed: 11/26/2022] Open
Abstract
Objective To evaluate the safety and efficacy of mechanical thrombectomy associated with standard medical treatment compared with standard medical treatment only to treat patients with acute ischemic stroke. Methods This was a systematic review and metaanalysis of randomized controlled trials. An electronic search was performed in the following databases: MEDLINE ® /PubMed ® , Cochrane Library (Trials), LILACS/IBECS (via Biblioteca Virtual em Saúde (BVS)) and Embase. Complementary searches were also conducted. The selection of studies and data collection were done by two investigators independently. Results The final analysis included 16 publications related to 15 studies. The mechanical thrombectomy was associated to a reduction in the risk of death of all cause (16.81% versus 20.13%; relative risk of 0.85; p=0.04), improvement in the number of patients with functional independence after 90 days (45.65% versus 27.45%; relative risk of 1.65; p<0.01), and improvement in the rate of revascularization (76.2% versus 33.85%; relative risk of 2.20; p<0.01). There was no significant difference in terms of symptomatic intracranial hemorrhage (4.78% versus 3.88%; relative risk of 1.27; p=0.21). Conclusion Mechanical thrombectomy associated with standard medical treatment seem to be safe and effective to treat patients with acute ischemic stroke compared with standard medical treatment only.
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Nivelle E, Dewilde S, Peeters A, Vanhooren G, Thijs V. Thrombectomy is a cost-saving procedure up to 24 h after onset. Acta Neurol Belg 2022; 122:163-171. [PMID: 34586595 DOI: 10.1007/s13760-021-01810-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 09/16/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION AND AIM The treatment of ischemic stroke due to large-vessel occlusion has been revolutionized by mechanical thrombectomy (MT), as multiple trials have consistently shown improved functional outcomes compared to standard medical management both in the early and late time windows after symptom onset. However, MT is an interventional procedure that is more costly than best supportive care (BSC). METHODS We set out to study the cost-utility and budget impact of MT + BSC versus BSC alone for large-vessel occlusion using a combined decision tree and Markov model. The analysis was conducted from a Belgian payer perspective over a lifetime horizon, and health states were defined by the modified Rankin Scale (mRS). The treatment effect of MT + BSC combined clinical outcomes from all published early and late treatment window studies showing improved mRS after 90 days. Resource use and utilities were informed by an observational Belgian study of 569 stroke patients. Long-term mRS transitions were sourced from the Oxford Vascular study. RESULTS MT + BSC generated 1.31 additional quality-adjusted life years and resulted in cost savings of €10,216 per patient over lifetime. Deterministic sensitivity analyses demonstrated dominance of MT over a wide range of parameter inputs. In a Belgian setting, adding MT to BSC within an early time window for 1575 eligible stroke patients every year produced cost savings between €6.3 million (year 1) and €14.6 million (year 5), or a total cost saving of €56.2 million over 5 years. CONCLUSION Mechanical thrombectomy is a highly cost-effective treatment for ischemic stroke patients, providing quality-adjusted survival at lower health care cost, both when given in an early time window, as well as in a late time window.
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Affiliation(s)
| | - Sarah Dewilde
- Services in Health Economics (SHE), Brussels, Belgium
- Department of Public Health, University of Ghent, Ghent, Belgium
| | - André Peeters
- Service de Neurologie, UCL St Luc, Unité Neuro-Vasculaire, Avenue Hippocrate 10, Brussels, Belgium
| | - Geert Vanhooren
- Department of Neurology, AZ Sint-Jan Brugge-Oostende, Ruddershove 10, Bruges, Belgium
| | - Vincent Thijs
- Stroke Theme, Florey Institute of Neuroscience and Mental Health, University of Melbourne, 245 Burgundy Street, Heidelberg, VIC, Australia.
- Department of Neurology, Austin Health, 145 Studley Road, Heidelberg, VIC, Australia.
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Kuczynski AM, Vyas MV. Investing in Endovascular Thrombectomy Programs: Saving Lives, Saving Money. Can J Neurol Sci 2021;:1-6. [PMID: 34425931 DOI: 10.1017/cjn.2021.200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Thanh NX, Jeerakathil T, Stang J, Halabi ML, Mann B, Buck BH, Rempel JL, Goyal M, Demchuk AM, Valaire S, Wasylak T, Hill MD. Return on Investment in Endovascular Care: The Case of Endovascular Reperfusion Alberta. Can J Neurol Sci 2021;:1-7. [PMID: 34353400 DOI: 10.1017/cjn.2021.189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVE We examined the return on investment (ROI) from the Endovascular Reperfusion Alberta (ERA) project, a provincially funded population-wide strategy to improve access to endovascular therapy (EVT), to inform policy regarding sustainability. METHODS We calculated net benefit (NB) as benefit minus cost and ROI as benefit divided by cost. Patients treated with EVT and their controls were identified from the ESCAPE trial. Using the provincial administrative databases, their health services utilization (HSU), including inpatient, outpatient, physician, long-term care services, and prescription drugs, were compared. This benefit was then extrapolated to the number of patients receiving EVT increased in 2018 and 2019 by the ERA implementation. We used three time horizons, including short (90 days), medium (1 year), and long-term (5 years). RESULTS EVT was associated with a reduced gross HSU cost for all the three time horizons. Given the total costs of ERA were $2.04 million in 2018 ($11,860/patient) and $3.73 million in 2019 ($17,070/patient), NB per patient in 2018 (2019) was estimated at -$7,313 (-$12,524), $54,592 ($49,381), and $47,070 ($41,859) for short, medium, and long-term time horizons, respectively. Total NB for the province in 2018 (2019) were -$1.26 (-$2.74), $9.40 ($10.78), and $8.11 ($9.14) million; ROI ratios were 0.4 (0.3), 5.6 (3.9) and 5.0 (3.5). Probabilities of ERA being cost saving were 39% (31%), 97% (96%), and 94% (91%), for short, medium, and long-term time horizons, respectively. CONCLUSION The ERA program was cost saving in the medium and long-term time horizons. Results emphasized the importance of considering a broad range of HSU and long-term impact to capture the full ROI.