Reduced Impact of Endovascular Thrombectomy on Disability in Real-World Practice, Relative to Randomized Controlled Trial Evidence in Australia

Abstract

Background and Aims: Disability-adjusted life years (DALYs) are an important measure of the global burden of disease that informs patient outcomes and policy decision-making. Our study aimed to compare the DALYs saved by endovascular thrombectomy (EVT) in the Australasian-based EXTEND-IA trial vs. clinical registry data from EVT in Australian routine clinical practice.Methods: The 3-month modified Rankin scale (mRS) outcome and treatment status of consecutively enrolled Australian patients with large vessel occlusion (LVO) stroke were taken from the International Stroke Perfusion Imaging Registry (INSPIRE). DALYs were calculated as the summation of years of life lost (YLL) due to premature death and years lived with a disability (YLD). A generalized linear model (GLM) with gamma family and log link was used to compare the difference in DALYs for patients receiving/not receiving EVT while controlling for key covariates. Ordered logit regression model was utilized to compare the difference in functional outcome at 3 months between the treatment groups. Cox regression analysis was undertaken to compare the difference in survival over an 18-year time horizon. Estimated long-term DALYs saved based on the EXTEND-IA randomized controlled trial (RCT) results were used as the comparator.Results: INSPIRE patients who received EVT treatment only achieved nominally better functional outcomes than the non-EVT group (p = 0.181) at 3 months. There was no significant survival gain from EVT over the first 3 months of stroke in both INSPIRE and EXTEND-IA patients. However, measured against no EVT in the long-term, EVT in INSPIRE was associated with no significant survival gain [hazard ratio (HR): 0.92, 95% confidence interval (CI): 0.78–1.08, p = 0.287] compared with the survival benefit extrapolated from the EXTEND-IA trial (HR: 0.42, 95% CI: 0.22–0.82, p = 0.01]. Offering EVT to patients with LVO stroke was also associated with fewer DALYs lost (11.04, 95% CI: 10.45–11.62) than those not receiving EVT in INSPIRE (12.13, 95% CI: 11.75–12.51), a reduction of −1.09 DALY (95% CI: −1.76 to −0.43, p = 0.002). The absolute magnitude of the treatment effect was lower than that seen in EXTEND-IA (−2.72 DALY reduction in EVT vs non-EVT patients).Conclusions: EVT for the treatment of LVO in a registry of routine care was associated with significantly lower DALYs lost than medical care alone, but the saved DALYs are less than those reported in clinical trials, as there were major differences in the baseline characteristics of the patients.

Burden of Parkinson Disease in China, 1990–2019: Findings from the 2019 Global Burden of Disease Study

“…The YLDs:DALYs ratio has been used in many previous studies as an indicator of the efficiency of the healthcare system [27][28][29][30]. In fact, both DALYs and YLDs were conceptualized by the GBD study as tools to improve the capacity of professionals to assess population health and establish evidence-based decision-making in public health [31,32]. The higher proportion of YLDs to DALYs reflects less premature death from disease and its complications, expressed as years of life lost.…”

RCT versus real-world cohorts: Differences in patient characteristics drive associations with outcome after EVT

“…Such data are leveraged from different real-world registries as well as RCTs and are often reported side by side. Previous studies comparing real-world registry- and RCT-derived data were either constrained by analyzing cumulative and not individual patient-level data or were focused on the comparison of functional outcomes and adverse effects 20 , 21 and did not include a comparison of individual predictors. Our analyses point toward considerable differences between RCT and real-world cohorts in how variables such as age and time from onset to treatment initiation are related to outcome.…”

Stroke in the young

“…Hyperacute treatments in arterial ischemic stroke have advanced profoundly over the past 30 years, and successes in thrombolytic, thrombectomy, and mobile stroke unit trials have led to improved outcomes for thousands of patients worldwide [24,25]. Major hyperacute stroke trials have generally included patients 18 or older, and the benefit of these therapies in young adult stroke patients is widely accepted.…”