Cost-effectiveness of remote robotic mechanical thrombectomy in acute ischemic stroke

Maria X. SanmartinCenter for Health Innovations and Outcomes Research (CHIOR), Feinstein Institutes for Medical Research, Manhasset;
Siemens Medical Solutions USA Inc., Malvern, Pennsylvania;

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Jeffrey M. KatzDepartments of Radiology and
Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York;

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Christian EusemannSiemens Medical Solutions USA Inc., Malvern, Pennsylvania;

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Artem T. BoltyenkovCenter for Health Innovations and Outcomes Research (CHIOR), Feinstein Institutes for Medical Research, Manhasset;
Siemens Medical Solutions USA Inc., Malvern, Pennsylvania;

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Kinpritma SanghaCenter for Health Innovations and Outcomes Research (CHIOR), Feinstein Institutes for Medical Research, Manhasset;
Siemens Medical Solutions USA Inc., Malvern, Pennsylvania;

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Mehrad BastaniCenter for Health Innovations and Outcomes Research (CHIOR), Feinstein Institutes for Medical Research, Manhasset;

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Raymond TurnerSiemens Medical Solutions USA Inc., Malvern, Pennsylvania;
Department of Neurosurgery, PRISMA Health, University of South Carolina, Greenville, South Carolina;

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Adnan H. SiddiquiDepartment of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York;

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Vitor Mendes PereiraDepartment of Surgery, Division of Neurosurgery, St. Michael’s Hospital, University of Toronto, Ontario, Canada;

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Ferdinand K. HuiNeuroscience Institute, The Queen’s Medical Center, Honolulu, Hawaii; and

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J MoccoDepartment of Neurosurgery, The Mount Sinai Hospital, New York, New York

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Pina C. SanelliCenter for Health Innovations and Outcomes Research (CHIOR), Feinstein Institutes for Medical Research, Manhasset;
Departments of Radiology and

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OBJECTIVE

Clinical outcomes following endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) treatment are highly time sensitive. Remote robotic (RR)–EVT systems may be capable of mitigating time delays in patient transfer from a primary stroke center (PSC) to a comprehensive/thrombectomy-capable stroke center. However, health economic evidence is needed to assess the costs and benefits of an RR-EVT system. Therefore, the authors of this study aimed to determine whether performing RR-EVT in suspected AIS patients at a PSC as opposed to standard of care might translate to cost-effectiveness over a lifetime.

METHODS

An economic evaluation study was performed from a US healthcare perspective, combining decision analysis and Markov modeling methods over a lifetime horizon to evaluate the cost-effectiveness of RR-EVT in suspected AIS patients at a PSC compared to the standard-of-care approach. Total expected costs and quality-adjusted life-years (QALYs) were estimated.

RESULTS

In the cost-effectiveness analysis, RR-EVT yielded greater effectiveness per patient (4.05 vs 3.88 QALYs) and lower costs (US$321,269 vs US$321,397) than the standard-of-care approach. Owing to these lower costs and greater health benefits, RR-EVT was the dominant cost-effective strategy. After initiation of an RR-EVT system, the average costs per year were similar (or slightly reduced), according to this simulation. Sensitivity analyses revealed that RR-EVT remains cost-effective in a wide variety of time delays and cost assumptions. In a one-way sensitivity analysis, RR-EVT remained the most cost-effective strategy when time delays were greater than 2.5 minutes, its complication rate did not exceed 37%, and costs were lower than $54,081. When the cost of the RR-EVT strategy ranged from $19,340 to $54,081 and its complication rate varied from 15% to 37%, the RR-EVT strategy remained the most cost-effective throughout the two ranges. RR-EVT was also the most cost-effective strategy even when its cost doubled (to approximately $40,000) and time delays exceeded 20 minutes. In a probabilistic sensitivity analysis, RR-EVT was the long-term cost-effective strategy in 89.8% of iterations at a willingness-to-pay threshold of $100,000/QALY.

CONCLUSIONS

This analysis suggests that RR-EVT as an innovative solution to expedite EVT is cost-effective. An RR-EVT system could potentially extend access to care in underserved communities and rural areas, as well as improve care for socioeconomically disadvantaged populations affected by health inequities.

ABBREVIATIONS

AIS = acute ischemic stroke; CSC = comprehensive stroke center; EVT = endovascular thrombectomy; FDA = Food and Drug Administration; ICER = incremental cost-effectiveness ratio; INMB = incremental net monetary benefit; LVO = large vessel occlusion; mRS = modified Rankin Scale; PSA = probabilistic sensitivity analysis; PSC = primary stroke center; QALY = quality-adjusted life-year; RCT = randomized controlled trial; RR = remote robotic; TSC = thrombectomy-capable stroke center; WTP = willingness to pay.

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