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Sevick LK, Demchuk AM, Shuaib A, Smith EE, Rempel JL, Butcher K, Menon BK, Jeerakathil T, Kamal N, Thornton J, Williams D, Poppe AY, Roy D, Goyal M, Hill MD, Clement F; ESCAPE Trialists. A Prospective Economic Evaluation of Rapid Endovascular Therapy for Acute Ischemic Stroke. Can J Neurol Sci 2021;:1-8. [PMID: 33431075 DOI: 10.1017/cjn.2021.4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND During the Randomized Assessment of Rapid Endovascular Treatment (EVT) of Ischemic Stroke (ESCAPE) trial, patient-level micro-costing data were collected. We report a cost-effectiveness analysis of EVT, using ESCAPE trial data and Markov simulation, from a universal, single-payer system using a societal perspective over a patient's lifetime. METHODS Primary data collection alongside the ESCAPE trial provided a 3-month trial-specific, non-model, based cost per quality-adjusted life year (QALY). A Markov model utilizing ongoing lifetime costs and life expectancy from the literature was built to simulate the cost per QALY adopting a lifetime horizon. Health states were defined using the modified Rankin Scale (mRS) scores. Uncertainty was explored using scenario analysis and probabilistic sensitivity analysis. RESULTS The 3-month trial-based analysis resulted in a cost per QALY of $201,243 of EVT compared to the best standard of care. In the model-based analysis, using a societal perspective and a lifetime horizon, EVT dominated the standard of care; EVT was both more effective and less costly than the standard of care (-$91). When the time horizon was shortened to 1 year, EVT remains cost savings compared to standard of care (∼$15,376 per QALY gained with EVT). However, if the estimate of clinical effectiveness is 4% less than that demonstrated in ESCAPE, EVT is no longer cost savings compared to standard of care. CONCLUSIONS Results support the adoption of EVT as a treatment option for acute ischemic stroke, as the increase in costs associated with caring for EVT patients was recouped within the first year of stroke, and continued to provide cost savings over a patient's lifetime.Clinical Trial Registration: NCT01778335.
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Sarraj A, Pizzo E, Lobotesis K, Grotta JC, Hassan AE, Abraham MG, Blackburn S, Day AL, Dannenbaum MJ, Hicks W, Vora NA, Budzik RF, Sharrief AZ, Martin-Schild S, Sitton CW, Pujara DK, Lansberg MG, Gupta R, Albers GW, Kunz WG. Endovascular thrombectomy in patients with large core ischemic stroke: a cost-effectiveness analysis from the SELECT study. J Neurointerv Surg 2020; 13:875-882. [DOI: 10.1136/neurintsurg-2020-016766] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/16/2020] [Accepted: 10/19/2020] [Indexed: 11/04/2022]
Abstract
BackgroundIt is unknown whether endovascular thrombectomy (EVT) is cost effective in large ischemic core infarcts.MethodsIn the prospective, multicenter, cohort study of imaging selection study (SELECT), large core was defined as computed tomography (CT) ASPECTS<6 or computed tomography perfusion (CTP) ischemic core volume (rCBF<30%) ≥50 cc. A Markov model estimated costs, quality-adjusted life years (QALYs) and the incremental cost-effectiveness ratio (ICER) of EVT compared with medical management (MM) over lifetime. The willingness to pay (WTP) per QALY was set at $50 000 and $100 000 and the net monetary benefits (NMB) were calculated. Probabilistic sensitivity analysis (PSA) and cost-effectiveness acceptability curves (CEAC) for EVT were assessed in SELECT and other pivotal trials.ResultsFrom 361 patients enrolled in SELECT, 105 had large core on CT or CTP (EVT 62, MM 43). 19 (31%) EVT vs 6 (14%) MM patients achieved modified Rankin Scale (mRS) score 0–2 (OR 3.27, 95% CI 1.11 to 9.62, P=0.03) with a shift towards better mRS (cOR 2.12, 95% CI 1.05 to 4.31, P=0.04). Over the projected lifetime of patients presenting with large core, EVT led to incremental costs of $33 094 and a gain of 1.34 QALYs per patient, resulting in ICER of $24 665 per QALY. EVT has a higher NMB compared with MM at lower (EVT -$42 747, MM -$76 740) and upper (EVT $155 041, MM $57 134) WTP thresholds. PSA confirmed the results and CEAC showed 77% and 92% acceptability of EVT at the WTP of $50 000 and $100 000, respectively. EVT was associated with an increment of $29 225 in societal costs. The pivotal EVT trials (HERMES, DAWN, DEFUSE 3) were dominant in a sensitivity analysis at the same inputs, with societal cost-savings of $37 901, $86 164 and $22 501 and a gain of 1.62, 2.36 and 2.21 QALYs, respectively.ConclusionsIn a non-randomized prospective cohort study, EVT resulted in better outcomes in large core patients with higher QALYs, NMB and high cost-effectiveness acceptability rates at current WTP thresholds. Randomized trials are needed to confirm these results.Clinical trial registrationNCT02446587
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Ontario Health (Quality). Automated CT Perfusion Imaging to Aid in the Selection of Patients With Acute Ischemic Stroke for Mechanical Thrombectomy: A Health Technology Assessment. Ont Health Technol Assess Ser 2020; 20:1-87. [PMID: 33240454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Stroke is a sudden interruption in the blood supply to a part of the brain, causing loss of neurological function. It is the third leading cause of death in Canada and affects mainly older people. In the acute setting, neuroimaging is integral to stroke evaluation and decision-making. The neuroimaging results guide patient selection for mechanical thrombectomy. Using automated image processing techniques facilitates efficient review of this information and communication between centres. We conducted a health technology assessment of automated CT perfusion imaging as a tool for selecting stroke patients with anterior circulation occlusion for mechanical thrombectomy. This assessment included an evaluation of clinical effectiveness, cost-effectiveness, and the budget impact of publicly funding automated CT perfusion imaging. METHODS We performed a systematic literature search of the clinical evidence. We assessed the risk of bias of each study using QUADAS-2 or the Cochrane risk-of-bias tool, and the quality of the body of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. We performed a systematic economic literature search and approximated cost-effectiveness based on previous analyses. We also analyzed the budget impact of publicly funding automated CT perfusion imaging to evaluate people with acute ischemic stroke in Ontario. RESULTS Automated CT perfusion imaging had a sensitivity of 84% for identifying the infarct core (dead tissue that does not recover despite restoring blood flow with mechanical thrombectomy), compared with diffusion-weighted MRI imaging at 24 hours. One study reported that 7% of patients were misclassified with respect to eligibility for mechanical thrombectomy (either erroneously classified as eligible or erroneously