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A Cost-Utility Analysis of Endovascular Thrombectomy in a Real-World Setting

  • Prosper S. Koto (a1), Sherry X. Hu (a2), Karim Virani (a3), Wendy L. Simpkin (a4), Christine A. Christian (a4), Huiling Cao (a5), Jai J. S. Shankar (a3) and Stephen J. Phillips (a2)...

Abstract:

Objective:

Endovascular thrombectomy (EVT) is efficacious for ischemic stroke caused by proximal intracranial large-vessel occlusion involving the anterior cerebral circulation. However, evidence of its cost-effectiveness, especially in a real-world setting, is limited. We assessed whether EVT ± tissue plasminogen activator (tPA) was cost-effective when compared with standard care ± tPA at our center.

Method:

We identified patients treated with EVT ± tPA after the Endovascular treatment for Small Core and Anterior circulation Proximal occlusion with Emphasis on minimizing computed tomography to recanalization times trial from our prospective stroke registry from February 1, 2013 to January 31, 2017. Patients admitted before February 2013 and treated with standard care ± tPA constitute the controls. The sample size was 88. Cost-effectiveness was assessed using the net monetary benefit (NMB). Differences in average costs and quality-adjusted life years (QALYs) were estimated using the augmented inverse probability weighted estimator. We accounted for sampling and methodological uncertainty in sensitivity analyses.

Results:

Patients treated with EVT ± tPA had a net gain of 2.89 [95% confidence interval (CI): 0.93–4.99] QALYs at an additional cost of $22,200 (95% CI: −28,902–78,244) per patient compared with the standard care ± tPA group. The NMB was $122,300 (95% CI: −4777–253,133) with a 0.85 probability of being cost-effective. The expected savings to the healthcare system would amount to $321,334 per year.

Conclusion:

EVT ± tPA had higher costs and higher QALYs compared with the control, and is likely to be cost-effective at a willingness-to-pay threshold of $50,000 per QALY.

Analyse coût-efficacité de la thrombectomie endovasculaire dans un contexte réel. Objectif : La thrombectomie endovasculaire (TE) est efficace dans le cas d’accidents ischémiques cérébraux (AIC) causés par une occlusion proximale de l’artère cérébrale antérieure. Toutefois, les preuves d’un bon rapport coût-efficacité, particulièrement dans le cadre d’une pratique réelle, demeurent limitées. Nous avons ainsi évalué au sein de notre établissement dans quelle mesure la thrombectomie endovasculaire jumelée à un traitement au moyen d’un activateur tissulaire du plasminogène (t-PA) étaient davantage rentables en comparaison avec des soins usuels également jumelés à un traitement de t-PA. Méthodes : En consultant nos registres prospectifs, nous avons identifié des patients traités par une thrombectomie endovasculaire jumelée à un traitement de t-PA après avoir subi, du 1er février 2013 au 31 janvier 2017, un traitement endovasculaire destiné à un petit AVC central et ischémique à occlusion proximale avec un accent mis sur la minimisation du temps de recanalisation par tomodensitométrie. Les patients hospitalisés avant février 2013 et auxquels des soins usuels avaient été prodigués de concert avec l’administration d’un t-PA ont fait partie de notre groupe témoin. Au total, notre échantillon était formé de 88 patients. Nous avons évalué le rapport coût-efficacité au moyen du concept d’avantage monétaire net (AMN). Nous avons également estimé les différences en ce qui concerne les coûts moyens et l’indicateur QALY (quality-adjusted life years) en faisant appel à un estimateur pondéré par l’inverse de la probabilité inverse (augmented inverse probability weighted estimator). Enfin, nous avons tenu compte de l’incertitude de notre échantillonnage et de nos choix méthodologiques dans nos analyses de sensibilité. Résultats : Les patients traités par thrombectomie endovasculaire et l’administration d’un t-PA ont donné à voir un gain net de 2,89 années selon l’indicateur QALY (IC 95 % : 0,93 – 4,99) pour un coût additionnel de 22 200 $ (IC 95 % : −28,902 – 78,244) par patient si on les compare à notre groupe témoin. L’AMN s’est quant à lui élevé à 122 300 $ (IC 95 % : −4 777 – 253 133), sa probabilité d’être rentable atteignant 0,85. À cet égard, les économies annuelles pour le système de soins de santé pourraient atteindre les 321 334 $. Conclusion : Il appert que la thrombectomie endovasculaire jumelée à un traitement de t-PA entraînent des coûts plus élevés et un meilleur indicateur QALY en comparaison avec notre groupe témoin. Il est probable qu’une telle approche soit rentable en vertu d’un seuil de disposition à payer (willingness-to-pay threshold) avoisinant les 50 000 $ par année selon le QALY.

