Quick search in Citations
This JournalAnywhereCitation
Advanced Search
Research Article
Originally Published 6 August 2015
Open Access

Cost-Utility Analysis of Mechanical Thrombectomy Using Stent Retrievers in Acute Ischemic Stroke

Jeban Ganesalingam, MBBS, MRCP (Neuro), PhD, Elena Pizzo, PhD, Stephen Morris, PhD, Tom Sunderland, MSc, Diane Ames, MBBS, FRCP, and Kyriakos Lobotesis, MBBS, FRCRAuthor Info & Affiliations
Stroke
Volume 46, Number 9
https://doi.org/10.1161/STROKEAHA.115.009396
Track CitationsAdd to favorites
PDF/EPUB

Abstract

Background and Purpose—

Recently, 5 randomized controlled trials demonstrated the benefit of endovascular therapy compared with intravenous tissue-type plasminogen activator in acute stroke. Economic evidence evaluating stent retrievers is limited. We compared the cost-effectiveness of intravenous tissue-type plasminogen activator alone versus mechanical thrombectomy and intravenous tissue-type plasminogen activator as a bridging therapy in eligible patients in the UK National Health Service.

Methods—

A model-based cost-utility analysis was performed using a lifetime horizon. A Markov model was constructed and populated with probabilities, outcomes, and cost data from published sources, including 1-way and probabilistic sensitivity analysis.

Results—

Mechanical thrombectomy was more expensive than intravenous tissue-type plasminogen activator, but it improved quality-adjusted life expectancy. The incremental cost per (quality-adjusted life year) gained of mechanical thrombectomy over a 20 year period was $11 651 (£7061). The probabilistic sensitivity analysis demonstrated that thrombectomy had a 100% probability of being cost-effective at the minimum willingness to pay for a quality-adjusted life year commonly used in United Kingdom.

Conclusions—

Although the upfront costs of thrombectomy are high, the potential quality-adjusted life year gains mean this intervention is cost-effective. This is an important factor for consideration in deciding whether to commission this intervention.

Introduction

Ischemic stroke is the third highest cause of death in the United Kingdom and a leading cause of disability.1 The overall incidence is postulated to increase over the next 5 years by the WHO.2 The economic burden of stroke is estimated at £9 billion per year in the United Kingdom ($38 billion in the United States) and is estimated to rise.3,4 Intravenous tissue-type plasminogen activator (IV-tPA) for cerebral arterial occlusion is the proven therapy for acute ischemic stroke.5,6 However, new strategies are increasingly involving adjunctive endovascular techniques, especially when fibrinolysis is contraindicated or has failed.
Recently, 5 randomised controlled trials (Endovascular Treatment for Acute Ischemic Stroke in the Netherlands [MR CLEAN], Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke (ESCAPE), Extending the Time for Thrombolysis in Emergency Neurological Deficits - Intra-Arterial (EXTEND-IA), Solitaire With the Intention for Thrombectomy as Primary Endovascular Treatment (SWIFT PRIME) Trial, and Endovascular Revascularization With Solitaire Device Versus Best Medical Therapy in Anterior Circulation Stroke Within 8 Hours (REVASCAT)) demonstrated superior benefit of adjunctive mechanical thrombectomy versus IV-tPA alone when there is a major vessel occlusion.7–11 This has been propagated by a new generation of thrombectomy devices, stent retrievers, which demonstrate a higher arterial recanalization rate and a better clinical outcome.12–14 More importantly, this is in patients with proximal large vessel occlusions who are known through the natural history of the disease to have a poor outcome.15
Stent retrievers have consistently shown significantly better angiographic, safety, and clinical outcome data than the Merci Retriever.16–21 Stent retrievers also seem to produce higher complete recanalization rates than Penumbra, although no head-to-head trial has been performed.22 A meta-analysis demonstrated that early vessel recanalization, using a range of methods, is associated with a 4- to 5-fold increase in the odds of good final clinical outcome, with a similar decrease in odds of death.12
Benefit of treatments is usually measured according to functional outcome at 3 months. Implementation of new treatments also depends on cost and affordability, for which a health economic study is usually needed. Stroke itself is an expensive disease in terms of its societal, personal, and financial impact. The rationalization concerning the clinical value and effectiveness of thrombectomy is guided by information regarding the benefits, risks, and costs associated. It has been suggested that although the upfront costs of thrombectomy are high, the potential reduction in morbidity can result in savings downstream both in the hospital and in the community setting, resulting in a significant reduction in the overall economic burden from stroke.
Decisions to implement new technologies in the UK National Health Service are increasingly being made taking into account economic considerations, such as cost-effectiveness and budget impact. Previous economic evaluations of thrombectomy have been undertaken in the United States and are based on single arm studies of a range of mechanical devices, now superseded in a rapidly developing field.22–25 Therefore, the purpose of this study was to model the cost-effectiveness of mechanical thrombectomy in the hyperacute management of stroke in the United Kingdom, based on a meta-analysis of the data recently published using the 5 randomized control trials, which have used predominantly stent retrievers.