classified non-eligible). Two randomized controlled trials (DEFUSE 3 and DAWN) demonstrated the efficacy of mechanical thrombectomy up to 24 hours after stroke onset, with patient selection guided by automated CT perfusion imaging. These data showed that a significantly higher proportion of patients in the mechanical thrombectomy group achieved functional independence compared with the standard care group (DEFUSE 3: risk ratio: 2.67 [95% confidence interval 1.60-4.48]; DAWN: adjusted rate difference: 33% [95% credible interval 21%-44%]; GRADE: Moderate).A previous health technology assessment in stroke patients presenting at 0 to 6 hours after stroke symptom onset and the results from recent randomized controlled trials for patients presenting at 6 to 24 hours informed the evaluation of cost-effectiveness. Mechanical thrombectomy informed by automated CT perfusion imaging to assess eligibility is likely to be cost-effective for patients presenting at 6 to 24 hours after stroke symptom onset. The annual budget impact of publicly funding automated CT perfusion imaging in Ontario over the next 5 years would be $1.3 million in year 1 and $0.9 million each year thereafter. Some of the costs of automated CT perfusion imaging could be offset by avoiding unnecessary patient transfers between hospitals. CONCLUSIONS Automated CT perfusion imaging has an acceptable sensitivity and specificity for detecting brain areas that have been affected by stroke. In patients selected for mechanical thrombectomy using automated CT perfusion imaging, there was significant improvement in functional independence. Mechanical thrombectomy informed by automated CT perfusion imaging is likely to be cost-effective. We estimate that publicly funding automated CT perfusion imaging in Ontario would result in additional costs of $1.3 million in year 1 and $0.9 million per year thereafter.
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Barral M, Armoiry X, Boudour S, Aulagner G, Schott AM, Turjman F, Gory B, Viprey M. Cost-effectiveness of stent-retriever thrombectomy in large vessel occlusion strokes of the anterior circulation: Analysis from the French societal perspective. Rev Neurol (Paris) 2020; 176:180-188. [DOI: 10.1016/j.neurol.2019.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 02/05/2019] [Accepted: 06/06/2019] [Indexed: 10/26/2022]
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Koto PS, Hu SX, Virani K, Simpkin WL, Christian CA, Cao H, Shankar JJS, Phillips SJ. A Cost-Utility Analysis of Endovascular Thrombectomy in a Real-World Setting. Can J Neurol Sci 2020; 47:50-60. [PMID: 31587672 DOI: 10.1017/cjn.2019.308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Endovascular thrombectomy (EVT) is efficacious for ischemic stroke caused by proximal intracranial large-vessel occlusion involving the anterior cerebral circulation. However, evidence of its cost-effectiveness, especially in a real-world setting, is limited. We assessed whether EVT ± tissue plasminogen activator (tPA) was cost-effective when compared with standard care ± tPA at our center. METHOD We identified patients treated with EVT ± tPA after the Endovascular treatment for Small Core and Anterior circulation Proximal occlusion with Emphasis on minimizing computed tomography to recanalization times trial from our prospective stroke registry from February 1, 2013 to January 31, 2017. Patients admitted before February 2013 and treated with standard care ± tPA constitute the controls. The sample size was 88. Cost-effectiveness was assessed using the net monetary benefit (NMB). Differences in average costs and quality-adjusted life years (QALYs) were estimated using the augmented inverse probability weighted estimator. We accounted for sampling and methodological uncertainty in sensitivity analyses. RESULTS Patients treated with EVT ± tPA had a net gain of 2.89 [95% confidence interval (CI): 0.93-4.99] QALYs at an additional cost of $22,200 (95% CI: -28,902-78,244) per patient compared with the standard care ± tPA group. The NMB was $122,300 (95% CI: -4777-253,133) with a 0.85 probability of being cost-effective. The expected savings to the healthcare system would amount to $321,334 per year. CONCLUSION EVT ± tPA had higher costs and higher QALYs compared with the control, and is likely to be cost-effective at a willingness-to-pay threshold of $50,000 per QALY.
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Nativel F, Detraz L, Mauduit N, Riche VP, Desal H, Grimandi G. Economic challenges of using innovative medical devices in major public health pathologies: Example of acute ischemic stroke management by mechanical thrombectomy. Rev Epidemiol Sante Publique 2019; 67:361-8. [PMID: 31662284 DOI: 10.1016/j.respe.2019.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 06/20/2019] [Accepted: 08/28/2019] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Activity-based Funding can induce financial imbalances for health institutions if innovative medical devices (MD) used to perform acts are included in Diagnosis Related Groups (DRG) tariff. To be reimbursed in addition to the DRG tariff, innovative MD must have received a favorable evaluation by the French National Authority for Health (Haute Autorité de Santé) and be registered on the positive list. The aim of this study was to evaluate the expenses and incomes generated by each scenario (before and after the reimbursement of MD), and the financial reports. This study concerned the management of ischemic stroke by mechanical thrombectomy devices, in high-volume French hospital. METHODS All patients who have had an acute ischemic stroke and admitted to the interventional neuroradiology unit between January 2016 and December 2017 were included retrospectively in this monocentric study. They were divided into four subgroups based on the severity of the DRG. The cost study was carried out using the French National Cost Study Methodology adjusted for the duration of the stays and by micro-costing on MD. RESULTS A total of 267 patients were included. Over the study period, the average cost of the hospital stay was €10,492±6364 for a refund of €9838±6749 per patient. The acts performed became profitable once the MD were registered on the positive list (€-1017±3551 vs. €560±2671; P<0.05). Despite this reimbursement, this activity remained in deficit for DRG lowest severity (level 1) patients (€-492±1244). Specific MD used for mechanical thrombectomy represented 37% of the total cost of stay. CONCLUSION The time required to evaluate MD reimbursement files is too long compared to their development. As a result, practitioners are in difficulty to be able to carry out acts according to the consensual practices of their learned societies, without causing any financial deficit of their institutions.
