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Socioeconomics
Original research
Novel model of direct and indirect cost–benefit analysis of mechanical embolectomy over IV tPA for large vessel occlusions: a real-world dollar analysis based on improvements in mRS
  1. Sundeep Mangla1,2,
  2. Keara O'Connell1,2,
  3. Divya Kumari3,
  4. Maryam Shahrzad3
  1. 1Departments of Interventional Neuroradiology, Radiology, Neurology, Neurosurgery, SUNY Downstate Health Science Center, Brooklyn, New York, USA
  2. 2Department of Radiology, Lincoln Medical Center, Bronx, New York, USA
  3. 3Departments of Internal Medicine and Critical Care, Lincoln Medical Center, Bronx, New York, USA
  1. Correspondence to Dr Sundeep Mangla, Departments of Interventional Neuroradiology, Radiology, Neurology, Neurosurgery, SUNY Downstate Medical Center, 450 Clarkson Ave, P.O. Box 1189, Brooklyn, NY 11203-2098, USA; smangla{at}downstate.edu, sundeep.mangla{at}gmail.com

Abstract

Background Ischemic strokes result in significant healthcare expenditures (direct costs) and loss of quality-adjusted life years (QALYs) (indirect costs). Interventional therapy has demonstrated improved functional outcomes in patients with large vessel occlusions (LVOs), which are likely to reduce the economic burden of strokes.

Objective To develop a novel real-world dollar model to assess the direct and indirect cost–benefit of mechanical embolectomy compared with medical treatment with intravenous tissue plasminogen activator (IV tPA) based on shifts in modified Rankin scores (mRS).

Method A cost model was developed including multiple parameters to account for both direct and indirect stroke costs. These were adjusted based upon functional outcome (mRS). The model compared IV tPA with mechanical embolectomy to assess the costs and benefits of both therapies. Direct stroke-related costs included hospitalization, inpatient and outpatient rehabilitation, home care, skilled nursing facilities, and long-term care facility costs. Indirect costs included years of life expectancy lost and lost QALYs. Values for the model cost parameters were derived from numerous resources and functional outcomes were derived from the MR CLEAN study as a reflective sample of LVOs. Direct and indirect costs and benefits for the two treatments were assessed using Microsoft Excel 2013.

Results This cost–benefit model found a cost–benefit of mechanical embolectomy over IV tPA of $163 624.27 per patient and the cost benefit for 50 000 patients on an annual basis is $8 181 213 653.77.

Conclusions If applied widely within the USA, mechanical embolectomy will significantly reduce the direct and indirect financial burden of stroke ($8 billion/50 000 patients).

  • Economics
  • Intervention
  • Stroke
  • Thrombolysis
  • Thrombectomy

https://doi.org/10.1136/neurintsurg-2015-012152

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    Introduction

    Stroke remains a leading cause of mortality and long-term morbidity in the USA.1 There are approximately 795 000 stroke cases annually of which 87% are ischemic strokes.2 Up to 50% of all stroke survivors are unable to regain independence and require long-term healthcare.3 The cognitive impairment and functional disabilities of stroke survivors translates into significant long-term healthcare costs. In 2010 it was estimated that direct and indirect stroke-related costs resulted in a healthcare expenditure of $73.7 billion.2 Ischemic stroke care has traditionally relied on recanalization of an occluded blood vessel and reperfusion of its territory by use of intravenous (IV) tissue plasminogen activator (tPA).2 Although IV tPA has remained the standard treatment for most acute ischemic strokes, its benefits for large vessel occlusions (LVOs) have remained limited and abundant new evidence suggests that mechanical embolectomy (ME) performed with third-generation devices including stent retrievers is able to afford profound long-term functional benefits to ischemic stroke patients with LVOs.4–9 It is suggested that improvements in functional outcomes will result in reductions in stroke-related healthcare expenditure. This study sought to develop a novel model of real-world direct and indirect costs to assess the benefits of ME in comparison to medical treatment with IV tPA based on shifts in modified Rankin scores (mRS).

    Methods

    Cost–benefit model

    Neurologic and functional disability resulting from ischemic strokes causes significant acute and long-term healthcare expenditures. The extent of expenditure depends on the severity of disability, which is measured with the mRS. The total care costs include both direct and indirect costs.10 Interventional therapy has been shown to improve the functional outcomes of stroke patients, which is indicated by improvements in mRS. Improvements in functional outcomes or shifts in mRS may therefore be associated with reductions in stroke cost. As such, it is necessary to evaluate the health costs related to each functional mRS state for comparison.

