Cost-effectiveness analysis of endovascular treatment with or without intravenous thrombolysis in acute ischemic stroke

Adnan I. QureshiZeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri;

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Yasemin AkinciZeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri;

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Wei HuangZeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri;

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Muhammad F. IshfaqZeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri;

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Ameer E. HassanDepartment of Neuroscience, Valley Baptist Medical Center, Harlingen, Texas;
Department of Neurology, University of Texas Rio Grande Valley School of Medicine, Harlingen, Texas; and

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Farhan SiddiqDivision of Neurosurgery, University of Missouri, Columbia, Missouri

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Camilo R. GomezZeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri;

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OBJECTIVE

Intravenous (IV) recombinant tissue plasminogen activator (r-tPA) may not provide additional benefit in terms of functional outcomes in patients with acute ischemic stroke (AIS) who undergo endovascular treatment (EVT). In this context, the cost-effectiveness of EVT alone compared with its application following IV r-tPA has not been evaluated.

METHODS

The authors determined the average rates of death or disability in each of the two treatment groups from four randomized clinical trials that enrolled patients with AIS within 4.5 hours of symptom onset and randomly assigned patients to EVT alone and IV r-tPA and EVT. By using three sources derived from previous studies, the authors determined the cost of IV r-tPA, cost of staff time for administration, cost of the EVT, cost of hospital stay, costs of supported discharge and community care, and cost of posthospitalization care and disability. They then assessed the cost-effectiveness of EVT alone using a decision tree for the 1st year after AIS and a Markov model with a 10-year horizon, including probabilistic assessment by Monte Carlo simulations.

RESULTS

The 1-year cost was higher with IV r-tPA and EVT compared with EVT alone (incremental cost ranging between $3554 and $13,788 per patient). The mean incremental cost-effectiveness ratios (ICERs) were −$1589, −$78,327, and −$15,471 per quality-adjusted life-year gained for cost sources 1, 2, and 3, respectively, for EVT alone compared with IV r-tPA and EVT at 10 years. The ceiling ICER (willingness to pay) for a probability of 100% that EVT alone was more cost-effective ranged between $25,000 and $100,000 in the three models.

CONCLUSIONS

EVT alone appears to be more cost-effective compared with EVT and IV r-tPA for the treatment of AIS patients presenting within 4.5 hours of symptom onset.

ABBREVIATIONS

AIS = acute ischemic stroke; CEAC = cost-effectiveness acceptability curve; EVT = endovascular treatment; ICER = incremental cost-effectiveness ratio; IV = intravenous; mRS = modified Rankin Scale; QALY = quality-adjusted life-year; r-tPA = recombinant tissue plasminogen activator.
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Figure from Ramos et al. (pp 95–103).

  • 1

    Powers WJ, Rabinstein AA, Ackerson T, et al. 2018 Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2018;49(3):e46e110.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Hassan AE, Ringheanu VM, Preston L, Tekle W, Qureshi AI. IV tPA is associated with increase in rates of intracerebral hemorrhage and length of stay in patients with acute stroke treated with endovascular treatment within 4.5 hours: should we bypass IV tPA in large vessel occlusion?. J Neurointerv Surg. 2021;13(2):114118.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Kaesmacher J, Mordasini P, Arnold M, et al. Direct mechanical thrombectomy in tPA-ineligible and -eligible patients versus the bridging approach: a meta-analysis. J Neurointerv Surg. 2019;11(1):2027.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Lin CH, Saver JL, Ovbiagele B, Huang WY, Lee M. Endovascular thrombectomy without versus with intravenous thrombolysis in acute ischemic stroke: a non-inferiority meta-analysis of randomized clinical trials. J Neurointerv Surg. 2022;14(3):227232.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Suzuki K, Matsumaru Y, Takeuchi M, et al. Effect of mechanical thrombectomy without vs with intravenous thrombolysis on functional outcome among patients with acute ischemic stroke: the SKIP randomized clinical trial. JAMA. 2021;325(3):244253.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Yang P, Zhang Y, Zhang L, et al. Endovascular thrombectomy with or without intravenous alteplase in acute stroke. N Engl J Med. 2020;382(21):19811993.