Copyright

Corresponding author

Correspondence to: Stephen J. Phillips, Division of Neurology, Department of Medicine, Dalhousie University and Nova Scotia Health Authority, 1796 Summer St., Room 3835B, Halifax, NS B3H 2A7, Canada. Email: stephen.phillips@dal.ca

References

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1. Goyal, M, Demchuk, AM, Menon, BK, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372(11):1019–30. doi: 10.1056/NEJMoa1414905
2. Boulanger, J, Lindsay, M, Gubitz, G, et al. Canadian stroke best practice recommendations for acute stroke management: prehospital, emergency department, and acute inpatient stroke care, 6th edition, update 2018. Int J Stroke. 2018;13(9):949–84. doi: 10.1177/1747493018786616
3. Xie, X, Lambrinos, A, Chan, B, et al. Mechanical thrombectomy in patients with acute ischemic stroke: a cost-utility analysis. CMAJ Open. 2016;4(2):E316–25. doi: 10.9778/cmajo.20150088
4. Kim, AS, Nguyen-Huynh, M, Johnston, SC. A cost-utility analysis of mechanical thrombectomy as an adjunct to intravenous tissue-type plasminogen activator for acute large-vessel ischemic stroke. Stroke. 2011;42(7):2013–18. doi: 10.1161/STROKEAHA.110.606889
5. Endovascular Thrombectomy for Patients with Ischemic Stroke: Clinical and Cost –Effectiveness. Ottawa: CADTH; 2018 Jun. (CADTH rapid response report: summary of abstracts). https://www.cadth.ca/endovascular-thrombectomy-patients-ischemic-stroke-clinical-and-cost-effectiveness-0; accessed December 19, 2018.
6. Sevick, LK, Ghali, S, Hill, MD, et al. Systematic review of the cost and cost-effectiveness of rapid endovascular therapy for acute ischemic stroke. Stroke. 2017;48(9):2519–26. doi: 10.1161/STROKEAHA.117.017199
7. Abadie, A, Imbens, GW. Matching on the estimated propensity score. Econometrica. 2016;84(2):781807. doi: 10.3982/ECTA11293
8. Cattaneo, MD, Drukker, DM, Holland, AD. Estimation of multivalued treatment effects under conditional independence. Stata J. 2013;13(3):407–50. https://ideas.repec.org/a/tsj/stataj/v13y2013i3p407-450.html; accessed October 18, 2018.
9. Drummond, MF, Sculpher, MJ, Claxton, K, Stoddart, GL, Torrance, GW. Methods for the economic evaluation of health care programmes, 4th ed. Oxford, UK; New York, NY, USA: Oxford University Press; 2015.
10. Achit, H, Soudant, M, Hosseini, K, et al. Cost-effectiveness of thrombectomy in patients with acute ischemic stroke. Stroke. 2017;48(10):2843–7. doi: 10.1161/STROKEAHA.117.017856
11. Leal, J, Ahrabian, D, Davies, MJ, et al. Cost-effectiveness of a pragmatic structured education intervention for the prevention of type 2 diabetes: economic evaluation of data from the Let’s Prevent Diabetes cluster-randomised controlled trial. BMJ Open. 2017;7(1):e013592. doi: 10.1136/bmjopen-2016013592
12. Berger, ML, Sox, H, Willke, RJ, et al. Good practices for real-world data studies of treatment and/or comparative effectiveness: recommendations from the joint ISPOR-ISPE Special Task Force on real-world evidence in health care decision making. Pharmacoepidemiol Drug Saf. 2017;26(9):1033–9. doi: 10.1002/pds.4297
13. Cox, E, Martin, BC, Van Staa, T, Garbe, E, Siebert, U, Johnson, ML. Good research practices for comparative effectiveness research: approaches to mitigate bias and confounding in the design of nonrandomized studies of treatment effects using secondary data sources: the international society for pharmacoeconomics and outcomes research good research practices for retrospective database analysis task force report--part II. Value Health J Int Soc Pharmacoeconomics Outcomes Res. 2009;12(8):1053–61. doi: 10.1111/j.1524–4733.2009.00601.x
14. Phillips, SJ, Eskes, GA, Gubitz, GJ, Queen Elizabeth, II. Health sciences centre acute stroke team. Description and evaluation of an acute stroke unit. CMAJ Can Med Assoc J J Assoc Medicale Can. 2002;167(6):655–60.