    Various cost parameters were assessed for each functional outcome according to mRS. The model assumed a patient experienced an acute stroke secondary to LVO and was considered to be eligible for medical or interventional treatment. For initial evaluation of this LVO population and our novel model, average patient characteristics and functional mRS outcomes were derived from patients enrolled in the MR CLEAN trial. Two treatment options were considered in the model and the average healthcare costs and benefits were estimated from the time of stroke onset until death. It was assumed that patients remained in the same health state until death. The cost considerations used in our model were estimated from a variety of published literature and databases and adjusted for the functional outcome and needs of patients.

    Model parameters

    Direct costs

    Direct stroke-related costs included hospitalization and procedural costs, inpatient and outpatient rehabilitation costs, home care, skilled nursing facility, and long-term care facility costs. The direct stroke costs for the aforementioned parameters were adjusted to 2015 US$ and are shown in table 1. Outpatient rehabilitation costs were derived from previous literature.11 Outpatient rehabilitation care was based upon the cost of services for 1 year ($18 121.25). Long-term nursing home costs were derived from the average annual nursing home cost ($85 775) according to the 2015 Genworth survey.12 The cost of long-term nursing care was adjusted for the functional requirements of a stroke patient. For example, patients with mRS of 5 would have additional functional requirements such as percutaneous feeding, mechanical ventilation, and incontinence care. The mechanical ventilation costs were converted from 2000 ($37 600) to 2015 US$ ($51 924.90),13 annual percutaneous feeding costs were converted from 2001 ($31 832) to 2015 US$ ($42 743.13),14 fecal incontinence care costs were converted from 2010 ($2353) to 2015 US$ ($2566.11), and urinary incontinence care costs were converted from 2000 ($5173.87) to 2015 US$ ($7145.02).15 The costs for functional patient needs were converted to 2015 US$ with the Bureau of Labor Statistics consumer price index calculator. Skilled nursing facility costs were derived from the average Medicare payment for initial stays for stroke patients.16 Long-term nursing home costs for 1 year were also multiplied by years of life remaining to determine the lifetime cost of nursing home care in patients with LVO. Home care costs were calculated based on the average number of hours of informal care for stroke patients (46.38 h per week) and the average annual salary of a home health aide ($45 760 for 44 h per week).11 ,17 Home care costs were adjusted based on the functional outcome of a stroke patient and estimated hours of care required for remaining lifetime. The hours for home care were estimated to be 20.4 h/week for an mRS of 1, 33.39 h/week for an mRS of 2, and 46.38 h/week for an mRS of 3. Although patients with an mRS of 1 and 2 are ‘functionally independent’ and are likely to be able to take care of most of their own activities of daily living, we attributed part-time home care to these mRS categories because patients with persistent minor non-disabling deficits are likely to require assistance with more complex daily tasks such as house cleaning, shopping, and meal preparation. Many of these may be provided by informal caregivers (ie, family and friends), but many patients may need external support. The equation used to calculate home care costs is shown in table 1.

    View this table:
    Table 1

    Direct and indirect cost parameters

    It was assumed that patients with an mRS up to 3 could be cared for at home and those with an mRS of 0 would not require home aide. Additionally, we assumed patients with an mRS of 4 or 5 would require care in a nursing home. Patients with an mRS of 5 would have the additional aforementioned functional requirements (mechanical ventilation, feeding, and incontinence care). Outpatient rehabilitation, home care, and nursing home care were calculated based upon years of life remaining (see table 1).

    Procedural and inpatient hospitalization costs for patients receiving ME were estimated to be equal to the national average reimbursement for MS-DRG (Medicare Severity Diagnostic-Related Group) 024, which refers to craniotomies with major device implant or acute complex central nervous system principal diagnosis without major comorbidities or complications.10 ,18 ,19 The hospitalization and procedural costs for patients receiving standard medical therapy was estimated to be equal to the reimbursement for MS-DRG 065, which refers to intracranial hemorrhage or cerebral infarction with comorbidities or complications or tPA in 24 h.12–14 Inpatient rehabilitation costs were derived in a similar manner. Inpatient rehabilitation costs were estimated to be equal to the national Medicare reimbursement for MS-DRG 946, which refers to rehabilitation without major comorbidities or complications. The national repayment averages for inpatient stroke and rehabilitation care are listed in accordance with their MS-DRG code in table 1.

    Indirect costs

    Indirect costs were accounted for in terms of years of life expectancy lost and lost quality-adjusted life years (QALYs). Indirect cost parameters are listed in table 1. QALY weights were derived from Cho et al for each mRS level.20 The health benefits were measured in QALYs, which account for the effects of treatment on morbidity and mortality rates. The life expectancy estimates used in the model were derived from Slot et al.21 The indirect costs have been calculated using the parameters mentioned previously and the results are listed in table 1. Table 1 also contains the equation used to calculate lost life expectancy based upon mRS.