Methods

This was a model-based cost-utility analysis, with outcomes measured in terms of quality adjusted life years (QALYs),26 which are the recommended outcomes for economic evaluation in the United Kingdom.27 The number of deaths averted is also reported as an additional outcome measure.

Model Structure

A short-run decision analytic model (Figure 1A) was created to analyze data on costs and clinical outcomes within 3 months from stroke and subsequently was used to distribute a theoretical cohort of patients into 1 of 3 possible health states (see Outcomes). A long-run Markov state-transition model was then used to estimate the expected costs and outcomes over a life-time horizon of 20 years, using cycles of 3 months (Figure 1B). The analysis was undertaken from the perspective of the UK National Health Service and Personal Social Services. Costs were calculated in 2013–2014 UK pounds and are presented in US$ using an exchange rate of £1=US$1.65.28 Where appropriate, costs were converted to 2013–2014 prices using National Health Service Pay and Prices Indices.29 Outcomes are measured in terms of deaths averted and quality adjusted life years (QALYs) gained. In the long-run model, all costs and outcomes after the first year are discounted at an annual rate of 3.5%.27
Figure 1. Decision model. A, Short-run analytic model. B, Long-run Markov model structure. IV-tPA indicates intravenous tissue-type plasminogen activator; and mRS, modified Rankin Scale.

Management Strategies

Two treatment options were considered, IV-tPA alone versus mechanical thrombectomy and IV-tPA used as a bridging therapy. Only data from the recently published randomized controlled trials using predominantly stent retrievers were used (see Table I in the online-only Data Supplement). For both strategies, outcomes were based on modified Rankin Scale (mRS) scores measured at 90 days after stroke, which were assumed to be affected by recanalization rates and symptomatic hemorrhage rates. We assumed that all other aspects of inpatient care, including imaging and laboratory studies, would be otherwise comparable and consistent with published clinical guidelines.30