  • 7

    Zi W, Qiu Z, Li F, et al. Effect of endovascular treatment alone vs intravenous alteplase plus endovascular treatment on functional independence in patients with acute ischemic stroke: the DEVT randomized clinical trial. JAMA. 2021;325(3):234243.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Current US inflation rates: 2000-2022. US Inflation Calculator. Accessed April 5, 2022. https://www.usinflationcalculator.com/inflation/current-inflation-rates/

    • Search Google Scholar
    • Export Citation
  • 9

    LeCouffe NE, Kappelhof M, Treurniet KM, et al. A randomized trial of intravenous alteplase before endovascular treatment for stroke. N Engl J Med. 2021;385(20):18331844.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Banks JL, Marotta CA. Outcomes validity and reliability of the modified Rankin Scale: implications for stroke clinical trials: a literature review and synthesis. Stroke. 2007;38(3):10911096.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Ganesalingam J, Pizzo E, Morris S, Sunderland T, Ames D, Lobotesis K. Cost-utility analysis of mechanical thrombectomy using stent retrievers in acute ischemic stroke. Stroke. 2015;46(9):25912598.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    NICE technology appraisal guidance. Alteplase for treating acute ischaemic stroke (review of technology appraisal 264). National Institute for Health and Care Excellence. Updated September 26, 2012. Accessed May 10, 2022. https://www.nice.org.uk/guidance/TA264

    • Search Google Scholar
    • Export Citation
  • 13

    Morris S, Hunter R, Davie C, et al. Cost-Effectiveness Analysis of the London Stroke Service. University College;2011.

  • 14

    Barrett ML, Hensche MB, Welch J, Ross DN. Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample: Change in Structure Due to ICD-10-CM/PCS Beginning With 2016 Data. U.S. Agency for Healthcare Research and Quality; 2021.Accessed May 12, 2022. https://www.hcup-us.ahrq.gov/db/nation/nis/nisdbdocumentation.jsp

    • Search Google Scholar
    • Export Citation
  • 15

    Hassan AE, Chaudhry SA, Grigoryan M, Tekle WG, Qureshi AI. National trends in utilization and outcomes of endovascular treatment of acute ischemic stroke patients in the mechanical thrombectomy era. Stroke. 2012;43(11):30123017.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Qureshi AI, Singh B, Huang W, et al. Mechanical thrombectomy in acute ischemic stroke patients performed within and outside clinical trials in the United States. Neurosurgery. 2020;86(1):E2E8.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Maud A, Lakshminarayan K, Suri MF, Vazquez G, Lanzino G, Qureshi AI. Cost-effectiveness analysis of endovascular versus neurosurgical treatment for ruptured intracranial aneurysms in the United States. J Neurosurg. 2009;110(5):880886.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Khan AA, Chaudhry SA, Sivagnanam K, Hassan AE, Suri MF, Qureshi AI. Cost-effectiveness of carotid artery stent placement versus endarterectomy in patients with carotid artery stenosis. J Neurosurg. 2012;117(1):8993.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Qureshi AI, Chaudhry SA, Sapkota BL, Rodriguez GJ, Suri MF. Discharge destination as a surrogate for Modified Rankin Scale defined outcomes at 3- and 12-months poststroke among stroke survivors. Arch Phys Med Rehabil. 2012;93(8):14081413.e1.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Mu F, Hurley D, Betts KA, et al. Real-world costs of ischemic stroke by discharge status. Curr Med Res Opin. 2017;33(2):371378.

  • 21

    Hassan AE, Kotta H, Garza L, et al. Pre-thrombectomy intravenous thrombolytics are associated with increased hospital bills without improved outcomes compared with mechanical thrombectomy alone. J Neurointerv Surg. 2019;11(12):11871190.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Shireman TI, Wang K, Saver JL, et al. Cost-effectiveness of Solitaire Stent Retriever thrombectomy for acute ischemic stroke: results from the SWIFT-PRIME Trial (Solitaire With the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke). Stroke. 2017;48(2):379387.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Anderson CS, Jamrozik KD, Broadhurst RJ, Stewart-Wynne EG. Predicting survival for 1 year among different subtypes of stroke. Results from the Perth Community Stroke Study. Stroke. 1994;25(10):19351944.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Kolominsky-Rabas PL, Sarti C, Heuschmann PU, et al. A prospective community-based study of stroke in Germany--the Erlangen Stroke Project (ESPro): incidence and case fatality at 1, 3, and 12 months. Stroke. 1998;29(12):25012506.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Molyneux A, Kerr R, Stratton I, et al. International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet. 2002;360(9342):12671274.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Dorman PJ, Waddell F, Slattery J, Dennis M, Sandercock P. Is the EuroQol a valid measure of health-related quality of life after stroke?. Stroke. 1997;28(10):18761882.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Mandelblatt JS, Fryback DG, Weinstein MC, Russell LB, Gold MR. Assessing the effectiveness of health interventions for cost-effectiveness analysis. J Gen Intern Med. 1997;12(9):551558.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Boudreau DM, Guzauskas GF, Chen E, et al. Cost-effectiveness of recombinant tissue-type plasminogen activator within 3 hours of acute ischemic stroke: current evidence. Stroke. 2014;45(10):30323039.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Saver JL, Goyal M, Bonafe A, et al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med. 2015;372(24):22852295.