    The value of a QALY ($129 090) was derived from Lee et al.22 Lost QALY values adjusted for mRS levels were calculated based upon QALY weights from Cho et al20 and the value of a QALY. Differences in direct and indirect costs and benefits between medical and interventional treatment were assessed using Microsoft Excel 2013. The overall net cost–benefit for IV tPA and ME was based upon the total costs of stroke care. It included the direct costs and the indirect costs and benefits. To assess the benefit of ME over IV tPA, the net cost–benefit was multiplied by the percentages of mRS obtained in the MR CLEAN study. The financial benefits of interventional care were assessed at the individual level and in up to 50 000 patients.

    Results

    The total costs for each mRS for stroke care are listed in table 2, which indicates the equations used in calculations. The total costs account for costs for each mRS excluding treatment and hospitalization costs. This indicates the cost incurred by stroke patients regardless of treatment, only based on mRS. The direct costs for stroke with medical or interventional treatment and hospitalization added are listed in online supplementary table S1. This accounts for the direct cost incurred by stroke patients for each mRS based upon administration of ME or IV tPA. Similarly, the indirect cost–benefits are listed in online supplementary table S2 for both treatment strategies. The direct and indirect costs use the MR CLEAN findings, identifying the percentage of patients that could fall within each mRS state. The net total direct and indirect return/cost per mRS following treatment with IV tPA or ME is shown in table 3. Table 4 summarizes the direct and indirect costs associated with IV tPA and ME. Table 4 also highlights the significant financial benefit for ME intervention over IV tPA administration per patient, 100 patients, and 50 000 patients. There is not a significant difference in direct costs for IV tPA and ME ($26 848 025.32 and $26 669 211.13 per 100 patients, respectively). Although there is a reduction in mRS outcomes in the ME group, there is no significant reduction in life years remaining (LYR) direct cost as the remaining cost parameters (eg, nursing care, rehabilitation, home care) have similar LYR costs between the two groups despite improvements in mRS and lower annual expenditures secondary to more remaining LYR in lower mRS levels (ie, mRS 2 higher LYR direct cost than mRS 3:11.7 vs 8.4-year LYR). The benefit of ME becomes more readily apparent when examining the indirect stroke costs. ME is associated with $37 743 940.92 in QALYs retained while IV tPA results in only $21 560 327.20 in QALYs retained per 100 patients. ME therefore saves $16 183 613.72 in QALY retained compared with IV tPA based upon 100 patients. The overall direct and indirect cost–benefit for 50 000 ME patients annually is $89 407 093.27 and $8 091 806 560.50, respectively. The total cost–benefit for ME for 50 000 patients is $8 181 213 653.77 on a yearly basis. The cost–benefit of ME over IV tPA per patient is estimated to be $163 624.27. The majority of financial savings is achieved in the indirect costs. This is supported by the fact that 98.91% of the total savings were indirect QALY savings as the direct costs savings were applied towards increased LYR at diminished levels of disability.

    View this table:
    Table 2

    Total cost by mRS

    View this table:
    Table 3

    Total cost–benefit by mRS

    View this table:
    Table 4

    Cost–benefit ME versus IV tPA (100 patients)

    Discussion

    The current standard of treatment for ischemic stroke is IV tPA, which may be administered up to 4.5 h from symptom onset.2 Interventional treatment may, however, be administered up to 6 h (perhaps 12 h) from symptom onset in selected patients and has been demonstrated to have significantly improved functional clinical outcomes (MR CLEAN, SWIFT-PRIME, EXTEND-IA, and ESCAPE).4–9 The largest and broadest population of LVOs within these studies, the MR CLEAN study, showed that 32.6% and 19.1% patients achieved functional independence at 90 days (mRS 0–2) due to interventional and medical treatment, respectively.4 Our novel model based on improvements in functional mRS may be applied to any study population that uses mRS as an outcome measure. The MR CLEAN study population was used because it represented the broadest and most conservative estimates of improvement in functional outcomes of CT angiography-positive LVO patients, unscreened by advanced perfusion and penumbral imaging. The greater benefits observed in more selectively screened populations are only likely to enhance our estimates of financial benefit. These studies have already altered the current standards of stroke care and our study sought to develop a novel model to assess implementation of these new standards for financial benefits in real-world dollars.

