Cost-Effectiveness Analysis of Early Minimally Invasive Removal of Intracerebral Hemorrhage

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Cost-Effectiveness Analysis of Early Minimally Invasive Removal of Intracerebral Hemorrhage

Janel Hanmer, MD, PhD https://orcid.org/0000-0001-6159-2482 hanmerjz@upmc.edu, Jonathan Arnold, MD, MS https://orcid.org/0000-0003-1185-555X, Alex Hall, DHSc, MS https://orcid.org/0000-0001-8532-524X, Jonathan J. Ratcliff, MD, MPH https://orcid.org/0009-0006-1274-2417, Jason W. Allen, MD, PhD https://orcid.org/0000-0002-5274-1105, Michael Frankel, MD, David W. Wright, MD, Daniel L. Barrow, MD https://orcid.org/0000-0003-0413-7883, Gustavo Pradilla, MD https://orcid.org/0000-0002-3661-3269, and Kenneth J. Smith, MD, MS for the ENRICH Trial InvestigatorsAuthor Info & Affiliations

Stroke

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https://doi.org/10.1161/STROKEAHA.124.048493

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Abstract

BACKGROUND:

Supratentorial intracerebral hemorrhage (ICH) is common and often devastating. In a randomized controlled trial, ICH evacuation with minimally invasive trans-sulcal parafascicular surgery (MIPS) improved functional outcomes at 180 days compared with medical management (MM), primarily in patients with lobar hemorrhages. The cost-effectiveness of MIPS compared with MM is explored.

METHODS:

A Markov model compared costs and outcomes using ENRICH trial (Early Minimally Invasive Removal of Intracerebral Hemorrhage) data for MIPS versus MM over the 6-month trial duration. Costs were $2020 and effectiveness was quality-adjusted life years. Monthly model transitions between modified Rankin Scale score health states were estimated from trial data. Costs were obtained from US databases and literature. MIPS device costs were $5705/patient. Primary outcomes were total hospital costs from the hospital perspective and the incremental cost-effectiveness ratio between MIPS and MM (ie, the 6-month cost difference between strategies divided by quality-adjusted life year difference) for the healthcare perspective for patients with lobar ICH. Sensitivity analyses were performed.

RESULTS:

From the hospital perspective, MIPS costs were $2782 less per patient than MM ($74 252 versus $77 034), with MIPS having decreased the intensive care unit hospital length of stay, non-MIPS neurosurgery, mortality, and rehospitalization. From the healthcare perspective, including hospital and nonhospital costs, MIPS in lobar ICH cost $8850 less and gained 0.068 quality-adjusted life year per patient compared with MM; thus MIPS was dominant (less costly and more effective). Results were robust to individual parameter variation over plausible ranges and, with all parameters varied simultaneously in a probabilistic sensitivity analysis, MIPS was dominant in >93% of 10 000 model iterations and favored in >99% at $100 000/quality-adjusted life year gained (a common US benchmark).

CONCLUSIONS:

In the ENRICH randomized controlled trial, MIPS cost less and was more effective compared with MM from both hospital and healthcare perspectives for patients with lobar ICH.

REGISTRATION:

Unique identifier: NCT02880878.

Graphical Abstract

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