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Costs and health effects of CT perfusion-based selection for endovascular thrombectomy within 6 hours of stroke onset: a model-based health economic evaluatin
Abstract
Background Although CT perfusion (CTP) is often incorporated in acute stroke workflows, it remains largely unclear what the associated costs and health implications are in the long run of CTP-based patient selection for endovascular treatment (EVT) in patients presenting within 6 hours after symptom onset with a large vessel occlusion.
Methods Patients with a large vessel occlusion were included from a Dutch nationwide cohort (n=703) if CTP imaging was performed before EVT within 6 hours after stroke onset. Simulated cost and health effects during 5 and 10 years follow-up were compared between CTP based patient selection for EVT and providing EVT to all patients. Outcome measures were the net monetary benefit at a willingness-to-pay of €80 000 per quality-adjusted life year, incremental cost-effectiveness ratio), difference in costs from a healthcare payer perspective (ΔCosts) and quality-adjusted life years (ΔQALY) per 1000 patients for 1000 model iterations as outcomes.
Results Compared with treating all patients, CTP-based selection for EVT at the optimised ischaemic core volume (ICV≥110 mL) or core-penumbra mismatch ratio (MMR≤1.4) thresholds resulted in losses of health (median ΔQALYs for ICV≥110 mL: −3.3 (IQR: −5.9 to −1.1), for MMR≤1.4: 0.0 (IQR: −1.3 to 0.0)) with median ΔCosts for ICV≥110 mL of −€348 966 (IQR: −€712 406 to −€51 158) and for MMR≤1.4 of €266 513 (IQR: €229 403 to €380 110)) per 1000 patients. Sensitivity analyses did not yield any scenarios for CTP-based selection of patients for EVT that were cost-effective for improving health, including patients aged ≥80 years
Conclusion In EVT-eligible patients presenting within 6 hours after symptom onset, excluding patients based on CTP parameters was not cost-effective and could potentially harm patients.
Data availability statement
Data are available upon reasonable request. The complete de-identified patient data sets from the MR CLEAN-NO IV, and MR CLEAN-MED trials will be available from 18 months after publication until 15 years from publication. Data can be obtained from https://www.contrast-consortium.nl/data-request-form/. The data will be made available to researchers who are CONTRAST consortium members or collaborators, and whose proposed use of the data has been approved by the CONTRAST data access and writing committee. The data will be made available for specified purposes, as defined in the substudy proposal and approved by the CONTRAST data access and writing committee. The data will be made available after approval of the proposal by the CONTRAST data access and writing committee. To ensure publication transparency and quality, researchers should adhere to the CONTRAST publication policy, accessible on https://www.contrast-consortium.nl/publication-policy-contrast/. For the patients included in the MR CLEAN Registry and the local cohort, individual patient data cannot be made available under Dutch law since we did not obtain patient approval for sharing individual patient data. All syntax files and output of statistical analyses are available on reasonable request to the corresponding author.
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