“Strokenomics”: bending the cost curve in stroke care

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OBJECTIVE

The mortality rates for stroke are decreasing, yet it remains a leading cause of disability and the principal neurological diagnosis in patients discharged to nursing homes. The societal and economic burdens of stroke are substantial, with the total annual health care costs of stroke expected to reach $240.7 billion by 2030. Mechanical thrombectomy has been shown to improve functional outcomes compared to medical therapy alone. Despite an incremental cost of $10,840 compared to medical therapy, the improvement in functional outcomes and decreased disability have contributed to the cost-effectiveness of the procedure. In this study the authors describe a physician-led device bundle purchase program implemented for the delivery of stroke care.

METHODS

The authors retrospectively reviewed the clinical and radiographic data and device-associated charges of 45 consecutive patients in whom a virtual “stroke bundle” model was used to purchase mechanical thrombectomy devices.

RESULTS

Use of the stroke bundle to purchase mechanical thrombectomy devices resulted in an average savings per case of $2900.93. Compared to the traditional model of charging for devices à la carte, this represented an average savings of 25.2% per case. The total amount of savings for these initial 45 cases was $130,542.00. Thrombolysis in Cerebral Infarction scale grade 2b or 3 recanalization occurred in 38 patients (84.4%) using these devices.

CONCLUSIONS

Purchasing devices through a bundled model resulted in substantial cost savings while maintaining the therapeutic efficacy of the procedure, further pushing the already beneficial long-term cost-benefit curve in favor of thrombectomy.

ABBREVIATIONS CMS = Centers for Medicare and Medicaid Services; DRG = diagnosis-related group; ICA = internal carotid artery; MCA = middle cerebral artery; SAH = subarachnoid hemorrhage; TICI = Thrombolysis in Cerebral Infarction.
Article Information

Contributor Notes

Correspondence Elad I. Levy: University at Buffalo, NY. elevy@ubns.com.INCLUDE WHEN CITING Published online January 24, 2020; DOI: 10.3171/2019.11.JNS191960.Disclosures Dr. Davies reports receiving a research grant (no. KL2TR001413) from the National Center for Advancing Translational Sciences of the NIH awarded to the University at Buffalo; being a consultant to Medtronic; receiving honoraria from Neurotrauma Science, LLC; and having shareholder/ownership interests in RIST Neurovascular and Cerebrotech. Dr. Levy reports shareholder/ownership interests in NeXtGen Biologics, RAPID Medical, Claret Medical, Cognition Medical, Imperative Care (formerly the Stroke Project), Rebound Therapeutics, StimMed, and Three Rivers Medical; being on national principal investigator/steering committees for Medtronic (merged with Covidien Neurovascular) SWIFT Prime and SWIFT Direct Trials; receiving honoraria from Medtronic (training and lectures); being a consultant for Claret Medical, GLG Consulting, Guidepoint Global, Imperative Care, Medtronic, Rebound, and StimMed; serving on the Advisory Board for Stryker (AIS Clinical Advisory Board), NeXtGen Biologics, MEDX, Cognition Medical, and Endostream Medical; being a site principal investigator for the CONFIDENCE study (MicroVention) and STRATIS Study—Sub I (Medtronic); and rendering medical legal opinions as an expert witness. Dr. Siddiqui reports financial interest/investor/stock options/ownership in Amnis Therapeutics, Apama Medical, Blink TBI Inc., Buffalo Technology Partners Inc., Cardinal Consultants LLC, Cerebrotech Medical Systems Inc., Cognition Medical, Endostream Medical Ltd., Imperative Care, International Medical Distribution Partners, Neurovascular Diagnostics Inc., Q’Apel Medical Inc., Rebound Therapeutics Corp., Rist Neurovascular Inc., Serenity Medical Inc., Silk Road Medical, StimMed, Synchron, Three Rivers Medical Inc., and Viseon Spine Inc; serving as a consultant and/or on the advisory board of Amnis Therapeutics, Boston Scientific, Canon Medical Systems USA Inc., Cerebrotech Medical Systems Inc., Cerenovus, Corindus Inc., Endostream Medical Ltd., Guidepoint Global Consulting, Imperative Care, Integra LifeSciences Corp., Medtronic, MicroVention, Northwest University–DSMB Chair for HEAT Trial, Penumbra, Q’Apel Medical Inc., Rapid Medical, Rebound Therapeutics Corp., Serenity Medical Inc., Silk Road Medical, StimMed, Stryker, Three Rivers Medical, Inc., VasSol, and W.L. Gore & Associates; and being a principal investigator and/or steering comment on the following trials: Cerenovus LARGE and ARISE II, Medtronic SWIFT PRIME and SWIFT DIRECT, MicroVention FRED trial & CONFIDENCE study, MUSC POSITIVE, Penumbra 3D Separator, COMPASS, and INVEST. Dr. Snyder reports consulting and teaching for Canon Medical Systems Corporation, Penumbra Inc., Medtronic, and Jacobs Institute; and being a co-founder of Neurovascular Diagnostics, Inc.
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References
  • 1

    Achit HSoudant MHosseini KBannay AEpstein JBracard S: Cost-effectiveness of thrombectomy in patients with acute ischemic stroke: The THRACE randomized controlled trial. Stroke 48:284328472017

