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Original research
Cost-effectiveness of thrombectomy in patients with minor stroke and large vessel occlusion: effect of thrombus location on cost-effectiveness and outcomes
  1. Mihir Khunte1,
  2. Xiao Wu2,
  3. Andrew Koo3,
  4. Seyedmehdi Payabvash1,
  5. Charles Matouk3,
  6. Jeremy J Heit4,
  7. Max Wintermark5,
  8. Albers W Gregory6,
  9. Pina C Sanelli7,
  10. Dheeraj Gandhi8,
  11. Ajay Malhotra1
  1. 1Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
  2. 2Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
  3. 3Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
  4. 4Radiology, Neuroadiology and Neurointervention Division, Stanford University, Stanford, California, USA
  5. 5Department of Neuroradiology, MD Anderson, Houston, TX, USA
  6. 6Department of Neurology and Neurosurgery, Stanford University, Stanford, California, USA
  7. 7Hofstra Northwell School of Medicine at Hofstra University, Hempstead, New York, USA
  8. 8Department of Interventional Neuroradiology, University of Maryland, Baltimore, Maryland, USA
  1. Correspondence to Dr Ajay Malhotra, Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT 06510, USA; ajay.malhotra{at}yale.edu

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.

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Footnotes

  • Twitter @JeremyHeitMDPHD, @stanfordNRAD, @AjayMalhotraRad

  • 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.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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