Costs

The cost of IV-tPA was estimated to be $2953 (£1214). This includes the cost of the medication (assuming an average patient weight of 76 kg)31,32 and the cost of staff time for the administration29,33 (Table 1). Staff costs were estimated using the data on the average cost per hour.29
Table 1. Model Parameters and Range of Values for Sensitivity Analysis: Utilities Scores, Costs, Probabilities, and Transition Probabilities
 Base-Case ValueUnivariate Sensitivity AnalysisDistributionRangeAlpha-BetaSource
Probabilities
 mRS 0-1-2 after IV-tPA and thrombectomy0.46 Dirichlet0–1291-342Multiple sources
 mRS 3-4-5 after IV-tPA and thrombectomy0.39 Dirichlet0–1247-386Multiple sources
 mRS 6 after IV-tPA and thrombectomy0.15 Dirichlet0–195-538Multiple sources
 mRS 0-1-2 after IV-tPA alone0.26 Dirichlet0–1169-481Multiple sources
 mRS 3-4-5 after IV-tPA alone0.55 Dirichlet0–1358-293Multiple sources
 mRS 6 after IV-tPA alone0.19 Dirichlet0–1124-527Multiple sources
 If IV-tPA alone
  mRS 0-1-2 after recurrent stroke0.26 Dirichlet0–1260-740Short-run model
  mRS 3-4-5 after recurrent stroke0.55 Dirichlet0–1550-450Short-run model
  mRS 6-death after recurrent stroke0.19 Dirichlet0–1190-810Short-run model
 If mechanical thrombectomy      
  mRS 0-1-2 after recurrent stroke0.46 Dirichlet0–1460-540Short-run model
  mRS 3-4-5 after recurrent stroke0.39 Dirichlet0–1390-610Short-run model
  mRS 6-death after recurrent stroke0.15 Dirichlet0–1150-850Short-run model
Transition probabilities
 Movement from up to end of year 1 to 3 months
  Independent mRS 0-1-2      
   Independent mRS 0-1-20.955 Dirichlet0–11337-63Ref. 33
   Dependent mRS 3-4-50.024 Dirichlet0–134-1366Ref. 33
   Recurrent stroke0.013 Dirichlet0–118-1382Ref. 33
   Dead mRS 60.008 Dirichlet0–111-1389Ref. 33
  Dependent mRS 3-4-5      
   Dependent mRS 3-4-50.919 Dirichlet0–11287-113Ref. 33
   Independent mRS 0-1-20.029 Dirichlet0–141-1359Ref. 33
   Recurrent stroke0.013 Dirichlet0–118-1382Ref. 33
   Dead mRS 60.039 Dirichlet0–155-1345Ref. 33
 Movement from after year 1 to 3 months
  Independent mRS 0-1-2      
   Independent mRS 0-1-20.979 Dirichlet0–11371-28Ref. 33
   Dependent mRS 3-4-50.000 Dirichlet0–117-1382Ref. 33
   Recurrent stroke0.013 Dirichlet0–111-1388Ref. 33
   Dead mRS 60.008 Dirichlet0–111-1388Ref. 33
  Dependent mRS 3-4-5      
   Dependent mRS 3-4-50.948 Dirichlet0–11327-72Ref. 33
   Independent mRS 0-1-20.000 Dirichlet0–117-1382Ref. 33
   Recurrent stroke0.013 Dirichlet0–154-1345Ref. 33
   Dead mRS 60.039 Dirichlet0–155-1345Ref. 33
  Recurrent stroke      
   Independent mRS 0-1-2 after IV-tPA alone0.834 Dirichlet0–1834-165Ref. 33, 34
   Dependent mRS 3-4-5 after IV-tPA alone0.137 Dirichlet0–1136-863Ref. 33, 34
   Dead mRS 6 after IV-tPA alone0.029 Dirichlet0–128-971Ref. 33, 34
   Independent mRS 0-1-2 after IV-tPA and thrombectomy0.867 Dirichlet0–1867-132Ref. 33, 34
   Dependent mRS 3-4-5 after IV-tPA and thrombectomy0.104 Dirichlet0–1103-896Ref. 33, 34
   Dead mRS 6 after IV-tPA and thrombectomy0.029 Dirichlet0–128-971Ref. 33, 34
Utilities
 Independent mRS 0-1-20.740.7–0.77Beta0–1684-3021Ref. 35
 Dependent mRS 3-4-50.380.29–0.47Beta0–160-590Ref. 35
 Recurrent stroke0.340.32–0.36Beta0–1540-5685Ref. 34
 Dead mRS 60  0  
Costs
 Cost of alteplase IV-tPA$2953.59 Gamma  Ref. 29, 31–33
 Cost of thrombectomy$13 803.04$9677–$17 943Gamma  Ref. 29, 31, 36, 37
 Acute costs first 3 months
  3 months acute costs independent mRS 0-1-2$11 309.46 Gamma  Ref. 29, 33, 36, 37
  3 months acute costs dependent mRS 3-4-5$24 201.35 Gamma  Ref. 29, 33, 36,37
  Cost of acute event fatal stroke mRS 6$15 547.44 Gamma  Ref. 29, 33, 36, 37
 Cost of recurrent stroke$589.20 Gamma  Internal model
 Ongoing costs every 3 months
  Independent mRS 0-1-2$771.88 Gamma  Ref. 29, 33, 36, 37
  Dependent mRS 3-4-5$2074.62 Gamma  Ref. 29, 33, 36, 37
IV-tPA indicates intravenous tissue-type plasminogen activator; and mRS, modified Rankin Scale.
The cost of the mechanical thrombectomy was estimated to be $13 803 (£8365), including the cost of the stent, the materials, and the surgery.29,36,37 The cost of the procedure was calculated using a microcosting approach, multiplying the average time of an intervention for the hourly cost for each grade of personnel29 (see Table II in the online-only Data Supplement).
The costs for the acute management of patients in the first 3 months after stroke and the following ongoing annual costs were taken from a published report.33 Acute and ongoing costs differ according to the level of disability, measured by mRS score. Acute costs include the length of stay in the Hyper Acute Stroke Unit, in the Acute High Dependence Unit, and in the rehabilitation ward, as well as the supported discharge cost and community care costs.
The cost of a recurrent stroke has been assessed internally assuming the cost is the same in each intervention arm. Because it is not possible to predict the type and severity of a recurrent stroke and therefore the correspondent treatment, the cost to treat a recurrent stroke is calculated as the mean expected cost to treat an average stroke that may not need thrombolysis or thrombectomy.

