Cost-effectiveness of endovascular thrombectomy in patients with low Alberta Stroke Program Early CT Scores (< 6) at presentation

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  • 1 Departments of Radiology and Biomedical Imaging and
  • | 2 Neurosurgery, Yale University School of Medicine, New Haven, Connecticut;
  • | 3 Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts;
  • | 4 Department of Radiology, Stanford University, Palo Alto, California;
  • | 5 Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York; and
  • | 6 Department of Radiology, Neurology and Neurosurgery, University of Maryland, Baltimore, Maryland
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OBJECTIVE

The utility of endovascular thrombectomy (EVT) in patients with acute ischemic stroke, large vessel occlusion (LVO), and low Alberta Stroke Program Early CT Scores (ASPECTS) remains uncertain. The objective of this study was to determine the health outcomes and cost-effectiveness of EVT versus medical management in patients with ASPECTS < 6.

METHODS

A decision-analytical study was performed with Markov modeling to estimate the lifetime quality-adjusted life-years (QALYs) and associated costs of EVT-treated patients compared to medical management. The study was performed over a lifetime horizon with a societal perspective in the US setting.

RESULTS

The incremental cost-effectiveness ratios were $412,411/QALY and $1,022,985/QALY for 55- and 65-year-old groups in the short-term model. EVT was the long-term cost-effective strategy in 96.16% of the iterations and resulted in differences in health benefit of 2.21 QALYs and 0.79 QALYs in the 55- and 65-year-old age groups, respectively, equivalent to 807 days and 288 days in perfect health. EVT remained the more cost-effective strategy when the probability of good outcome with EVT was above 16.8% or as long as the good outcome associated with the procedure was at least 1.6% higher in absolute value than that of medical management. EVT remained cost-effective even when its cost exceeded $100,000 (threshold was $108,036). Although the cost-effectiveness decreased with age, EVT was cost-effective for 75-year-old patients as well.

CONCLUSIONS

This study suggests that EVT is the more cost-effective approach compared to medical management in patients with ASPECTS < 6 in the long term (lifetime horizon), considering the poor outcomes and significant disability associated with nonreperfusion.

ABBREVIATIONS

ASPECTS = Alberta Stroke Program Early CT Scores; ETIS = Endovascular Treatment in Ischemic Stroke; EVT = endovascular thrombectomy; HERMES = Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke; ICER = incremental cost-effectiveness ratio; IV-tPA = intravenous tissue plasminogen activator; LVO = large vessel occlusion; NMB = net monetary benefit; OR = odds ratio; QALY = quality-adjusted life-year; WTP = willingness to pay.

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Contributor Notes

Correspondence Ajay Malhotra: Yale University School of Medicine, New Haven, CT. ajay.malhotra@yale.edu.

INCLUDE WHEN CITING Published online May 7, 2021; DOI: 10.3171/2020.9.JNS202965.

Disclosures Dr. Lev reports being a consultant for Takeda Pharmaceutical Co. and GE Healthcare. Dr. Gandhi reports receiving support of non–study-related clinical or research effort from MicroVention and the Focused Ultrasound Foundation.

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