Cost-effectiveness of an enhanced Paramedic Acute Stroke Treatment Assessment (PASTA) during emergency stroke care: Economic results from a pragmatic cluster randomized trial

Oh fuck, the stupidity of it all. 'COST' NOT RESULTS OR ANYTHING USEFUL TO SURVIVORS. That is where the stroke medical world is at, not solving stroke, concerned about cost. FUCK THEM, THEY ALL NEED TO BE FIRED!

 

Cost-effectiveness of an enhanced Paramedic Acute Stroke Treatment Assessment (PASTA) during emergency stroke care: Economic results from a pragmatic cluster randomized trial

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Nawaraj Bhattarai, Christopher I Price, Peter McMeekin, ...

First Published April 7, 2021 Research Article Find in PubMed 

https://doi.org/10.1177/17474930211006302

Article information

Abstract

Background

The Paramedic Acute Stroke Treatment Assessment (PASTA) trial evaluated an enhanced emergency care pathway which aimed to facilitate thrombolysis in hospital. A pre-planned health economic evaluation was included. The main results showed no statistical evidence of a difference in either thrombolysis volume (primary outcome) or 90-day dependency. However, counter-intuitive findings were observed with the intervention group showing fewer thrombolysis treatments but less dependency.

Aims

Cost-effectiveness of the PASTA intervention was examined relative to standard care.

Methods

A within trial cost-utility analysis estimated mean costs and quality-adjusted life years over 90 days’ time horizon. Costs were derived from resource utilization data for individual trial participants. Quality-adjusted life years were calculated by mapping modified Rankin scale scores to EQ-5D-3L utility tariffs. A post-hoc subgroup analysis examined cost-effectiveness when trial hospitals were divided into compliant and non-compliant with recommendations for a stroke specialist thrombolysis rota.

Results

The trial enrolled 1214 patients: 500 PASTA and 714 standard care. There was no evidence of a quality-adjusted life year difference between groups [0·007 (95% CI: −0·003 to 0·018)] but costs were lower in the PASTA group [−£1473 (95% CI: −£2736 to −£219)]. There was over 97.5% chance that the PASTA pathway would be considered cost-effective. There was no evidence of a difference in costs at seven thrombolysis rota compliant hospitals but costs at eight non-complaint hospitals costs were lower in PASTA with more dominant cost-effectiveness.

Conclusions

Analyses indicate that the PASTA pathway may be considered cost-effective, particularly if deployed in areas where stroke specialist availability is limited.

Trial Registration: ISRCTN12418919 www.isrctn.com/ISRCTN12418919

Keywords Stroke, cost-effectiveness, cluster randomized controlled trial, thrombolysis, paramedic, ambulance

Introduction

Intravenous thrombolysis for ischaemic stroke is a cost-effective treatment, but large variations in provision exist.^1,2 Previous studies have described improvements in the volume and/or speed of treatment following the introduction of ambulance pre-notification,³ multidisciplinary training⁴ and a higher priority response for suspected stroke,⁵ but none have reported the economic impact of a pre-hospital intervention intended to promote thrombolysis delivery.

The Paramedic Acute Stroke Treatment Assessment (PASTA) multicenter cluster randomized controlled trial examined whether an enhanced paramedic emergency stroke assessment pathway for patients presenting within 4 hours of stroke onset could improve thrombolysis volume (primary outcome) when compared to standard care (SC).^6,7 Secondary outcomes included dependency at day 90 after stroke (modified Rankin Score (mRS)) and resource utilization data for a pre-planned health economic analysis. The PASTA intervention comprised additional prehospital information collection, a structured hospital handover, practical assistance after handover, a pre-departure care checklist, and clinician feedback.

Although there was no statistical evidence of a difference between the trial groups for the proportion of patients who received thrombolysis (primary outcome), contrary to the anticipated effect of the intervention, less people received treatment in the PASTA group [PASTA: 197/500 (39.4%) versus SC: 319/714 (44.7%); adjusted Odds Ratio (aOR) 0·81 (95% CI: 0·61–1·08); p = 0·15].⁷ There was also no statistical evidence of a difference between the trial groups in dependency at day 90 after stroke (modified Rankin Score (mRS)) grades 3–6); however, counter-intuitive to the lower thrombolysis rate, fewer patients were dependent in the PASTA group [PASTA: 313/489 (64.0%) versus SC: 461/690 (66.8%); aOR 0.86 (95% CI: 0.60–1.20); p = 0.39]. These unexpected findings led to a post-hoc analysis to explore how stroke specialist availability impacted upon thrombolysis treatment. At 8/15 trial hospitals that were not fully compliant with a national recommendation for specialist input into all thrombolysis decisions, there was a significant 9.8% reduction in thrombolysis in the PASTA group compared to SC [99/276 (35.9%) PASTA versus 105/230 (45.7%) SC; unadjusted OR 0·67 (95% CI: 0·47–0·95); p = 0·03]. Whereas for the 7/15 hospitals that were compliant, there was no evidence of a difference in thrombolysis rates [98/224 (43.8%) PASTA vs. 214/484 (44·2%) SC; unadjusted OR 0·98 (95% CI: 0·71–1·35); p = 0·91]. We proposed a hypothesis that structured handover of additional information and/or a multidisciplinary checklist improved the selection of patients for thrombolysis, particularly in hospitals with reduced specialist availability.⁷ Cost-effectiveness results showing a similar pattern would be consistent with this theory.

Aim

This manuscript reports the pre-planned cost-effectiveness analysis of the PASTA intervention and analyses for the two post-hoc subgroups defined by local specialist availability.