Long-Term Cost-Effectiveness of Severity-Based Triaging for Large Vessel Occlusion Stroke

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Long-Term Cost-Effectiveness of Severity-Based Triaging for Large Vessel Occlusion Stroke

Lan Gao^1*†, Marj Moodie¹, Nawaf Yassi^2,3, Stephen M. Davis², Christopher F. Bladin^4,5, Karen Smith⁴, Stephen Bernard⁴, Michael Stephenson⁴, Leonid Churilov^2,6, Bruce C. V. Campbell^2,4†‡ and Henry Zhao^2,4†‡

• ¹Deakin Health Economics, Institute for Health Transformation, Faculty of Health, Deakin University, Geelong, VIC, Australia
• ²Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
• ³Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia
• ⁴Ambulance Victoria, Melbourne, VIC, Australia
• ⁵Department of Neurology, Faculty of Medicine, Nursing and Health Sciences, Eastern Health and Eastern Health Clinical School, Monash University, Melbourne, VIC, Australia
• ⁶Department of Medicine, Austin Health, University of Melbourne, Melbourne, VIC, Australia

Background and Purpose: Pre-hospital severity-based triaging using the Ambulance Clinical Triage For Acute Stroke Treatment (ACT-FAST) algorithm has been demonstrated to substantially reduce time to endovascular thrombectomy in Melbourne, Australia. We aimed to model the cost-effectiveness of an ACT-FAST bypass system from the healthcare system perspective.

Methods: A simulation model was developed to estimate the long-term costs and health benefits associated with diagnostic accuracy of the ACT-FAST algorithm. Three-month post stroke functional outcome was projected to the lifetime horizon to estimate the long-term cost-effectiveness between two strategies (ACT-FAST vs. standard care pathways). For ACT-FAST screened true positives (i.e., screened positive and eligible for EVT), a 52 mins time saving was applied unanimously to the onset to arterial time for EVT, while 10 mins delay in thrombolysis was applied for false-positive (i.e., screened positive but was ineligible for EVT) thrombolysis-eligible infarction. Quality-adjusted life year (QALY) was employed as the outcome measure to calculate the incremental cost-effectiveness ratio (ICER) between the ACT-FAST algorithm and the current standard care pathway.

Results: Over the lifetime, ACT-FAST was associated with lower costs (–$45) and greater QALY gains (0.006) compared to the current standard care pathway, resulting in it being the dominant strategy (less costly but more health benefits). Implementing ACT-FAST triaging led to higher proportion of patients received EVT procedure (30 more additional EVT performed per 10,000 patients). The total Net Monetary Benefit from ACT-FAST care estimated at A$0.76 million based on its implementation for a single year.

Conclusions: An ACT-FAST severity-triaging strategy is associated with cost-saving and increased benefits when compared to standard care pathways. Implementing ACT-FAST triaging increased the proportion of patients who received EVT procedure due to more patients arriving at EVT-capable hospitals within the 6-h time window (when imaging selection is less rigorous).

Introduction

Endovascular thrombectomy (EVT) has been increasingly offered to patients with large vessel occlusion (LVO) stroke. However, the restricted availability of EVT-capable comprehensive stroke centers (CSCs) worldwide has highlighted the importance of correctly and rapidly identifying patients who may benefit from EVT. Delayed EVT is associated with worse functional outcomes (1, 2) and multiple observational studies have linked the delay from secondary inter-hospital transfer with worse outcomes after EVT compared to direct-presenting patients.

Ambulance Clinical Triage for Acute Stroke Treatment (ACT-FAST) is a severity-based screening algorithm administered by paramedics to triage patients who would benefit from direct transfer to a CSC (3). A large real-world validation study showed that ACT-FAST had a sensitivity and specificity of 82.6 and 77.9% respectively in diagnosing LVO for patients with suspected stroke. While the ACT-FAST paramedics validation study reported the time saved from correctly bypassed patients and the avoidance of a potential delay in thrombolysis by bypassing the nearest PSC, the net impact (i.e., both correct and incorrect triaging) on patient outcomes and cost-effectiveness of ACT-FAST remain unclear.

This study aims to translate the ACT-FAST diagnostic accuracies reported in the validation study into long-term health benefits and assess the cost-effectiveness of a severity-based triaging system and estimate potential monetary savings nationally to inform the policy decision-making around its wider implementation.

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