15. Hu, S., Virani, K., Christian, C., et al. Case-control study of endovascular thrombectomy in a Canadian Stroke Centre. Can J Neurol Sci. 2019. doi: 10.1017/cjn.2019.315.
16.Canadian Patient Cost Database Technical Document: MIS Patient Costing Methodology, January 2019: 56.
17. Guidelines for the economic evaluation of Health Technologies: Canada, 4th ed. Ottawa: CADTH; 2017 Mar.
18. Bamford, J, Sandercock, P, Dennis, M, Burn, J, Warlow, C. A prospective study of acute cerebrovascular disease in the community: the Oxfordshire Community Stroke Project--1981–86. 2. Incidence, case fatality rates and overall outcome at one year of cerebral infarction, primary intracerebral and subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry. 1990;53(1):1622. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1014091/; accessed February 12, 2019.
19. Sassi, F. Calculating QALYs, comparing QALY and DALY calculations. Health Policy Plan. 2006;21(5):402–8. doi: 10.1093/heapol/czl018
20. Heart and Stroke foundation, Canada. Lives Disrupted: The Impact of Stroke on Women. 2018:24. =https://www.heartandstroke.ca/-/media/pdf-files/canada/stroke-report/strokereport2018.ashx?la=en.
21. The cost of long-term care: Canada’s retirement savings blind spot: Canada: HOOP, Feb 2018. =https://hoopp.com/docs/default-source/about-hoopp-library/advocacy/retirementsecurity-longtermcare-feb2018.pdf?sfvrsn=397a7d47_2; accessed December 11, 2018.
22. Bamford, J, Sandercock, P, Dennis, M, Burn, J, Warlow, C. Classification and natural history of clinically identifiable subtypes of cerebral infarction. Lancet Lond Engl. 1991;337(8756):1521–6.
23. Busso, M, DiNardo, J, McCrary, J. New evidence on the finite sample properties of propensity score reweighting and matching estimators. Rev Econ Stat. 2014;96(5):885–97. doi: 10.1162/REST_a_00431
24. Austin, PC. An introduction to propensity score methods for reducing the effects of confounding in observational studies. Multivar Behav Res. 2011;46(3):399–424. doi: 10.1080/00273171.2011.568786
25. Tan, Z. Bounded, efficient and doubly robust estimation with inverse weighting. Biometrika. 2010;97(3):661–82. https://www.jstor.org/stable/25734115; accessed December 17, 2018.
26. Rosenbaum, PR, Rubin, DB. The central role of the propensity score in observational studies for causal effects. Biometrika. 1983;70(1):4155. doi: 10.2307/2335942
27. Hong, K-S, Saver, JL. Quantifying the value of stroke disability outcomes: WHO global burden of disease project disability weights for each level of the modified Rankin Scale. Stroke. 2009;40(12):3828–33. doi: 10.1161/STROKEAHA.109.561365
28. Gray, AM, Clarke, P, Wolstenholme, J, Wordsworth, S. Applied Methods of Cost-effectiveness Analysis in Healthcare — Health Economics Research Centre. 2011. https://www.herc.ox.ac.uk/downloads/applied-methods-of-cost-effectiveness-analysis-in-healthcare; accessed October 18, 2018.
29. Fieller, EC. The biological standardization of insulin. Suppl J R Statist Soc. 1940;7:164.
30. Health Quality Ontario. Mechanical thrombectomy in patients with acute ischemic stroke: a health technology assessment. Ont Health Technol Assess Ser [Internet]. 2016 February;16(4):1–79. Available from: http://www.hqontario.ca/evidence/publications-and-ohtacrecommendations/ontario-health-technology-assessment-series/htamechanical-thrombectomyPortals/0/Documents/evidence/reports/hta-mechanical-thrombectomy-1602-en.pdf; accessed December 18, 2018.

Keywords

A Cost-Utility Analysis of Endovascular Thrombectomy in a Real-World Setting

  • Prosper S. Koto (a1), Sherry X. Hu (a2), Karim Virani (a3), Wendy L. Simpkin (a4), Christine A. Christian (a4), Huiling Cao (a5), Jai J. S. Shankar (a3) and Stephen J. Phillips (a2)...

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