    Prior cost analyses have established IV tPA and ME to be cost-effective therapies for ischemic stroke.23–25 Cost-effectiveness is based on the incremental cost-effectiveness ratio (ICER), which is a ratio that integrates cost and QALYs.23 Therapeutic interventions are generally considered to be cost-effective if the ICER is less than $50 000 per QALY gained.23 This value was, however, first established in 1982 for dialysis use in patients with chronic renal failure.23 As such, it has been suggested that this margin is too low and that a substantially higher value should be placed on 1 year of life without morbidity.24 Therefore, although these studies account for the clinical benefit of interventional treatment, the standard of measurement is too low in terms of accounting for financial benefit. In addition, these cost studies focused primarily on the acute direct costs associated with stroke. To date, there have been no studies that have assessed the real-world dollar cost–benefit of ME specifically in relation to total (ie, direct and indirect) stroke-related costs for implementation of next generation interventional therapy.

    Several papers have attempted to assess the indirect costs associated with ischemic stroke. Previous studies have suggested that the indirect costs of stroke account for anywhere between 3% and 71% of the total stroke expenditure.1 This wide disparity in results is due to the fact that previous cost analyses accounting for indirect stroke costs had a variety of methods, study designs, stroke types examined, and study settings.1 Our study specifically used lost years of life expectancy and lost QALYs to account for indirect costs. The direct costs in our model, like previous cost analyses, relied upon the use of Medicare reimbursement payments for inpatient hospitalization, procedures, and rehabilitation but also included home care and nursing home costs for LYR. Previous cost studies have indicated that ischemic stroke hospitalization costs are significantly higher than Medicare payments.26 ,27 In 2008 the median cost of hospitalization for patients ≥65 years treated with intravenous thrombolysis was $13 802 for those with a good outcome compared with an average Medicare payment of $10 098 for intravenous thrombolysis without complications.27 As such, the inpatient hospitalization, procedure, and rehabilitation figures implemented in our model may be an underestimation of the true cost of acute stroke care.

    Our study has several limitations in its model parameters and cost assumptions. One caveat to our study is that it does not fully encompass all the indirect cost parameters. Our study failed to account for work productivity lost, retained work capability, and personal expenditure by informal caregivers (family, friends, neighbors). This is due to the fact that there is little information available in the USA regarding informal caregivers.1 We attempted to account for informal home care costs using home health aide costs. However, this is not reflective of the true financial burden of stroke care for caregivers. The model fails to account for days of work missed or personal expenditure. Another limitation of our model is that it fails to distinguish expenditures resulting from comorbidities unrelated to stroke events. However, it is difficult to account for comorbidities separately as many are underlying risk factors for ischemic stroke. Our model assumes that patients remain in the same functional state until death and does not account for changes in functional state throughout the remaining life years (worsening or improvement). Previous cost analyses have attempted to account for this through the use of Markov models. However, these studies primarily accounted for acute direct costs only. Studies which include indirect cost analysis have not implemented the use of a Markov model but rather have employed an epidemiological model.28–30 The most notable of these studies by Taylor et al28 estimated the lifetime cost of a stroke as $140 048. Taylor et al's estimates of stroke cost may be a significant underestimation for LVOs and 2015 US$, but are still often used as a standard in cost analyses today. The epidemiological model implemented in previous cost analyses has assessed similar parameters to our cost analysis. However, the epidemiological model implemented previously has not categorized patients in relation to their functional state.

    Conclusion

    This study developed a novel model to account for direct and indirect stroke-related costs in real-world dollars. The developed model used numerous parameters to account for the acute and long-term direct and indirect costs associated with ischemic stroke. As such, the model sought to reflect the real-world cost for ischemic stroke survivors based upon treatment provided and improvements in mRS functional outcomes. Our model is similar to previous cost analyses in terms of parameters assessed and methodology implemented, and may be used in a variety of populations and disease states that rely on functional mRS as evidence of clinical benefit to determine the direct and indirect real-world dollar cost–benefit for these selected populations. The findings of our study using functional improvements in mRS from the MR CLEAN trial suggest a substantial financial benefit to interventional treatment for patients requiring ischemic stroke care of $8 billion if applied widely to an estimated 50 000 LVO patients annually in the USA.

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    Supplementary materials

    • Supplementary Data

      This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

    Footnotes

    • Contributors SM, KO'C: conception, design, acquisition, analysis, interpretation, drafting and revising manuscript, final draft approval, accountable for integrity. DK, MS: acquisition, analysis, interpretation, drafting and revising manuscript, final draft approval, accountable for integrity.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement All data used in this study are included in the main manuscript, online supplementary materials, and referenced literature and resources.