    • Search Google Scholar
    • Export Citation
  • 2

    Benjamin EJVirani SSCallaway CWChamberlain AMChang ARCheng S: Heart disease and stroke statistics–2018 update: a report from the American Heart Association. Circulation 137:e67e4922018

    • Search Google Scholar
    • Export Citation
  • 3

    Berkhemer OAFransen PSBeumer Dvan den Berg LALingsma HFYoo AJ: A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 372:11202015

    • Search Google Scholar
    • Export Citation
  • 4

    Boudour SBarral MGory BGiroudon CAulagner GSchott AM: A systematic review of economic evaluations on stent-retriever thrombectomy for acute ischemic stroke. J Neurol 265:151115202018

    • Search Google Scholar
    • Export Citation
  • 5

    Buntin MBColla CHDeb PSood NEscarce JJ: Medicare spending and outcomes after postacute care for stroke and hip fracture. Med Care 48:7767842010

    • Search Google Scholar
    • Export Citation
  • 6

    Campbell BCMitchell PJKleinig TJDewey HMChurilov LYassi N: Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med 372:100910182015

    • Search Google Scholar
    • Export Citation
  • 7

    Dobbs MR: Episode-based payment for ischemic stroke care with implications for neurologists. Neurol Clin Pract 4:2312382014

  • 8

    Fiorelli MBastianello Svon Kummer Rdel Zoppo GJLarrue VLesaffre E: Hemorrhagic transformation within 36 hours of a cerebral infarct: relationships with early clinical deterioration and 3-month outcome in the European Cooperative Acute Stroke Study I (ECASS I) cohort. Stroke 30:228022841999

    • Search Google Scholar
    • Export Citation
  • 9

    Ganesalingam JPizzo EMorris SSunderland TAmes DLobotesis K: Cost-utility analysis of mechanical thrombectomy using stent retrievers in acute ischemic stroke. Stroke 46:259125982015

    • Search Google Scholar
    • Export Citation
  • 10

    Goyal MDemchuk AMMenon BKEesa MRempel JLThornton J: Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med 372:101910302015

    • Search Google Scholar
    • Export Citation
  • 11

    Jovin TGChamorro ACobo Ede Miquel MAMolina CARovira A: Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med 372:229623062015

    • Search Google Scholar
    • Export Citation
  • 12

    Kim ASNguyen-Huynh MJohnston SC: A cost-utility analysis of mechanical thrombectomy as an adjunct to intravenous tissue-type plasminogen activator for acute large-vessel ischemic stroke. Stroke 42:201320182011

    • Search Google Scholar
    • Export Citation
  • 13

    Liao JMEmanuel EJPolsky DEHuang QShah YZhu J: National representativeness of hospitals and markets in Medicare’s mandatory bundled payment program. Health Aff (Millwood) 38:44532019

    • Search Google Scholar
    • Export Citation
  • 14

    Lobotesis KVeltkamp RCarpenter IHClaxton LMSaver JLHodgson R: Cost-effectiveness of stent-retriever thrombectomy in combination with IV t-PA compared with IV t-PA alone for acute ischemic stroke in the UK. J Med Econ 19:7857942016

    • Search Google Scholar
    • Export Citation
  • 15

    National Center for Health Statistics: National Health Interview Survey, 2014 Public-use data file and documentation: NCHS tabulations. CDC.gov (http://www.cdc.gov/nchs/nhis/nhis_2014_data_release.htm) [Accessed December 2 2019]

    • Search Google Scholar
    • Export Citation
  • 16

    Navathe ASLiao JMShah YLyon ZChatterjee PPolsky D: Characteristics of hospitals earning savings in the first year of mandatory bundled payment for hip and knee surgery. JAMA 319:9309322018

    • Search Google Scholar
    • Export Citation
  • 17

    Ovbiagele BGoldstein LBHigashida RTHoward VJJohnston SCKhavjou OA: Forecasting the future of stroke in the United States: a policy statement from the American Heart Association and American Stroke Association. Stroke 44:236123752013

    • Search Google Scholar
    • Export Citation
  • 18

    Ruggeri MBasile MZini AMangiafico SAgostoni ECLobotesis K: Cost-effectiveness analysis of mechanical thrombectomy with stent retriever in the treatment of acute ischemic stroke in Italy. J Med Econ 21:9029112018

    • Search Google Scholar
    • Export Citation
  • 19

    Saver JLGoyal MBonafe ADiener HCLevy EIPereira VM: Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med 372:228522952015

    • Search Google Scholar
    • Export Citation
  • 20

    Sevick LKGhali SHill MDDanthurebandara VLorenzetti DLNoseworthy T: Systematic review of the cost and cost-effectiveness of rapid endovascular therapy for acute ischemic stroke. Stroke 48:251925262017

    • Search Google Scholar
    • Export Citation
  • 21

    Wiącek MKaczorowski RSieczkowski BKanas NBartosik-Psujek H: Mechanical thrombectomy: Determining the proportion of eligible acute ischemic stroke patients in the cohort of single academic stroke center. Neurol Neurochir Pol 52:3593632018

    • Search Google Scholar
    • Export Citation
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