Cost-effectiveness of Endovascular Therapy for Acute Ischemic Stroke: A Systematic Review of the Impact of Patient Age

Abstract

Purpose To determine the impact of patient age on the cost-effectiveness of endovascular therapy (EVT) in addition to standard care (SC) in large-vessel-occlusion stroke for patients aged 50 to 100 years in the United States. Materials and Methods A decision-analytic Markov model was used to estimate direct and indirect lifetime costs and quality-adjusted life years (QALYs). Age-dependent input parameters were obtained from the literature. Deterministic and probabilistic sensitivity analysis for age at index stroke were used. The willingness-to-pay (WTP) was set to thresholds of $50 000, $100 000, and $150 000 per QALY. The study applied a U.S. setting for health care and societal perspectives. Incremental costs and effectiveness were derived from deterministic and probabilistic sensitivity analysis. Acceptability rates at different WTP thresholds were determined. Results EVT+SC was the dominant strategy in patients aged 50 to 79 years. The highest incremental effectiveness (2.61 QALYs) and cost-savings (health care perspective, $99 555; societal perspective, $146 385) were obtained in 50-year-old patients. In octogenarians (80-89 years), EVT+SC led to incremental QALYs at incremental costs with acceptability rates of more than 85%, more than 99%, and more than 99% at a WTP of $50 000, $100 000, and $150 000 per QALY, respectively. In nonagenarians (90-99 years), acceptability rates at a WTP of $50 000 per QALY dropped but stayed higher than 85% and higher than 95% at thresholds of $100 000 and $150 000 per QALY. Conclusion Using contemporary willingness-to-pay thresholds in the United States, endovascular therapy in addition to standard care reduces lifetime costs for patients up to 79 years of age and is cost-effective for patients aged 80 to 100 years.

Cost-Consequence Analysis of Advanced Imaging in Acute Ischemic Stroke Care

“…Importantly, this implies that the costs for long-term care will also be reduced. At $20,837/QALY, the advanced CTAP imaging strategy should be considered appropriate for adoption in clinical care when considering a threshold of $50,000/QALY, which is customarily used as a threshold in health policy (4,5,17,25,34). Furthermore, our model results, based on Medicare CPT reimbursement, showed that for diagnostic imaging, the advanced CTAP imaging strategy is more costly than the standard-of-care strategy.…”

“…The ongoing operational and clinical acute care costs were derived from the published literature as shown in Table 2, which utilize Medicare CPT codes to estimate the costs. It is standard practice in health economics evaluations to use Medicare reimbursement as a substitute for actual costs (25,33,34) to minimize bias from practice variation. These costs include depreciation on all depreciable type assets that are used to provide covered services to beneficiaries (35).…”

Cost-effectiveness of short-protocol emergency brain MRI after negative non-contrast CT for minor stroke detection

“…Our study adds to the field as it demonstrated the costeffectiveness of supplemental short-protocol MRI subsequent to negative head CT in neurological emergency patients. In many related fields of research, the additional utilization of procedures and diagnostic tests has been shown to be cost-effective: Despite high costs in the acute setting, interventional treatment has been shown to be cost-effective in major stroke patients, even in patients with a limited overall life expectancy [26,36]. Furthermore, a transition from a time window to a tissue window for stroke patients presenting with unknown onset time for endovascular treatment and intravenous thrombolysis has taken place [37][38][39].…”

Burden of large vessel occlusion stroke and the service gap of thrombectomy: A population-based study using a territory-wide public hospital system registry

“…19,20,25,26 In higher-income countries in Europe and North America, endovascular therapy have been found to be ''cost-effective'' using contemporary willingness-to-pay threshold for qualityadjusted life year (QALY) gained for patients up to 100 years old, and even cost-saving from a societal perspective for patients up to 79 years old. 27 Whether the same cost-utility analyses remain favorable in middle-or low-income countries is yet to be determined. Equitable access to thrombectomy service is another concern in these countries where income disparity may be significant and comprehensive public health care coverage lacking.…”