Late mechanical thrombectomy, standard care cost-effective vs. standard care alone
For U.S. patients with acute ischemic stroke, late mechanical thrombectomy combined with standard medical care was found to be a cost-effective option compared with standard care alone, researchers reported.
For this study, published in JAMA Network Open, investigators performed an economic evaluation of standard care in combination with mechanical thrombectomy performed more than 6 hours after stroke onset using results from the DAWN and DEFUSE 3 trials. The primary outcome was expected costs and lifetime quality-adjusted life-years.
“The randomized clinical trials DAWN and DEFUSE 3 demonstrated superior functional outcomes of mechanical thrombectomy at 90 days among patients with acute ischemic stroke treated 6 to 24 hours after they were last known well,” Anne-Claire Peultier, MSc, PhD candidate at the Erasmus School of Health Policy and Management in Rotterdam, the Netherlands, and colleagues wrote. “Analyzing the magnitude of the long-term cost-effectiveness of late window mechanical thrombectomy per patient subgroup could expand the evidence and help inform allocation of critical resources. The aim of this study was to compare the cost-effectiveness of mechanical thrombectomy with standard medical care vs. standard medical care alone by patient subgroup in the late window in the United States.”
Cost-effectiveness of late treatment
The DAWN trial enrolled 206 international patients from 2014 to 2017 and DEFUSE 3 enrolled 182 U.S. patients from 2016 to 2017. Patients were followed up for 3 months after stroke.
Researchers found that mechanical thrombectomy with standard care led to greater health care costs but increased QALYs vs. standard care alone, resulting in an incremental cost-effectiveness ratio of $662 per QALY for the DAWN trial and $13,877 per QALY for DEFUSE 3.
For patients with baseline NIH Stroke Scale scores of less than 16 in the DEFUSE 3 trial, $3,555 was the minimum cost to gain 1 QALY. Among patients with a baseline score of 16 or greater, the maximum cost to gain 1 QALY was $42,635.
Based on findings from DAWN, the maximum cost to gain 1 QALY was $19,994 for patients older than 80 years.
After performing a probabilistic sensitivity analysis on data from the two trials, researchers observed that mechanical thrombectomy with standard care had a 100% or a 99.9% likelihood of being cost-effective at the willingness-to-pay threshold of $100,000 per QALY, for DAWN and DEFUSE 3, respectively.
Moreover, at a willingness-to-pay threshold of $50,000 per QALY, the probability of mechanical thrombectomy with standard care to be cost-effective was 100% for DAWN and 97.5% for DEFUSE 3 results, researchers reported.
‘Focus on increasing access’
“Given that they demonstrated the cost-effectiveness of mechanical thrombectomy across all clinical subgroups, our findings have latent policy and clinical implications,” the researchers wrote. “Acute stroke treatment guidelines and quality measures should focus on increasing access to mechanical thrombectomy for all eligible U.S. patients rather than on tailoring policies that prioritize specific subgroups. Specifically, policies are needed to improve stroke recognition and transportation to comprehensive stroke centers (providing mechanical thrombectomy) in light of the cost-effectiveness of mechanical thrombectomy, which does not depreciate significantly by stroke severity or age. Should additional mechanical thrombectomy trials be conducted, our results suggest potential value in reducing the uncertainty regarding the cost-effectiveness of mechanical thrombectomy in certain subgroups (ie, patients with NIH Stroke Scale scores of 16 or greater and those aged 80 years and older).”
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