  • 30

    Tung CE, Win SS, Lansberg MG. Cost-effectiveness of tissue-type plasminogen activator in the 3- to 4.5-hour time window for acute ischemic stroke. Stroke. 2011;42(8):22572262.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31

    Kim AS, Nguyen-Huynh M, Johnston SC. A cost-utility analysis of mechanical thrombectomy as an adjunct to intravenous tissue-type plasminogen activator for acute large-vessel ischemic stroke. Stroke. 2011;42(7):20132018.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32

    Leppert MH, Campbell JD, Simpson JR, Burke JF. Cost-effectiveness of intra-arterial treatment as an adjunct to intravenous tissue-type plasminogen activator for acute ischemic stroke. Stroke. 2015;46(7):18701876.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33

    Kaboré N, Marnat G, Rouanet F, et al. Cost-effectiveness analysis of mechanical thrombectomy plus tissue-type plasminogen activator compared with tissue-type plasminogen activator alone for acute ischemic stroke in France. Rev Neurol (Paris). 2019;175(4):252260.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34

    Qureshi AI, Chaudhry SA, Rodriguez GJ, Suri MF, Lakshminarayan K, Ezzeddine MA. Outcome of the ‘drip-and-ship’ paradigm among patients with acute ischemic stroke: results of a statewide study. Cerebrovasc Dis Extra. 2012;2(1):18.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35

    Tekle WG, Chaudhry SA, Hassan AE, Rodriguez GJ, Suri MF, Qureshi AI. Drip-and-ship thrombolytic treatment paradigm among acute ischemic stroke patients in the United States. Stroke. 2012;43(7):19711974.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36

    Gerschenfeld G, Muresan IP, Blanc R, et al. Two paradigms for endovascular thrombectomy after intravenous thrombolysis for acute ischemic stroke. JAMA Neurol. 2017;74(5):549556.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37

    Goyal M, Almekhlafi MA, Fan L, et al. Evaluation of interval times from onset to reperfusion in patients undergoing endovascular therapy in the Interventional Management of Stroke III trial. Circulation. 2014;130(3):265272.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 38

    Menon BK, Sajobi TT, Zhang Y, et al. Analysis of workflow and time to treatment on thrombectomy outcome in the endovascular treatment for small core and proximal occlusion ischemic stroke (ESCAPE) randomized, controlled trial. Circulation. 2016;133(23):22792286.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 39

    Drummond MF, Jefferson TO. Guidelines for authors and peer reviewers of economic submissions to the BMJ. BMJ. 1996;313(7052):275283.

  • 40

    Jefferson T, Smith R, Yee Y, Drummond M, Pratt M, Gale R. Evaluating the BMJ guidelines for economic submissions: prospective audit of economic submissions to BMJ and The Lancet. JAMA. 1998;280(3):275277.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 41

    Kaplan RS. Improving value with TDABC. Healthc Financ Manage. 2014;68(6):7683.

  • 42

    Kaplan RS, Anderson SR. Time-driven activity-based costing. Harv Bus Rev. 2004;82(11):131138.150.

  • 43

    Eddy DM, Hollingworth W, Caro JJ, Tsevat J, McDonald KM, Wong JB. Model transparency and validation: a report of the ISPOR-SMDM Modeling Good Research Practices Task Force-7. Med Decis Making. 2012;32(5):733743.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 44

    Hoogendoorn M, Feenstra TL, Asukai Y, et al. External validation of health economic decision models for chronic obstructive pulmonary disease (COPD): report of the Third COPD Modeling Meeting. Value Health. 2017;20(3):397403.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 45

    Lopes S, Johansen P, Lamotte M, McEwan P, Olivieri AV, Foos V. External validation of the core obesity model to assess the cost-effectiveness of weight management interventions. PharmacoEconomics. 2020;38(10):11231133.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 46

    Potter S, Davies C, Davies G, Rice C, Hollingworth W. The use of micro-costing in economic analyses of surgical interventions: a systematic review. Health Econ Rev. 2020;10(1):3.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 47

    Qureshi AI, Saleem MA, Aytaç E, Malik AA. The effect of diagnostic catheter angiography on outcomes of acute ischemic stroke patients being considered for endovascular treatment. J Vasc Interv Neurol. 2017;9(3):4550.

    • PubMed
    • Search Google Scholar
    • Export Citation

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