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Saposnik G, Menon BK, Kashani N, Wilson AT, Yoshimura S, Campbell BC, Baxter B, Rabinstein A, Turjman F, Fischer U, Ospel JM, Mitchell PJ, Sylaja PN, Cherian M, Kim B, Heo JH, Podlasek A, Almekhlafi M, Foss MM, Demchuk AM, Hill MD, Goyal M. Factors Associated With the Decision-Making on Endovascular Thrombectomy for the Management of Acute Ischemic Stroke. Stroke 2019; 50:2441-2447. [DOI: 10.1161/strokeaha.119.025631] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background and Purpose—
Little is known about the real-life factors that clinicians use in selection of patients that would receive endovascular treatment (EVT) in the real world. We sought to determine patient, practitioner, and health system factors associated with therapeutic decisions around endovascular treatment.
Methods—
We conducted a multinational cross-sectional web-based study comprising of 607 clinicians and interventionalists from 38 countries who are directly involved in acute stroke care. Participants were randomly allocated to 10 from a pool of 22 acute stroke case scenarios. Each case was classified as either Class I, Class II, or unknown evidence according to the current guidelines. We used logistic regression analysis applying weight of evidence approach. Main outcome measures were multilevel factors associated with EVT, adherence to current EVT guidelines, and practice gaps between current and ideal practice settings.
Results—
Of the 1330 invited participants, 607 (45.6%) participants completed the study (53.7% neurologists, 28.5% neurointerventional radiologists, 17.8% other clinicians). The weighed evidence approach revealed that National Institutes of Health Stroke Scale (34.9%), level of evidence (30.2%), ASPECTS (Alberta Stroke Program Early CT Score) or ischemic core volume (22.4%), patient’s age (21.6%), and clinicians’ experience in EVT use (19.3%) are the most important factors for EVT decision. Of 2208 responses that met Class I evidence for EVT, 1917 (86.8%) were in favor of EVT. In case scenarios with no available guidelines, 1070 of 1380 (77.5%) responses favored EVT. Comparison between current and ideal practice settings revealed a small practice gap (941 of 6070 responses, 15.5%).
Conclusions—
In this large multinational survey, stroke severity, guideline-based level of evidence, baseline brain imaging, patients’ age and physicians’ experience were the most relevant factors for EVT decision-making. The high agreement between responses and Class I guideline recommendations and high EVT use even when guidelines were not available reflect the real-world acceptance of EVT as standard of care in patients with disabling acute ischemic stroke.
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Affiliation(s)
- Gustavo Saposnik
- From the Division of Neurology, Department of Medicine, St. Michael’s Hospital, University of Toronto, Canada (G.S.)
| | - Bijoy K. Menon
- Department of Clinical Neurosciences, University of Calgary, Canada (B.K.M., M.A., M.M.F., A.M.D., M.D.H., M.G.)
- Department of Radiology, University of Calgary, Canada (B.K.M., N.K., A.T.W., M.A., A.M.D., M.D.H., M.G.)
| | - Nima Kashani
- Department of Radiology, University of Calgary, Canada (B.K.M., N.K., A.T.W., M.A., A.M.D., M.D.H., M.G.)
| | - Alexis T. Wilson
- Department of Radiology, University of Calgary, Canada (B.K.M., N.K., A.T.W., M.A., A.M.D., M.D.H., M.G.)
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo College of Medicine 1-1 Mukogawa-cho, Nishinomiya, Japan (S.Y.)
| | - Bruce C.V. Campbell
- Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (B.C.V.C.)
| | - Blaise Baxter
- Department of Interventional Neuroradiology, Erlanger Hospital, University of Tennessee College of Medicine, Chattanooga (B.B.)
| | | | - Francis Turjman
- Department of interventional neuroradiology at Lyon University Hospital, University of Lyon, France (F.T.)
| | - Urs Fischer
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Switzerland (U.F.)
| | - Johanna M. Ospel
- Department of Radiology, University Hospital Basel, University of Basel, Switzerland (J.M.O.)
| | - Peter J. Mitchell
- Department of Radiology, Royal Melbourne Hospital, Parkville, Victoria, Australia (P.J.M.)
| | - Pillai N. Sylaja
- Department of Neurology, Comprehensive Stroke Program, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India (P.N.S.)
| | - Mathew Cherian
- Department of Radiology, Kovai Medical Center and Hospital, Coimbatore, India (M.C.)
| | - Byungmoon Kim
- Department of Radiology, Severance stroke center, Yunsei University College of Medicine, Seoul, South Korea (B.K.)
| | - Ji-Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea (J.-H.H.)
| | - Anna Podlasek
- Department of Stroke Medicine, Southend University Hospital, United Kingdom (A.P.)
| | - Mohammed Almekhlafi
- Department of Clinical Neurosciences, University of Calgary, Canada (B.K.M., M.A., M.M.F., A.M.D., M.D.H., M.G.)
- Department of Radiology, University of Calgary, Canada (B.K.M., N.K., A.T.W., M.A., A.M.D., M.D.H., M.G.)
| | - Mona M. Foss
- Department of Clinical Neurosciences, University of Calgary, Canada (B.K.M., M.A., M.M.F., A.M.D., M.D.H., M.G.)
| | - Andrew M. Demchuk
- Department of Clinical Neurosciences, University of Calgary, Canada (B.K.M., M.A., M.M.F., A.M.D., M.D.H., M.G.)