Outcomes

Patients were categorized into 1 of 3 health outcome states based on their predicted mRS scores: independent (mRS score ≤2), dependent (mRS score 3–5), or dead (mRS=6).38 We assumed the patient remained in the same health state for the first 3 months. After the initial allocation of patients into mRS categories, a Markov model distributed a theoretical cohort of 1000 patients into the 3 states over time and includes the additional health status of a patient having a recurrent stroke. The cohort of patients receiving the intervention treatment has been estimated using the national UK data from the stroke audit.39 According to the audit, 19 638 patients had a stroke between January and March 2014. Only 11.5% were given IV-tPA. We assume that patients eligible for thrombectomy are around 80% of those with a major occlusion (National Institute of Health Stroke Scale (NIHSS) score >16), which means 1800 patients.
QALYs combine length of life and quality of life, the latter being measured by utility scores. A utility score of 1 represents full health and a score of 0 of death. We used the utility scores from Dorman et al,35 the Sandercock et al40 systematic review, and the ScHARR report33 for the independent and dependent states because these are the most updated and reliable values available that take into account the EuroQol elicitation method (Table 1). We used the utility scores from Morris et al34 for recurrent strokes (Table 1). Other sources were used23,33 for the sensitivity analysis.

Probabilities

The probability of being independent, dependent, or dead in each treatment arm were calculated using the data provided from the 5 randomized controlled trials.7–11 We applied the transition probabilities in Table 1,23 transformed for cycles of 3 months. In the base-case, the transition probability of moving from an independent state to recurrent stroke was assumed to be the same as moving from a dependent state to recurrent stroke, but this was varied in sensitivity analysis. Those who were in the dependent state at 12 months were assumed to be unable to move to the independent state thereafter. Those in the independent state at 12 months were assumed to remain in that state unless they survived another stroke, in which case they could either die or move into a dependent state or remain independent.32,40,41

Measuring Cost-Effectiveness

Total QALYs and costs were calculated by multiplying the number of patients in each state by the calculated utilities and costs for that state.
Cost-effectiveness was measured in terms of the incremental cost per QALY gained and the Net Monetary Benefits (NMB) of thrombectomy plus IV-tPA compared with IV-tPA alone. The NMB was calculated as the mean QALYs per patient accruing to that treatment multiplied by the decision-maker’s maximum willingness to pay for a QALY (also referred to as the cost-effectiveness threshold) minus the mean cost per patient for the treatment. In the United Kingdom, the lower and upper limit of the maximum willingness to pay for a QALY are $33 000 (£20 000) and $49 500 (£30 000), respectively.27

