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During the Randomized Assessment of Rapid Endovascular Treatment (EVT) of Ischemic Stroke (ESCAPE) trial, patient-level micro-costing data were collected. We report a cost-effectiveness analysis of EVT, using ESCAPE trial data and Markov simulation, from a universal, single-payer system using a societal perspective over a patient’s lifetime.
Primary data collection alongside the ESCAPE trial provided a 3-month trial-specific, non-model, based cost per quality-adjusted life year (QALY). A Markov model utilizing ongoing lifetime costs and life expectancy from the literature was built to simulate the cost per QALY adopting a lifetime horizon. Health states were defined using the modified Rankin Scale (mRS) scores. Uncertainty was explored using scenario analysis and probabilistic sensitivity analysis.
The 3-month trial-based analysis resulted in a cost per QALY of $201,243 of EVT compared to the best standard of care. In the model-based analysis, using a societal perspective and a lifetime horizon, EVT dominated the standard of care; EVT was both more effective and less costly than the standard of care (−$91). When the time horizon was shortened to 1 year, EVT remains cost savings compared to standard of care (∼$15,376 per QALY gained with EVT). However, if the estimate of clinical effectiveness is 4% less than that demonstrated in ESCAPE, EVT is no longer cost savings compared to standard of care.
Results support the adoption of EVT as a treatment option for acute ischemic stroke, as the increase in costs associated with caring for EVT patients was recouped within the first year of stroke, and continued to provide cost savings over a patient’s lifetime.
For the purposes of this study I am defining West Central Africa largely by the watershed of the Congo River. If the region has a hydrographic center, it is the Lunda Plateau in eastern Angola, a relatively flat region at roughly 1,000 meters elevation, origin of many of the largest effluents of the Congo. This highland continues eastward until it reaches the great range of mountains that define the Rift Valley, and separate it from the Nile system. Because human geography is not always identical to natural geography, there are additions to this defined space.
An important addition is the rivers that drain from the low mountains that define the western end of the Congo watershed that flow westward into the Atlantic Ocean which are included in the study because many political units had borders that straddled the two, such as the Kingdoms of Ndongo and Kasanje, which were regularly engaged on both sides of the Kwango watershed, or the Luyana Kingdom, which lay squarely in the Zambezi River watershed but was in substantial communication with the Lunda Empire.
The death of Nawej II in 1852 marks the end of this history. In some ways, this date, like any other, has only limited significance. One might as easily chose the death of Henrique II in Kongo in 1856, or the death of several other powerful or influential rulers, as the region was not so tightly integrated politically as to give precedence to any one or the other.
But the mid-nineteenth century was a signal turning point for West Central Africa. In 1839 steamships from Europe began making regular stops in Africa, and for the first time in history it was possible to ship bulk commodities cheaply. The Industrial Revolution in Europe had reached a point where production of some vital commodities such as metal goods and textiles were sufficient in themselves to clothe and provide equipment for entire world regions, and export them there. The commodity revolution, the mass import of mundane products, began in earnest with that signal change.
Lunda becomes an important kingdom and begins expanding east and west, Matamba and Kasanje struggle over the Kwango Valley, the Portuguese consolidate their control over the colony of Angola, Kongo enters a period of civil war, and Beatriz Kimpa Vita tries to restore it
Based on substantial new research from primary sources and archives, this accessible interpretative history of West Central Africa from earliest times to 1852 gives comprehensive and in-depth coverage of the region. With equal focus given to both internal histories or inter-state interactions and external dynamics and relationships, this study represents an original approach to regional histories which goes beyond the existing scholarship on the area. By contextualising and expanding its range, to include treatment of the Portuguese colony of Angola, John K. Thornton provides new understandings of significant events, people, and inter-regional interactions which aid the grounding of the history of West Central Africa within a broader context. A valuable resource to students and scholars of African history.