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Intra-arterial treatment likely cost-effective for acute ischemic stroke
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Treatment with intra-arterial therapy after IV tissue-type plasminogen activator in patients with acute ischemic stroke appears cost-effective, according to an analysis published in Stroke.
Recent randomized controlled trials, including MR CLEAN, ESCAPE, EXTEND-IA and SWIFT PRIME, have demonstrated that intra-arterial therapy with the latest generation of endovascular thrombectomy devices is associated with dramatically improved outcomes in patients with severe acute ischemic stroke. The researchers undertook an analysis to determine whether the therapy also was cost-effective.
They developed a decision analytic model estimating the lifetime costs and outcomes associated with the additional benefit of intra-arterial therapy administered within 0 to 6 hours of stroke onset compared with IV tissue-type plasminogen activator (tPA) administered within 0 to 4.5 hours of onset alone. The model incorporated data from published literature, the MR CLEAN study and U.S. claims databases.
Michelle H. Leppert, MD, MBA, and colleagues measured outcomes in quality-adjusted life-years (QALYs) and assessed the treatment benefit by calculating the cost per QALY gained, with the threshold for cost-effectiveness defined as $50,000 or less per QALY.
Leppert, from the department of neurology at the University of Colorado, Aurora, and colleagues determined that the addition of intra-arterial therapy to IV tPA administration yielded a lifetime gain of 0.7 QALY and cost an additional $9,911, for a cost of $14,137 per QALY.
When the researchers ran simulations, multiway probabilistic sensitivity analysis predicted cost-effectiveness (≤ $50,000 per QALY) 97.6% of the time.
“[Intra-arterial therapy] is likely cost-effective for patients with anterior circulation strokes and proximal occlusion within the 6-hour window in addition to standard medical therapy,” Leppert and colleagues wrote. “From a societal perspective, we will have to start changing the mindset behind stroke care. Providers can no longer stop at administrating [IV] tPA, but patients with suspected anterior infarcts must also have vessel imaging to see whether they would be a candidate for [intra-arterial therapy]. Furthermore, it will involve widening the network of comprehensive stroke centers so that patients meeting the criteria can have prompt access to [intra-arterial therapy].” – by Erik Swain
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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Larry B. Goldstein, MD, FAAN, FANA, FAHA
This is a very reasonable analysis that supports the cost-effectiveness of endovascular thrombectomy for a specific subset of patients with anterior circulation ischemic stroke related to a proximal occlusion who can be treated soon after symptom onset. Although sensitivity analysis was performed, the underlying assumption is that clinical benefit found in clinical trials will be similar in routine practice. Based on an exploratory analysis of data from MR CLEAN, as with intravenous tPA, the magnitude of the benefit with endovascular thrombectomy diminishes over time after the onset of symptoms and loses statistical significance after about 6 hours. Therefore, the clinical and cost-effectiveness of the strategy in routine practice will depend on careful patient selection (including the exclusion of patients unlikely to benefit based on the extent of the ischemic core reflected in standardized radiological assessments, ie, ASPECTS score), very prompt intervention, and treatment by a skilled team of appropriately trained neuro-interventionalists and medical staff, with the patient cared for in multidisciplinary, stroke unit-type settings. The clinical benefit and therefore cost-effectiveness would likely diminish or be lost if these tenets — especially very rapid revascularization — are compromised. As the authors point out, the study does not account for some important factors, including infrastructure, service redesign, and specialist training. Given that the benefit of treatment is time-sensitive and that not every hospital will be able to afford to provide these services, determining the optimal distribution of resources to support widespread adoption that accounts for the likely low patient volume in rural areas will not be trivial.
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