Absolutely useless for stroke survivor recovery. Would have been 'Recovery Analysis of Advanced Imaging in Acute Ischemic Stroke Care' if survivors had been in charge.
Cost-Consequence Analysis of Advanced Imaging in Acute Ischemic Stroke Care
Artem T. Boltyenkov1,2,3*, 
Gabriela Martinez1,2,3, 
Ankur Pandya4, Jeffrey M. Katz3,5, Jason J. Wang1, 
Jason J. Naidich1,3, 
Elizabeth Rula6 and Pina C. Sanelli1,3- 1Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, NY, United States
- 2Siemens Healthcare, Malvern, PA, United States
- 3Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Hempstead, NY, United States
- 4Department of Health Policy and Management, School of Public Health, Harvard University, Boston, MA, United States
- 5Department of Neurology, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Hempstead, NY, United States
- 6Harvey L. Neiman Health Policy Institute, Reston, VA, United States
Introduction: The purpose of this study was to illustrate the potential costs and health consequences of implementing advanced CT angiography and perfusion (CTAP) as the initial imaging in patients presenting with acute ischemic stroke (AIS) symptoms at a comprehensive stroke center (CSC).
Methods: A decision-simulation model based on the American Heart Association's recommendations for AIS care pathways was developed to assess imaging strategies for a 5-year period from the institutional perspective. The following strategies were compared: (1) advanced CTAP imaging: NCCT + CTA + CT perfusion at the time of presentation; (2) standard-of-care: non-contrast CT (NCCT) at the time of presentation, with CT angiography (CTA) ± CT perfusion only in select patients (initial imaging to exclude hemorrhage and extensive ischemia) for mechanical thrombectomy (MT) evaluation. Model parameters were defined with evidence-based data. Cost-consequence and sensitivity analyses were performed. The modified Rankin Scale (mRS) at 90 days was used as the outcome measure.
Results: The decision-simulation modeling revealed that adoption of the advanced CTAP imaging increased per-patient imaging costs by 1.19% ($9.28/$779.72), increased per-patient treatment costs by 33.25% ($729.96/$2,195.24), and decreased other per-patient acute care costs by 0.7% (–$114.12/$16,285.85). The large increase in treatment costs was caused by higher proportion of patients being treated. However, improved outcomes lowered the other per-patient acute care costs. Over the five-year period, advanced CTAP imaging led to 1.63% (66/4,040) more patients with good outcomes (90-day mRS 0-2), 2.23% (66/2,960) fewer patients with poor outcomes (90-day mRS 3-5), and no change in mortality (90-day mRS 6). Our CT equipment utilization analysis showed that the demand for CT equipment in terms of scanner time (minutes) was 24% lower in the advanced CTAP imaging strategy compared to the standard-of-care strategy. The number of EVT procedures performed at the CSC may increase by 50%.
Conclusions: Our study reveals that adoption of advanced CTAP imaging at presentation increases the demand for treatment of acute ischemic stroke patients as more patients are diagnosed within the treatment time window compared to standard-of-care imaging. Advanced imaging also leads to more patients with good functional outcomes and fewer patients with dependent functional status.
Introduction
Stroke is one of the leading causes of morbidity and mortality in the United States. Imaging has been reported as the second largest and the fastest growing component of stroke care costs (1). The increased utilization of advanced imaging, such as angiography and perfusion using CT (CTAP) or MRI (MRAP), has been implicated as a contributing factor in the rising trend in stroke imaging costs (1).
Current guidelines endorsed by the American Heart Association (AHA) (2) state that in most patients, non-contrast CT (NCCT) imaging may be enough to obtain the necessary information for immediate stroke triage decisions. The guidelines emphasize that utilization of advanced imaging with angiography and perfusion should not delay treatment. The current standard-of-care practice is to perform NCCT at the time of initial presentation to determine if the patient is eligible for intravenous-thrombolytic therapy (IV-tPA). Advanced imaging such as CTAP or MRAP are utilized in patients who are otherwise eligible for endovascular therapy (EVT) (3, 4). With additional information from angiography and perfusion imaging, particularly regarding large vessel occlusion and the extent of brain infarction vs. salvageable brain tissue, patients may be better triaged for treatment with IV-tPA (3–5) and/or EVT at the time of initial presentation (6–8). Numerous studies have demonstrated that faster time-to-treatment from the acute stroke onset is associated with better clinical outcomes and functional independence (9–15). However, this relationship is non-linear. Therefore, even small efficiency improvements in the pre-treatment pathway, like the immediate performance of advanced imaging upon patient arrival to the emergency department (ED), may have a significant impact on the clinical outcomes of acute stroke patients. This is especially true for those with large vessel occlusion, who without treatment, or with delayed treatment, have the highest morbidity and mortality (16). Thus, some healthcare institutions have started to perform CTAP as the initial imaging strategy in all patients suspected of acute ischemic stroke at presentation to prevent delays in treatment (8).
Advanced CTAP imaging in acute ischemic stroke patients was shown to be cost-effective in prior work (17). In that study, the cost-effectiveness analysis was performed from a health care perspective. Institutions considering whether to adopt advanced CTAP imaging need to understand the costs and health consequences of this decision for their institution. In this research we look at the adoption of the advanced CTAP imaging from the institutional perspective, while using the many of the input parameters, assumptions and conclusions from the prior cost-effectiveness analysis (17).
The purpose of this study was to investigate the potential cost and health consequences of implementing CTAP at the time of initial presentation in the workflow of suspected acute ischemic stroke (AIS) patients, excluding stroke mimics, presenting to a comprehensive stroke center (CSC) within 24 h from symptom onset time (SOT) with National Institutes of Health Stroke Scale (NIHSS) score higher than or equal to 6, compared to the standard-of-care imaging strategy using advanced imaging only in select patients who may be eligible for EVT and return to the scanner for the additional imaging.
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