Article Text
Abstract
Background To evaluate the cost-effectiveness of endovascular thrombectomy (EVT) to treat large vessel occlusion (LVO) in patients with acute, minor stroke (National Institute of Health Stroke Scale (NIHSS) <6) and impact of occlusion site.
Methods A Markov decision-analytic model was constructed accounting for both costs and outcomes from a societal perspective. Two different management strategies were evaluated: EVT and medical management. Base case analysis was done for three different sites of occlusion: proximal M1, distal M1 and M2 occlusions. One-way, two-way and probabilistic sensitivity analyses were performed.
Results Base-case calculation showed EVT to be the dominant strategy in 65-year-old patients with proximal M1 occlusion and NIHSS <6, with lower cost (US$37 229 per patient) and higher effectiveness (1.47 quality-adjusted life years (QALYs)), equivalent to 537 days in perfect health or 603 days in modified Rankin score (mRS) 0–2 health state. EVT is the cost-effective strategy in 92.7% of iterations for patients with proximal M1 occlusion using a willingness-to-pay threshold of US$100 000/QALY. EVT was cost-effective if it had better outcomes in 2%–3% more patients than intravenous thrombolysis (IVT) in absolute numbers (base case difference −16%). EVT was cost-effective when the proportion of M2 occlusions was less than 37.1%.
Conclusions EVT is cost-effective in patients with minor stroke and LVO in the long term (lifetime horizon), considering the poor outcomes and significant disability associated with non-reperfusion. Our study emphasizes the need for caution in interpreting previous observational studies which concluded similar results in EVT versus medical management in patients with minor stroke due to a high proportion of patients with M2 occlusions in the two strategies.
- economics
- stroke
- thrombectomy
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information. Not applicable.
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Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information. Not applicable.
Footnotes
Twitter @JeremyHeitMDPHD, @stanfordNRAD, @AjayMalhotraRad
Correction notice Since this article was first published, the author name Albers W Gregory was updated to Gregory W Albers.
Contributors AM: Study concept and design, acquisition of data, analysis and interpretation, critical revision of the manuscript for important intellectual content, study supervision, guarantor of study. MK: Acquisition of data, analysis and interpretation, critical revision of the manuscript for important intellectual content. XW: Acquisition of data, analysis and interpretation, critical revision of the manuscript for important intellectual content. AK: Sam Payabvash: Acquisition of data, critical revision of the manuscript for important intellectual content. SP: Acquisition of data, critical revision of the manuscript for important intellectual content. JJH: Acquisition of data, critical revision of the manuscript for important intellectual content, study supervision. CM: Acquisition of data, critical revision of the manuscript for important intellectual content, study supervision. MW: Acquisition of data, critical revision of the manuscript for important intellectual content, study supervision. AWG: Acquisition of data, critical revision of the manuscript for important intellectual content, study supervision. PCS: Acquisition of data, critical revision of the manuscript for important intellectual content, study supervision. DG: Acquisition of data, critical revision of the manuscript for important intellectual content, study supervision.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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