- Department of Radiology, University of Calgary, Canada (B.K.M., N.K., A.T.W., M.A., A.M.D., M.D.H., M.G.)
| | - Michael D. Hill
- Department of Clinical Neurosciences, University of Calgary, Canada (B.K.M., M.A., M.M.F., A.M.D., M.D.H., M.G.)
- Department of Radiology, University of Calgary, Canada (B.K.M., N.K., A.T.W., M.A., A.M.D., M.D.H., M.G.)
| | - Mayank Goyal
- Department of Clinical Neurosciences, University of Calgary, Canada (B.K.M., M.A., M.M.F., A.M.D., M.D.H., M.G.)
- Department of Radiology, University of Calgary, Canada (B.K.M., N.K., A.T.W., M.A., A.M.D., M.D.H., M.G.)
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17
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Katsanos AH, Malhotra K, Goyal N, Arthur A, Schellinger PD, Köhrmann M, Krogias C, Turc G, Magoufis G, Leys D, Ahmed N, Khatri P, Goyal M, Alexandrov AV, Tsivgoulis G. Intravenous thrombolysis prior to mechanical thrombectomy in large vessel occlusions. Ann Neurol 2019; 86:395-406. [PMID: 31282044 DOI: 10.1002/ana.25544] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 07/02/2019] [Accepted: 07/05/2019] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The substantial clinical improvement in acute ischemic stroke (AIS) patients treated with mechanical thrombectomy (MT), combined with the poor response of proximal intracranial occlusions to intravenous thrombolysis (IVT), led to questions regarding the utility of bridging therapy (BT; IVT followed by MT) compared to direct mechanical thrombectomy (dMT) for AIS patients with large vessel occlusion (LVO). METHODS We aimed to investigate the comparative safety and efficacy of BT and dMT in AIS patients. We included all observational studies and post hoc analyses from randomized controlled clinical trials that provided data on the outcomes of AIS patients with LVO stratified by IVT treatment status prior to MT. RESULTS We identified 38 eligible observational studies (11,798 LVO patients, mean age = 68 years, 56% treated with BT). In unadjusted analyses, BT was associated with a higher likelihood of 3-month functional independence (odds ratio [OR] = 1.52, 95% confidence interval [CI] = 1.32-1.76), 3-month functional improvement (common OR [cOR] for 1-point decrease in modified Rankin Scale score = 1.52, 95% CI = 1.18-1.97), early neurological improvement (OR = 1.21, 95% CI = 1.83-1.76), successful recanalization (OR = 1.22, 95% CI = 1.02-1.46), and successful recanalization with ≤2 device passes (OR = 2.28, 95% CI = 1.43-3.64) compared to dMT. BT was also related to a lower likelihood of 3-month mortality (OR = 0.64, 95% CI = 0.57-0.73). In the adjusted analyses, BT was independently associated with a higher likelihood of 3-month functional independence (adjusted OR = 1.55, 95% CI = 1.26-1.91) and lower odds of 3-month mortality (adjusted OR = 0.80, 95% CI = 0.66-0.97) compared to dMT. The two groups did not differ in functional improvement (adjusted cOR = 1.24, 95% CI = 0.89-1.74) or symptomatic intracranial hemorrhage (adjusted OR = 0.87, 95% CI = 0.61-1.25). INTERPRETATION BT appears to be associated with improved functional independence without evidence for safety concerns, compared to dMT, for AIS patients with LVO. ANN NEUROL 2019;86:395-406.
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Affiliation(s)
- Aristeidis H Katsanos
- Second Department of Neurology, Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,Department of Neurology, St Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Konark Malhotra
- Department of Neurology, West Virginia University-Charleston Division, Charleston, WV
| | - Nitin Goyal
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN
| | - Adam Arthur
- Department of Neurosurgery, University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis, TN
| | - Peter D Schellinger
- Department of Neurology and Neurogeriatry, Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany
| | - Martin Köhrmann
- Department of Neurology, Essen University Hospital, Essen, Germany
| | - Christos Krogias
- Department of Neurology, St Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Guillaume Turc
- Department of Neurology, Saint Anne Hospital, Paris, France.,Paris Descartes University, Paris, France.,National Institute of Health and Medical Research U1266, Paris, France.,NeuroVasc University Hospital Department, Sorbonne Paris Cité, Paris, France
| | | | - Didier Leys
- University of Lille, National Institute of Health and Medical Research U1171, Lille University Hospital Center, Lille, France
| | - Niaz Ahmed
- Department of Neurology, Karolinska University Hospital Solna, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | | | - Mayank Goyal
- Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.,Department of Radiology, Seaman Family Magnetic Resonance Research Centre, Foothills Medical Centre, Alberta, Canada
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,Department of Neurology, University of Tennessee Health Science Center, Memphis, TN
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18
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Kamal N, Rogers E, Stang J, Mann B, Butcher KS, Rempel J, Jeerakathil T, Shuaib A, Goyal M, Menon BK, Demchuk AM, Hill MD. One-Year Healthcare Utilization for Patients That Received Endovascular Treatment Compared With Control. Stroke 2019; 50:1883-1886. [PMID: 31154945 DOI: 10.1161/strokeaha.119.024870] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Endovascular therapy has been shown to be highly efficacious based on 90-day modified Rankin Scale score. We examined actual daily healthcare utilization from stroke onset to 1 year afterward from the ESCAPE trial (Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis on Minimizing CT to Recanalization Time) and registry data. Methods- We examined patients from Alberta, Canada, that was enrolled into the ESCAPE trial and the Quality Improvement and Clinical Research registry in the 2016/2017 fiscal year. Through data linkages to several administrative data sets, the daily location of each patient was assessed in various healthcare settings. Results- A total of 286 patients were analyzed, 52 patients were in the treatment arm, and 47 patients were in the control arm of the ESCAPE trial while 187 patients received endovascular therapy as usual care (2016/2017 fiscal year). The odds of a patient being out of a healthcare setting over 1 year was significantly higher when they received endovascular therapy: 3.46 (1.68-7.30) in ESCAPE trial patients and 2.00 (1.08-3.75) in the Quality Improvement And Clinical Research patients. Conclusions- Endovascular therapy significantly reduces healthcare utilization up to 1 year after a stroke.
