Economic evaluation of the Melbourne Mobile Stroke Unit

What is way more fucking important is the results! How may got 100% recovered?  What in the world makes you think that stroke patients care about the cost? The mentors and senior researchers who approved this need to be fired for not including an objective on 100% recovery results. That will tell you if MSUs need to be continued, not cost. Faster treatment and reduced DALYs are NOT GOOD ENOUGH.

Economic evaluation of the Melbourne Mobile Stroke Unit 

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Joosup Kim, Damien Easton, Henry Zhao, ...

First Published June 14, 2020 Research Article

https://doi.org/10.1177/1747493020929944

Article information

Abstract

Background

The Melbourne Mobile Stroke Unit (MSU) is the first Australian service to provide prehospital acute stroke treatment, including thrombolysis and facilitated triage for endovascular thrombectomy.

Aims

To estimate the cost-effectiveness of the MSU during the first full year of operation compared with standard ambulance and hospital stroke care pathways (standard care).

Methods

The costs and benefits of the Melbourne MSU were estimated using an economic simulation model. Operational costs and service utilization data were obtained from the MSU financial and patient tracking reports. The health benefits were estimated as disability-adjusted life years (DALYs) avoided using local data on reperfusion therapy and estimates from the published literature on their effectiveness. Costs were presented in Australian dollars. The robustness of results was assessed using multivariable (model inputs varied simultaneously: 10,000 Monte Carlo iterations) and various one-way sensitivity analyses.

Results

In 2018, the MSU was dispatched to 1244 patients during 200 days of operation. Overall, 167 patients were diagnosed with acute ischemic stroke, and 58 received thrombolysis, endovascular thrombectomy, or both. We estimated 27.94 DALYs avoided with earlier access to endovascular thrombectomy (95% confidence interval (CI) 15.30 to 35.93) and 16.90 DALYs avoided with improvements in access to thrombolysis (95% CI 9.05 to 24.68). The MSU was estimated to cost an additional $30,982 per DALY avoided (95% CI $21,142 to $47,517) compared to standard care.

Conclusions

There is evidence that the introduction of MSU is cost-effective when compared with standard care due to earlier provision of reperfusion therapies.

Keywords Economic evaluation, mobile stroke unit, prehospital stroke treatment

Introduction

For patients with suspected stroke, early assessment and diagnosis are essential to ensure that appropriate interventions are provided in a timely and safe manner. In patients with ischemic stroke, thrombolysis and endovascular thrombectomy (EVT) are recommended within defined time windows,¹ and are more effective the earlier they are provided.^2,3 In particular, the first 60 minutes after stroke onset (termed “the Golden Hour”) is the target window in which treatment can most effectively modify the disease course and reduce the risk of disability or death.⁴ However, many patients do not arrive early enough to hospital after stroke to be eligible for treatment. For example, only 37% of patients in Australia with ischemic stroke arrive at hospital within the 4.5 hour time window for thrombolysis.⁵
The next frontier in stroke care is to bring rapid treatment ???directly to the patient, using mobile stroke units (MSUs) carrying portable computed tomography (CT) scans to enable prehospital imaging(I'm sorry but even this mobile unit is way too fucking slow to really do any good. See all my posts on fast diagnosis.). This allows immediate treatment decisions to be made to reduce time to treatment with thrombolysis. In addition, clinically informed triage can occur with identification of patients with large vessel occlusion, enabling rapid transport to the closest EVT capable hospital. In a standard care pathway, assessment for reperfusion therapy can only be made after arrival at hospital and onward inter-hospital transfer may be needed for specialized treatments including EVT and neurosurgery.
Despite the relative novelty of this model of care and limited uptake around the world to date, the clinical effectiveness of MSUs for improving stroke management has been reported for several countries.⁶ The economic implications of this type of prehospital model of care remain largely unknown, with evidence of cost-effectiveness available from two evaluations conducted in Germany and one in the United States of America.^7–9 However, these studies occurred prior to the development of EVT and there is a need to establish cost-effectiveness in a number of different geographical settings.

Aim

To provide an estimate of the cost-effectiveness of the first MSU in Australia in its initial full calendar of year of operation, when compared to standard ambulance and hospital stroke care pathways.

Methods

In November 2017, the first Australian MSU with CT angiography capability was launched in Melbourne. Following a brief pilot phase, the MSU followed standard procedures from 1 January 2018. The Melbourne MSU was staffed by two paramedics, a CT radiographer, a stroke neurologist, and a stroke nurse specialist, and was typically dispatched within a 20 km radius of the Royal Melbourne Hospital between 8 a.m. and 6 p.m. on weekdays, excluding public holidays and days when vehicle maintenance was required. As is typical with other MSUs, the Melbourne MSU is dual-dispatched alongside a standard ambulance (selected by availability and proximity to the case from the standard ambulance fleet based in Melbourne) to suspected stroke cases or activated by request from an attending paramedic crew.¹⁰
In almost all cases, the standard ambulance is able to arrive on scene before the MSU, allowing for primary assessment of the patient and MSU cancellation as required. Among the cases the MSU attends, only those who receive prehospital stroke treatment are transported to hospital by the MSU. Other patients who are not deemed suitable for immediate treatment are handed back over to the paramedics who first arrived on scene. This allows the MSU to be available for the next dispatch.
The MSU pre-notifies all receiving destination hospitals of assessed cases and may recommend a downgrade of transport urgency to hospital in cases of non-stroke or ineligibility for reperfusion therapies. Data for all MSU dispatched cases were collected prospectively in the Melbourne MSU data registry, including all time metrics relating to dispatch, arrival, and treatment. The Melbourne Mobile Stroke Unit evaluation was approved by Melbourne Health Human Research Ethics Committee (HREC/17/MH/375).
The costs and benefits of the Melbourne MSU were estimated by authors JK and DAC using an economic simulation model. Model inputs were derived from a range of sources described in the following sections and the online supplement. Where required, assumptions for the model were agreed with the program leads/senior operational staff. Costs are presented in Australian dollars (AUD) for 2018 (purchasing power parity conversion to 2018 $US: 1.432694).¹¹ The potential cost-effectiveness of the MSU was determined by comparing the estimated costs and benefits incurred by the 2018 cohort treated in the MSU to a counterfactual (hypothetical) scenario where this cohort would have received standard care. Standard care was defined as the usual management of patients with suspected stroke assessed by standard ambulances with subsequent transport to the nearest ED for hospital management. Within Australia, most EDs will initiate a “code stroke” following triage (if suspected stroke identified/confirmed) whereby the stroke service team is notified to assess and treat a patient, including thrombolysis and EVT.
Research materials related to this manuscript can be accessed with approval from the corresponding author.