Sensitivity Analysis

One-way sensitivity analysis was undertaken, varying the probabilities, utilities, and costs, one at a time within the ranges listed in Table 1.
A probabilistic sensitivity analysis was also undertaken to determine the impact of the uncertainty surrounding the model input parameters (see Table III in the online-only Data Supplement).27 In Table 1, we describe the distribution assigned to each parameter value.42 A random value from the corresponding distribution was selected. This generated an estimate of the mean cost and mean QALY and the NMB associated with each treatment. This was repeated 10 000 times, and the results for each simulation were noted. The proportion of times either treatment (thrombectomy or IV-tPA) had the highest NMB was calculated for a range of values of the willingness to pay for a QALY. The results are summarized using cost-effectiveness acceptability curves in Figure 2. The mean cost, QALYs, and NMB for each treatment were calculated from the 10 000 simulations; these are probabililistic results (Figure 3; online-only Data Supplement).
Figure 2. Cost-effectiveness acceptability curves showing the probability that each option is cost-effective at different values of the willingness to pay for a quality-adjusted life years (QALY). In the United Kingdom, the lower and upper limit of the maximum willingness to pay for a QALY are $33 000 (£20 000) and $49 500 (£30 000) respectively.
Figure 3. Monte Carlo simulations of incremental cost per quality-adjusted life years (QALY) gained of the mechanical thrombectomy on a cohort of 1000 patients.

Results

Using base-case values, mechanical thrombectomy after an IV-tPA to treat acute large-vessel ischemic stroke was associated with incremental costs of $12 262 (£7431) per patient and a gain of 1.05 QALYs per patient over 20 years (Table 2). The additional costs were because of the cost of the device and the cost of the procedure. QALYs are higher for mechanical thrombectomy because it saves more lives, and those patients who survive are more likely to have a better health outcomes and be independent (mRS 0,1,2). Assuming a cohort of 1000 patients, the number of deaths over 20 years was 787 in patients treated with IV-tPA alone and 716 in patients treated with thrombectomy. Therefore, the mechanic thrombectomy averted 71 deaths over 20 years.
Table 2. Base-Case Results: Expected Values per 1000 Patients
 IV-tPAMechanical ThrombectomyDifference
Costs$52 494 730$64 757 281$12 262 551
Deaths787716−71
QALYs379048421052
ICER  $11 651
Net monetary benefit
 Lower$72 563 794$95 031 346 
 Upper$135 093 056$174 925 660 
Costs are based on 2013–2014 prices. The point estimates are calculated using base-case values of the model parameters (deterministic results). The Net Monetary Benefit is calculated at the lower and upper limits of the willingness to pay for a QALY, which in the UK are $33 000 (£20 000) and $49 500 (£30 000), respectively. ICER indicates Incremental cost-effectiveness ratio; IV-tPA, intravenous tissue-type plasminogen activator; and QALY, quality-adjusted life years.
The incremental cost-effectiveness ratio of mechanical thrombectomy compared with IV-tPA was $11 651(£7061) per QALY gained. The NMB of thrombectomy plus IV-tPA was higher than the NMB of IV-tPA alone at both the lower and upper limits of the maximum willingness to pay for a QALY, indicating that this option was preferred on cost-effectiveness ground. As expected, the probabilistic results were similar (see Table III in the online-only Data Supplement).
The results of the 1-way sensitivity analysis showed that increasing the cost of thrombectomy by 139% from $13 803 (£8365) to US $33 000 (£20 000) will make the new intervention borderline cost-effective for the lower value of the maximum willingness to pay for QALY. If the utility for the independent patients (mRS 0-1-2) were decreased from 0.74 to 0.34, then the intervention is borderline cost-effective. The results were not sensitive to changing the values of any of the other parameters included in the univariate sensitivity analysis.
The cost-effectiveness acceptability curves for the 2 interventions show that mechanical thrombectomy had 100% probability of being cost-effective at the lower and upper values of the maximum willingness to pay for QALY commonly used in United Kingdom (Figure 2).