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Affiliation(s)
- Noreen Kamal
- From the Department of Industrial Engineering, Dalhousie University, Halifax, Nova Scotia, Canada (N.K.)
| | - Edwin Rogers
- Data Analytics, Alberta Health Services, Canada (E.R., J.S.)
| | - Jillian Stang
- Data Analytics, Alberta Health Services, Canada (E.R., J.S.)
| | - Balraj Mann
- Cardiovascular Health and Stroke, Strategic Clinical Network, Alberta Health Services, Edmonton, Canada (B.M.)
| | - Kenneth S Butcher
- Prince of Wales Clinical School, University of New South Wales, Sydney, Australia (K.S.B., T.J., A.S.).,Division of Neurology, Department of Medicine (K.S.B.), University of Alberta, Edmonton, Canada
| | - Jeremy Rempel
- Department of Radiology and Diagnostic Imaging (J.R.), University of Alberta, Edmonton, Canada
| | - Thomas Jeerakathil
- Prince of Wales Clinical School, University of New South Wales, Sydney, Australia (K.S.B., T.J., A.S.)
| | - Ashfaq Shuaib
- Prince of Wales Clinical School, University of New South Wales, Sydney, Australia (K.S.B., T.J., A.S.)
| | - Mayank Goyal
- Department of Clinical Neurosciences (M.G., B.K.M., A.M.D., M.D.H.).,Department of Radiology (M.G., B.K.M., M.D.H.).,Hotchkiss Brain Institute (M.G., B.K.M., A.M.D., M.D.H.)
| | - Bijoy K Menon
- Department of Clinical Neurosciences (M.G., B.K.M., A.M.D., M.D.H.).,Department of Radiology (M.G., B.K.M., M.D.H.).,Hotchkiss Brain Institute (M.G., B.K.M., A.M.D., M.D.H.)
| | - Andrew M Demchuk
- Department of Clinical Neurosciences (M.G., B.K.M., A.M.D., M.D.H.).,Hotchkiss Brain Institute (M.G., B.K.M., A.M.D., M.D.H.)
| | - Michael D Hill
- Department of Clinical Neurosciences (M.G., B.K.M., A.M.D., M.D.H.).,Department of Radiology (M.G., B.K.M., M.D.H.).,Hotchkiss Brain Institute (M.G., B.K.M., A.M.D., M.D.H.).,Department of Community Health Sciences (M.D.H.).,Department of Medicine, University of Calgary, Alberta, Canada (M.D.H.)
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19
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Abstract
Background Recently, two randomized controlled trials demonstrated the benefit of mechanical thrombectomy performed between 6 and 24 h in acute ischemic stroke. The current economic evidence is supporting the intervention only within 6 h, but extended thrombectomy treatment times may result in better long-term outcomes for a larger cohort of patients. Aims We compared the cost-utility of mechanical thrombectomy in addition to medical treatment versus medical treatment alone performed beyond 6 h from stroke onset in the UK National Health Service (NHS). Methods A cost-utility analysis of mechanical thrombectomy compared to medical treatment was performed using a Markov model that estimates expected costs and quality-adjusted life years (QALYs) over a 20-year time horizon. We present the results of three models using the data from the DEFUSE 3 and DAWN trials and evidence from published sources. Results Over a 20-year period, the incremental cost per QALY of mechanical thrombectomy was $1564 (£1219) when performed after 12 h from onset, $5253 (£4096) after 16 h and $3712 (£2894) after 24 h. The probabilistic sensitivity analysis demonstrated that thrombectomy had a 99.9% probability of being cost-effective at the minimum willingness to pay for a QALY commonly used in the UK. Conclusions The results of this study demonstrate that performing mechanical thrombectomy up to 24 h from acute ischemic stroke symptom onset is still cost-effective, suggesting that this intervention should be implemented by the NHS on the basis of improvement in quality of life as well as economic grounds.
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Affiliation(s)
- Elena Pizzo
- Department of Applied Health Research, University College London, London, UK
| | - Maureen Dumba
- Imaging Department, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
| | - Kyriakos Lobotesis
- Imaging Department, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
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20
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Kaboré N, Marnat G, Rouanet F, Barreau X, Verpillot E, Menegon P, Maachi I, Berge J, Sibon I, Bénard A. Cost-effectiveness analysis of mechanical thrombectomy plus tissue-type plasminogen activator compared with tissue-type plasminogen activator alone for acute ischemic stroke in France. Rev Neurol (Paris) 2019; 175:252-260. [PMID: 30642680 DOI: 10.1016/j.neurol.2018.06.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 05/29/2018] [Accepted: 06/14/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND PURPOSE Recent studies demonstrated the benefit of mechanical thrombectomy (MT) plus intravenous tissue-type plasminogen activator (IV-tPA) (MT-IV-tPA) in acute ischemic stroke. This study aimed to estimate the cost-utility of MT-IV-tPA compared with IV-tPA alone from the perspective of the French National Health Insurance. METHODS We developed a decision tree for the first 3 months after stroke onset and a Markov model until 10 years post-stroke. The health states of the Markov model were according to the modified Rankin Scale (mRS): independent (mRS=0-2), dependent (mRS=3-5), dead (mRS=6). Recurrent stroke was the fourth health stage of our model. We conducted systematic literature reviews and meta-analyses to estimate the cost and utility of each health state, and the transition probabilities between health states. A microcosting study was conducted to estimate the cost of MT. We estimated the incremental cost-effectiveness ratio of MT-IV-tPA and conducted a probabilistic analysis in order to estimate the probability that MT-IV-tPA is cost-effective compared to IV-tPA, the expected value of perfect information (EVPI), and the expected value of partial perfect information (EVPPI), given the uncertainty surrounding the value of our model's parameters. RESULTS The total mean (standard deviation (SD) cost of MT was €6708.9 (2357.0). The incremental cost-effectiveness ratio (ICER) of the strategy using IV-tPA combined to MT costs was €14,715 per QALY gained as compared to a strategy using IV-tPA alone. The probabilistic analysis showed that the probability of MT-IV-TPA being cost-effective was 85.4% at threshold willingness-to-pay of €30,000 per QALY gained, reaching 98% at €50,000 per QALY gained. CONCLUSION Although there is no universally accepted willingness-to-pay threshold in France, our analysis suggest that MT combined to IV-tPA can be considered a cost-effective treatment compared with IV-tPA alone.
