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A Prospective Economic Evaluation of Rapid Endovascular Therapy for Acute Ischemic Stroke

Published online by Cambridge University Press:  12 January 2021

Laura K. Sevick
Affiliation:
Department Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
Andrew M. Demchuk
Affiliation:
Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
Ashfaq Shuaib
Affiliation:
Department of Medicine, Division of Neurology, University of Alberta, Edmonton, Alberta, Canada
Eric E. Smith
Affiliation:
Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
Jeremy L. Rempel
Affiliation:
Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada
Kenneth Butcher
Affiliation:
Department of Medicine, Division of Neurology, University of Alberta, Edmonton, Alberta, Canada
Bijoy K. Menon
Affiliation:
Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
Thomas Jeerakathil
Affiliation:
Department of Medicine, Division of Neurology, University of Alberta, Edmonton, Alberta, Canada
Noreen Kamal
Affiliation:
Department of Electrical and Computer Engineering, Schulich School of Engineering, University of Calgary, Calgary, AB, Canada
John Thornton
Affiliation:
Royal College of Surgeons and Beaumont Hospital, Dublin, Ireland
David Williams
Affiliation:
Royal College of Surgeons and Beaumont Hospital, Dublin, Ireland
Alexandre Y. Poppe
Affiliation:
Département de Neurosciences, CHUM-Hopital Notre Dame, Montreal, Quebec, Canada
Daniel Roy
Affiliation:
Département de Neurosciences, CHUM-Hopital Notre Dame, Montreal, Quebec, Canada
Mayank Goyal
Affiliation:
Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
Michael D. Hill
Affiliation:
Department Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
Fiona Clement
Affiliation:
Department Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada O’Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
Corresponding
E-mail address:

Abstract:

Background:

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.

Methods:

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.

Results:

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.

Conclusions:

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.

Clinical Trial Registration: NCT01778335

Résumé :

RÉSUMÉ :

Évaluation économique prospective de la thérapie endovasculaire rapide dans le cas de patients victimes d’accidents ischémiques aigus.

Contexte :

C’est dans le cadre des essais ESCAPE (Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke) et d’une évaluation randomisée de la thérapie endovasculaire (TEV) rapide destinée aux patients victimes d’accidents ischémiques qu’ont été collectées des données portant sur le calcul des coûts de traitement pour chaque patient pris individuellement. Nous voulons présenter ici une analyse coût-efficacité de la TEV au moyen de ces données et de la méthode de simulation des chaînes de Markov, et ce, dans le cadre d’un système universel de santé à payeur unique et en recourant à une perspective sociétale valide tout au long de la vie des patients.

Méthodes :

Cette collecte de données primaires liée aux essais ESCAPE nous a permis, au cours d’une période de 3 mois, d’analyser de façon spécifique et indépendamment d’un modèle les coûts de la TEV par année de vie ajustée en fonction de la qualité (AVAQ). Nous avons ensuite fait appel à un modèle basé sur la méthode de simulation des chaînes de Markov, modèle utilisant les coûts récurrents pendant une vie et l’espérance de vie en se basant sur ce qui est disponible dans la littérature scientifique. L’état de santé des patients a été défini à l’aide des scores à l’échelle de Rankin modifiée. Enfin, l'incertitude a été explorée à l'aide d'une analyse de scénarios et d'une analyse de sensibilité probabiliste (ASP).

Résultats :

En comparaison avec la meilleure norme en matière de soins, notre analyse basée sur les essais ESCAPE d’une durée de 3 mois a permis d’établir un coût par AVAQ de 201 243 $ en ce qui concerne la TEV. Dans une analyse basée sur un modèle, en recourant à une perspective sociétale et en fonction d’un horizon temporel couvrant une vie entière, la TEV a dépassé la meilleure norme en matière de soins en s’avérant à la fois plus efficace et moins coûteuse (- 91 $). Lorsque cet horizon temporel a été écourté d’un an, la TEV s’est aussi révélée moins coûteuse si on la compare à la norme des soins (~ 15 376 $ par AVAQ). Cela dit, la TEV pourrait cesser d’être synonyme de réduction de coûts en comparaison avec la meilleure norme en matière de soins si l’on admet que l’estimation de son efficacité clinique serait 4 % moindre que celle démontrée lors des essais ESCAPE.

Conclusions :

Ces résultats militent donc en faveur de l’adoption de la TEV comme traitement des accidents ischémiques aigus car l’augmentation des coûts associée aux soins prodigués aux patients ayant bénéficié de la TEV a été amortie pendant la première année consécutive à un AVC. Soulignons en outre qu’un tel traitement a continué à représenter des économies tout au long de la vie des patients.

Type
Original Article
Copyright
Copyright © The Author(s), 2021. Published by Cambridge University Press on behalf of The Canadian Journal of Neurological Sciences Inc.

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