Real-World Cost-Effectiveness of Late Time Window Thrombectomy for Patients With Ischemic Stroke

More reasons for YOU TO HAVE THE CORRECT STROKE, so your doctors can actually treat you. YOUR RESPONSIBILITY!

But the worst is researching cost rather than recovery.

Oh God, measuring cost rather than 100% recovery as a reason to do this research. The mentors and senior researchers need remedial training in patient stroke goals. THIS FUCKING STUPIDITY is why survivors need to be in charge. They would keep their eye on the only goal in stroke; 100% RECOVERY.

 

Real-World Cost-Effectiveness of Late Time Window Thrombectomy for Patients With Ischemic Stroke

 

Lan Gao^1*, Andrew Bivard², Mark Parsons^2,3,4, Neil J. Spratt³, Christopher Levi³, Kenneth Butcher⁵, Timothy Kleinig⁶, Bernard Yan², Qiang Dong⁷, Xin Cheng⁷, Min Lou⁸, Congguo Yin⁹, Chushuang Chen³, Peng Wang¹⁰, Longting Lin¹¹, Philip Choi¹², Ferdinand Miteff³ and Marj Moodie¹

• ¹Deakin Health Economics, Institute for Health Transformation, Deakin University, Geelong, VIC, Australia
• ²Melbourne Brain Centre, Royal Melbourne Hospital, Parkville, VIC, Australia
• ³Departments of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, NSW, Australia
• ⁴Department of Neurology, UNSW South Western Clinical School, Liverpool Hospital, University of New South Wales, Kensington, NSW, Australia
• ⁵Department of Neurology, Prince of Wales Hospital, University of New South Wales, Sydney, NSW, Australia
• ⁶Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
• ⁷Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
• ⁸Department of Neurology, Second Affiliated Hospital of Zhejiang University, Hangzhou, China
• ⁹Department of Neurology, Hangzhou First Hospital, Zhejiang University School of Medicine, Hangzhou, China
• ¹⁰Zhejiang Provincial People's Hospital, Zhejiang, China
• ¹¹School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
• ¹²Department of Neurology, Box Hill Hospital, Eastern Health, Box Hill, VIC, Australia

Background: To compare the cost-effectiveness of providing endovascular thrombectomy (EVT) for patients with ischemic stroke in the >4.5 h time window between patient groups who met and did not meet the perfusion imaging trial criteria.

Methods: A discrete event simulation (DES) model was developed to simulate the long-term outcome post EVT in patients meeting or not meeting the extended time window clinical trial perfusion imaging criteria at presentation, vs. medical treatment alone (including intravenous thrombolysis). The effectiveness of thrombectomy in patients meeting the landmark trial criteria (DEFUSE 3 and DAWN) was derived from a prospective cohort study of Australian patients who received EVT for ischemic stroke, between 2015 and 2019, in the extended time window (>4.5 h).

Results: Endovascular thrombectomy was shown to be a cost-effective treatment for patients satisfying the clinical trial criteria in our prospective cohort [incremental cost-effectiveness ratio (ICER) of $11,608/quality-adjusted life year (QALY) for DEFUSE 3-postive or $34,416/QALY for DAWN-positive]. However, offering EVT to patients outside of clinical trial criteria was associated with reduced benefit (−1.02 QALY for DEFUSE 3; −1.43 QALY for DAWN) and higher long-term patient costs ($8,955 for DEFUSE 3; $9,271 for DAWN), thereby making it unlikely to be cost-effective in Australia.

Conclusions: Treating patients not meeting the DAWN or DEFUSE 3 clinical trial criteria in the extended time window for EVT was associated with less gain in QALYs and higher cost. Caution should be exercised when considering this procedure for patients not satisfying the trial perfusion imaging criteria for EVT.

Introduction

Seven large clinical trials have demonstrated that endovascular thrombectomy (EVT) is highly effective in increasing disability-free survival compared to the previous standard care, intravenous thrombolysis (IVT), in strokes due to a large vessel occlusion (LVO) (1–7). Based on these foundational trials, DAWN and DEFUSE 3 trials also extended the treatment time window for patients screened with perfusion imaging to identify treatment responders from 6 h out to 24 h (8, 9). These ground-breaking trials were highly selective but demonstrated considerable patient benefits. Since its introduction as routine care in Australia, providing EVT to patients with an LVO has seen a significant amount of “scope creep,” where a large proportion of patients are now offered therapy outside of the trial criteria. Previous post-hoc analysis has shown that providing EVT to patients meeting the trial criteria is highly cost-effective within the normal and extended time window (10–16); however, it is not known if this cost-effectiveness is maintained when patients are treated outside of the trial criteria.

Patient outcomes after stroke and EVT are highly influenced by patient characteristics (17, 18), such as age, pre-morbid disability, co-morbidities, and imaging characteristics including the site of the vessel occlusion and the volume of core/penumbra (19). It is important to acknowledge that in clinical practice, which is distinct from controlled trials that are subject to strict selection criteria, the clinicians are more likely to treat patients who do not enroll into these trials, and not all these patients benefit from the treatment to the same extent, while some are even harmed due to hemorrhage, vessel perforation, or reperfusion injury. To investigate the effect of this scope creep on the likely cost of therapy, we undertook a discrete event simulation to assess the cost-effectiveness of EVT in the real world with respect to patients meeting/not meeting the clinical trial criteria, in comparison to the medical treatment alone.

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