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Affiliation(s)
- N Kaboré
- Pôle de santé publique, service d'information médicale, USMR & CIC-EC 14-01, CHU de Bordeaux, 33000 Bordeaux, France; Inserm, Bordeaux Population Health Research Center, team EMOS, UMR 1219, université Bordeaux, 33000 Bordeaux, France
| | - G Marnat
- Pôle imagerie médicale, service de radiologie et de neuro-imagerie diagnostique et thérapeutique, CHU de Bordeaux, 33000 Bordeaux, France
| | - F Rouanet
- Pôle neurosciences cliniques, unité neurovasculaire, CHU de Bordeaux, 33000 Bordeaux, France
| | - X Barreau
- Pôle imagerie médicale, service de radiologie et de neuro-imagerie diagnostique et thérapeutique, CHU de Bordeaux, 33000 Bordeaux, France
| | - E Verpillot
- Inserm, Bordeaux Population Health Research Center, team EMOS, UMR 1219, université Bordeaux, 33000 Bordeaux, France
| | - P Menegon
- Pôle imagerie médicale, service de radiologie et de neuro-imagerie diagnostique et thérapeutique, CHU de Bordeaux, 33000 Bordeaux, France
| | - I Maachi
- Pôle produits de santé, pharmacie clinique dispositifs médicaux, CHU de Bordeaux, 33000 Bordeaux, France
| | - J Berge
- Pôle imagerie médicale, service de radiologie et de neuro-imagerie diagnostique et thérapeutique, CHU de Bordeaux, 33000 Bordeaux, France
| | - I Sibon
- Pôle neurosciences cliniques, unité neurovasculaire, CHU de Bordeaux, 33000 Bordeaux, France; INCIA, CNRS UMR 5287, université de Bordeaux, 33000 Bordeaux, France
| | - A Bénard
- Pôle de santé publique, service d'information médicale, USMR & CIC-EC 14-01, CHU de Bordeaux, 33000 Bordeaux, France; Inserm, Bordeaux Population Health Research Center, team EMOS, UMR 1219, université Bordeaux, 33000 Bordeaux, France.
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21
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Teljeur C, Harrington P, Glynn RW, Ryan M. Acute ischaemic stroke: a systematic review of the cost-effectiveness of emergency endovascular therapy using mechanical thrombectomy. Ir J Med Sci 2018; 188:751-759. [PMID: 30536140 DOI: 10.1007/s11845-018-1946-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 12/03/2018] [Indexed: 12/15/2022]
Abstract
PURPOSE Although good evidence exists regarding the clinical effectiveness of mechanical thrombectomy for people with acute ischaemic stroke, cost-effectiveness should also be considered. The aim of this study was to systematically review the evidence of cost-effectiveness of emergency endovascular therapy using mechanical thrombectomy in the management of acute ischaemic stroke. METHODS The search was carried out in PubMed, EMBASE, Cochrane Library, and a grey literature search. Studies were included if they compared the costs and consequences of mechanical thrombectomy added to usual medical care compared to usual care alone for people with acute ischaemic stroke in the anterior and/or posterior region. Study quality was assessed using two appraisal tools tailored to economic evaluations. FINDINGS Thirteen studies were identified including twelve cost-utility analyses and one cost-benefit analysis. Studies could be dichotomised into those that evaluated first-generation (n = 4) and second-generation (n = 9) mechanical thrombectomy devices. Six studies had low applicability, six had moderate applicability, and one had high applicability to other settings. All cost-utility studies reported incremental cost-effectiveness ratios that would be considered cost-effective under typical willingness-to-pay thresholds. CONCLUSIONS If the outcomes of the trials underpinning the evidence of clinical effectiveness can be replicated, then mechanical thrombectomy is likely to be cost-effective by typical willingness-to-pay thresholds. This finding holds under the assumption that no investment is required to develop stroke centres to the standard required to provide a safe emergency endovascular service and that additional expenditure on timely patient transport is not required.
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Affiliation(s)
- Conor Teljeur
- Health Information and Quality Authority, George's Court, George's Lane, Dublin, D07 E98Y, Ireland. .,Trinity College Dublin, Dublin, Ireland.
