Cost-effectiveness analysis of mechanical thrombectomy in acute ischemic stroke

Clinical article

Chirag G. Patil M.D.1, Elisa F. Long M.S.2, and Maarten G. Lansberg M.D., Ph.D.3
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  • 1 Department of Neurosurgery, Stanford University School of Medicine;
  • | 2 Department of Management Science & Engineering, Stanford University, Stanford; and
  • | 3 Stanford Stroke Center, Stanford University Medical Center, Palo Alto, California
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Object

Mechanical thrombectomy is increasingly being used for the treatment of large-vessel ischemic stroke in patients who arrive outside of the 3-hour tissue plasminogen activator time window. In this study, the authors evaluated the cost and effectiveness of mechanical thrombectomy compared with standard medical therapy in patients who are ineligible to receive tissue plasminogen activator.

Methods

Clinical outcomes of an open-label study of mechanical thrombectomy were compared with a hypothetical control group with a lower recanalization rate (18 vs 60%) and a lower rate of symptomatic intracranial hemorrhage (0.6 vs 7.8%) than the active treatment group. A Markov cost-effectiveness model was built to compare the health benefits and costs associated with mechanical thrombectomy compared with standard medical therapy. All probabilities, quality-of-life factors, and costs were estimated from the published literature. Univariate sensitivity analyses were performed to assess how variations in model parameters affect health and economic outcomes.

Results

Treatment of acute ischemic stroke with mechanical thrombectomy increased survival time by 0.54 quality-adjusted life years (QALYs), compared with standard medical therapy (2.37 vs 1.83 QALYs), at an increased cost of $6600. This yielded an incremental cost-effectiveness ratio (ICER) of $12,120 per QALY gained, a value generally considered cost-effective. Sensitivity analysis showed that mechanical thrombectomy remained cost-effective (ICER < $50,000 per QALY gained) for all model inputs varied over a reasonable range, except for age at stroke treatment. For patients older than 82 years of age, the treatment was only borderline cost-effective (ICER of $50,000–100,000 per QALY gained).

Conclusions

The treatment of large-vessel ischemic stroke with mechanical thrombectomy appears to be costeffective. These results require validation when data from a randomized, controlled trial of mechanical thrombectomy become available.

Abbreviations used in this paper:

FDA = Food and Drug Administration; ICER = incremental cost-effectiveness ratio; MERCI = Mechanical Embolus Removal in Cerebral Ischemia; mRS = modified Rankin Scale; MS-DRG = Medicare Severity Diagnostic-Related Group; NINDS = National Institute of Neurological Disorders and Stroke; PROACT = Pro-Urokinase for Acute Cerebral Thromboembolism; QALY = quality-adjusted life year; sICH = symptomatic intracerebral hemorrhage; tPA = tissue plasminogen activator.

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Contributor Notes

Address correspondence to: Chirag G. Patil, M.D., Stanford Hospital, Department of Neurosurgery, 300 Pasteur Drive, Room R200 MC5327, Stanford, California 94305. email: chiragpatil@gmail.com.
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