Impact of collateral flow on cost-effectiveness of endovascular thrombectomy

Mihir KhunteDepartment of Radiology and Biomedical Imaging, Yale University, New Haven, Connecticut;

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Xiao WuDepartment of Radiology and Biomedical Imaging, University of California, San Francisco, California;

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Emily W. AveryDepartment of Radiology and Biomedical Imaging, Yale University, New Haven, Connecticut;

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Dheeraj GandhiDepartment of Radiology, University of Maryland Medical Center, Baltimore, Maryland;

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Seyedmehdi PayabvashDepartment of Radiology and Biomedical Imaging, Yale University, New Haven, Connecticut;

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Charles MatoukDepartment of Radiology and Biomedical Imaging, Yale University, New Haven, Connecticut;
Department of Neurosurgery, Yale University, New Haven, Connecticut;

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Jeremy J. HeitDepartment of Radiology,
Department of Neurosurgery, and

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Max WintermarkDepartment of Radiology,

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Gregory W. AlbersDepartment of Neurosurgery, and
Department of Neurology, Stanford University, Stanford, California; and

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Pina SanelliDonald and Barbara Zucker School of Medicine at Hofstra/Northwell, Long Island, New York

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Ajay MalhotraDepartment of Radiology and Biomedical Imaging, Yale University, New Haven, Connecticut;

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OBJECTIVE

Acute ischemic stroke patients with large-vessel occlusion and good collateral blood flow have significantly better outcomes than patients with poor collateral circulation. The purpose of this study was to evaluate the cost-effectiveness of endovascular thrombectomy (EVT) based on collateral status and, in particular, to analyze its effectiveness in ischemic stroke patients with poor collaterals.

METHODS

A decision analysis study was performed with Markov modeling to estimate the lifetime quality-adjusted life-years (QALYs) and associated costs of EVT based on collateral status. The study was performed over a lifetime horizon with a societal perspective in the US setting. Base-case analysis was done for good, intermediate, and poor collateral status. One-way, two-way, and probabilistic sensitivity analyses were performed.

RESULTS

EVT resulted in greater effectiveness of treatment compared to no EVT/medical therapy (2.56 QALYs in patients with good collaterals, 1.88 QALYs in those with intermediate collaterals, and 1.79 QALYs in patients with poor collaterals), which was equivalent to 1050, 771, and 734 days, respectively, in a health state characterized by a modified Rankin Scale (mRS) score of 0–2. EVT also resulted in lower costs in patients with good and intermediate collaterals. For patients with poor collateral status, the EVT strategy had higher effectiveness and higher costs, with an incremental cost-effectiveness ratio (ICER) of $44,326/QALY. EVT was more cost-effective as long as it had better outcomes in absolute numbers in at least 4%–8% more patients than medical management.

CONCLUSIONS

EVT treatment in the early time window for good outcome after ischemic stroke is cost-effective irrespective of the quality of collateral circulation, and patients should not be excluded from thrombectomy solely on the basis of collateral status. Despite relatively lower benefits of EVT in patients with poor collaterals, even smaller differences in better outcomes have significant long-term financial implications that make EVT cost-effective.

ABBREVIATIONS

CTP = CT perfusion; EVT = endovascular thrombectomy; HERMES = Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke; ICER = incremental cost-effectiveness ratio; IVT = intravenous thrombolysis; LVO = large-vessel occlusion; mRS = modified Rankin Scale; NMB = net monetary benefit; QALY = quality-adjusted life-year; WTP = willingness to pay.

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Figure from Kim et al. (pp 1601–1609).

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