| | - Patricia Harrington
- Health Information and Quality Authority, George's Court, George's Lane, Dublin, D07 E98Y, Ireland.,Trinity College Dublin, Dublin, Ireland
| | - Ronan W Glynn
- Health Information and Quality Authority, George's Court, George's Lane, Dublin, D07 E98Y, Ireland
| | - Máirín Ryan
- Health Information and Quality Authority, George's Court, George's Lane, Dublin, D07 E98Y, Ireland.,Trinity College Dublin, Dublin, Ireland
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Yan C, Zheng Y, Hill MD, Mann B, Jeerakathil T, Kamal N, Amlani S, Chuck AW. Health Technology Optimization Analysis: Conceptual Approach and Illustrative Application. MDM Policy Pract 2018; 3:2381468318774804. [PMID: 30288446 PMCID: PMC6157433 DOI: 10.1177/2381468318774804] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 04/06/2018] [Indexed: 01/19/2023] Open
Abstract
We present a conceptual approach to determine the optimal solution to delivering
a health technology, consistent with the objective of maximizing patient
outcomes subject to resources available to a publicly funded health system. The
article addresses two key policy questions: 1) adding system values through
appropriate planning of health services delivery and 2) considering the tradeoff
between patient outcomes and costs to the health system through appropriate use
of health technologies for conditions with time-dependent treatment outcomes. We
develop a health technology optimization framework that considers geographical
variation and searches for the best delivery method through a pairwise
comparison of all possible strategies, factoring in controlled variables
including disease epidemiology, time or distance to hospitals, available medical
services, treatment eligibility, treatment efficacy, and costs. Taking
variations of these factors into account would help support a more efficient
allocation of health resources. Drawing identified strategies together then
creates a map of optimal strategies. We apply the proposed method to a
policy-relevant health technology assessment of endovascular therapy (EVT) for
treating acute ischemic stroke. The best strategy for providing EVT relies on
the geographical location of stroke onset and the decision maker’s preference
for either patient outcomes or economic efficiency. The proposed method produced
an optimization map showing the optimal strategy for EVT delivery, which
maximizes patient outcomes while minimizing health system costs. In the
illustrative case study, there were no tradeoffs between health outcomes and
costs, meaning that the delivery strategies that were clinically optimal for
patients were also the most cost-effective. In conclusion, the health technology
optimization approach is a useful tool for informing implementation decisions
and coordinating the delivery of complex health services such as EVT.
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Affiliation(s)
- Charles Yan
- Institute of Health Economics, Edmonton, Alberta, Canada
| | - Yufei Zheng
- Institute of Health Economics, Edmonton, Alberta, Canada
| | | | - Balraj Mann
- Cardiovascular Health & Stroke SCN, Alberta Health Services, Alberta, Canada
| | | | | | - Shy Amlani
- Alberta Health Services, Edmonton, Alberta, Canada
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Trippoli S, Caccese E, Marinai C, Messori A. Value-based procurement of medical devices: Application to devices for mechanical thrombectomy in ischemic stroke. Clin Neurol Neurosurg 2018; 166:61-5. [DOI: 10.1016/j.clineuro.2018.01.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 01/11/2018] [Accepted: 01/22/2018] [Indexed: 11/19/2022]
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Pan Y, Cai X, Huo X, Zhao X, Liu L, Wang Y, Miao Z, Wang Y. Cost-effectiveness of mechanical thrombectomy within 6 hours of acute ischaemic stroke in China. BMJ Open 2018; 8:e018951. [PMID: 29472264 PMCID: PMC5855394 DOI: 10.1136/bmjopen-2017-018951] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 12/29/2017] [Accepted: 01/17/2018] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Endovascular mechanical thrombectomy is an effective but expensive therapy for acute ischaemic stroke with proximal anterior circulation occlusion. This study aimed to determine the cost-effectiveness of mechanical thrombectomy in China, which is the largest developing country. DESIGN A combination of decision tree and Markov model was developed. Outcome and cost data were derived from the published literature and claims database. The efficacy data were derived from the meta-analyses of nine trials. One-way and probabilistic sensitivity analyses were performed in order to assess the uncertainty of the results. SETTING Hospitals in China. PARTICIPANTS The patients with acute ischaemic stroke caused by proximal anterior circulation occlusion within 6 hours. INTERVENTIONS Mechanical thrombectomy within 6 hours with intravenous tissue plasminogen activator (tPA) treatment within 4.5 hours versus intravenous tPA treatment alone. OUTCOME MEASURES The benefit conferred by the treatment was assessed by estimating the cost per quality-adjusted life-year (QALY) gained in the long term (30 years). RESULTS The addition of mechanical thrombectomy to intravenous tPA treatment compared with standard treatment alone yielded a lifetime gain of 0.794 QALYs at an additional cost of CNY 50 000 (US$7700), resulting in a cost of CNY 63 010 (US$9690) per QALY gained. The probabilistic sensitivity analysis indicated that mechanical thrombectomy was cost-effective in 99.9% of the simulation runs at a willingness-to-pay threshold of CNY 125 700 (US$19 300) per QALY. CONCLUSIONS Mechanical thrombectomy for acute ischaemic stroke caused by proximal anterior circulation occlusion within 6 hours was cost-effective in China. The data may be used as a reference with regard to medical resources allocation for stroke treatment in low-income and middle-income countries as well as in the remote areas in the developed countries.
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Affiliation(s)
- Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
- Centre of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China
| | - Xueli Cai
- Department of Neurology, Lishui Hospital of Zhejiang University (the Central Hospital of Lishui), Lishui, China
| | - Xiaochuan Huo
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
- Centre of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
- Centre of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
- Centre of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
- Centre of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Zhongrong Miao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
- Centre of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
- Centre of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
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Boudour S, Barral M, Gory B, Giroudon C, Aulagner G, Schott AM, Turjman F, Viprey M, Armoiry X. A systematic review of economic evaluations on stent-retriever thrombectomy for acute ischemic stroke. J Neurol 2018; 265:1511-1520. [DOI: 10.1007/s00415-018-8760-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 01/17/2018] [Accepted: 01/18/2018] [Indexed: 10/18/2022]
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Trippoli S, Chiumente M, Messori A. Promoting the use of Markovian simulation models to study outcomes of thrombectomy after acute ischemic stroke. J Cardiovasc Med (Hagerstown) 2017; 18:777-779. [PMID: 28858948 DOI: 10.2459/jcm.0000000000000532] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Sabrina Trippoli
- aHTA Unit, ESTAR, Regional Health Service, FlorencebItalian Society for Clinical Pharmacy and Therapeutics, Milan, Italy
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Sevick LK, Ghali S, Hill MD, Danthurebandara V, Lorenzetti DL, Noseworthy T, Spackman E, Clement F. Systematic Review of the Cost and Cost-Effectiveness of Rapid Endovascular Therapy for Acute Ischemic Stroke. Stroke 2017; 48:2519-26. [DOI: 10.1161/strokeaha.117.017199] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 06/04/2017] [Accepted: 06/14/2017] [Indexed: 11/16/2022]
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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: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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
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