Systematic Review, Critical Appraisal, and Analysis of the Quality of Economic Evaluations in Stroke Imaging

Abstract

P atients with stroke often require extensive inpatient and outpatient care. In Canada, the annual cost of stroke care was recently estimated at Cdn $2.7 billion.1-3 These high human and economic costs may be mitigated by decreasing stroke-related morbidity and mortality. Optimal acute ischemic stroke (AIS) management includes timely access to neuroimaging (computed tomographic [CT] or MRI scanning) as well as thrombolytic therapy when indicated. 4,5 Baseline neuroimaging is used to rule out intracerebral hemorrhage and confirm the presence of infarction. 6In general, the use of economic evaluations to assess medical imaging technology is in its infancy. However, radiological interventions for cerebrovascular disease are 1 of the top 2 clinical areas in which imaging-focused economic evaluations are being undertaken.7 Although the number of economic evaluations within medical imaging has increased, the quality of these studies has been called into question. [7][8][9] Despite the publication of guidelines for health economic studies, there has not been a concomitant increase in the quality of published, imaging-specific economic evaluations. 7,10,11 High-quality economic evaluations can be powerful tools that generate robust estimates of the impact of a heath technology on health outcomes and costs. General methodological issues, and factors specific to patients with stroke, need to be considered when assessing the validity of economic evaluations of imaging after stroke. These include the model structure of the economic evaluation, the data chosen to populate the model, as well as the accuracy of stroke outcome measures and outcomes specific to the use of certain imaging Background and Purpose-This study reviews the quality of economic evaluations of imaging after acute stroke and identifies areas for improvement. Methods-We performed full-text searches of electronic databases that included Medline, Econlit, the National Health Service Economic Evaluation Database, and the Tufts Cost Effectiveness Analysis Registry through July 2012. Search strategy terms included the following: stroke*; cost*; or cost-benefit analysis*; and imag*. Inclusion criteria were empirical studies published in any language that reported the results of economic evaluations of imaging interventions for patients with stroke symptoms. Study quality was assessed by a commonly used checklist (with a score range of 0% to 100%). Results-Of 568 unique potential articles identified, 5 were included in the review. Four of 5 articles were explicit in their analysis perspectives, which included healthcare system payers, hospitals, and stroke services. Two studies reported results during a 5-year time horizon, and 3 studies reported lifetime results. All included the modified Rankin Scale score as an outcome measure. The median quality score was 84.4% (range=71.9%-93.5%). Most studies did not consider the possibility that patients could not tolerate contrast media or could incur contrast-induced nephropathy. Three studies compared perfusion computed...

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“…This possibility would facilitate the selection of patients who may benefit from revascularization treatments, excluding those for whom the risk of complications is very high or the brain damage by infarct is irreversible [1,2].…”