Discussion

Our principle finding is that the interventional treatment arm consisting of IV-tPA followed by mechanical thrombectomy for acute large-vessel ischemic stroke saves 1 life for every 14 thrombectomies performed, reduces disability, and is cost-effective when compared with IV-tPA alone.
Although the cost of thrombectomy is higher than that of IV-tPA initially, it leads to savings downstream in the stroke care pathway because of better outcomes. Between January and March 2014, 19 638 new cases of stroke were registered in the United Kingdom39; 87.3% were ischemic strokes and 11.5% had thrombolysis. 15% of ischemic strokes registered an acute large vessel stroke with an NIHSS score >16; therefore, thrombectomy could potentially be performed in 20% of patients who had thrombolysis. This means that in 1 year, around 1800 patients could have had a thrombectomy, for an incremental cost (budgetary impact) of $22 million (£13.4 million).
The recent Oxford Vascular study reports that each additional point in the NIHSS score can increase total costs over 5 years by 15%.43 Therefore, modest improved outcomes are often cost-effective from a societal perspective. These benefits need to be weighed against the procedural risks and the increased risk of symptomatic intracerebral hemorrhages. Although initially symptomatic hemorrhage appeared to be higher among those undergoing thrombectomy, subsequent studies have shown similar rates for IV-tPA and thrombectomy versus tPA alone as evident in Tables III in the online-only Data Supplement. In fact, in the studies included in this article, the average hemorrhage rates were similar (4.6% for thrombectomy versus 3.8% for IV-tPA).
Earlier this year, the first randomized controlled studies, MR CLEAN, ESCAPE, EXTEND IA, SWIFT-PRIME, and REVASCAT, demonstrate significant benefit with thrombectomy, which was contributed by the higher recanalization rate.7–11 Studies to date have shown a correlation between recanalization and clinical outcome.12,44 It is likely that the development and evolution of mechanical thrombectomy in time will lead to better recanalization rates. We expect the cost of thrombectomy to decrease over time because of decreasing costs of the intervention and discounts in the device used secondary to market competition. This will improve the cost-effectiveness of the new intervention.
There is no other cost-effectiveness study for thrombectomy performed in the United Kingdom. However, similar studies have been done in the United States based on single arm studies, which also demonstrated cost-effectiveness of $16 001 per QALY gained,23 $12 120 per QALY gained,25 and $9386 per QALY gained.24 Patil et al focussed on patients whom could receive treatment within 8 hours but were not eligible for IV-tPA. Nguyen-Huynh et al studied patients beyond 3 hours and who were then offered mechanical thrombectomy or antiplatelet therapy and supportive care.24 However, Kim et al looked at a similar question to ours, that is, the use of IV-tPA as a bridging therapy to mechanical thrombectomy versus IV-tPA alone.23 However, their data were based on the Multi-MERCI study using the Merci retrieval systems (Concentric, s-Hertogenbosch, Netherlands), as well as some use of intra-arterial thrombolysis and angioplasty. As mentioned earlier, stent retrievers have been shown to be significantly better than the Merci retrieval system.16–21 The advantage of this study is that we have used data from randomized controlled trials predominantly using stent retriever devices. Despite several differences among cost-effectiveness studies, all have concluded that mechanical thrombectomy is cost-effective compared with medical therapy.
The analysis has several limitations. In the absence of data, we have assumed the probability of a recurrent stroke is the same irrespective of the level of disability after initial stroke, when we might expect the probability of recurrent stroke to be higher among the more disabled. The results of our sensitivity analysis showed that our conclusions were not sensitive to this assumption.
The analysis was undertaken from the perspective of the UK National Health Service. A wider perspective, such as a societal one, would also include impacts on the rest of society, including patients, families, and business. Given that stroke is the leading cause of disability in United Kingdom,1 it is likely that the cost savings attributable to mechanical thrombectomy would be greater than demonstrated if costs from other viewpoints were included.

Summary

We have demonstrated in this first cost-effectiveness study that the use of predominantly stent retrievers in mechanical thrombectomy after IV-tPA is cost-effective in the United Kingdom, based on current data. However, we hope that this study will supplement the recently published randomized controlled trials together with evidence demonstrating an increasing prevalence of stroke among young adults45,46 to assist healthcare commissioners regarding purchasing and investing in this new aspect of acute stroke services.

Acknowledgments

All authors have made substantial contributions to this study. J. Ganesalingam, E. Pizzo, S. Morris, D. Ames, and K. Lobotesis were responsible for the conception and design of the study. J. Ganesalingam, E. Pizzo, T. Sunderland, S. Morris, and K. Lobotesis were responsible for the acquisition of data. J. Ganesalingam, E. Pizzo, T. Sunderland, S. Morris, and K. Lobotesis were responsible for the analysis and interpretation of data. J. Ganesalingam, E. Pizzo, T. Sunderland, D. Ames, S. Morris, and K. Lobotesis were responsible for drafting the article or revising it critically for important intellectual content.

Supplemental Material

File (str_stroke-2015-009396_supp1.pdf)

References

1.
Adamson J, Beswick A, Ebrahim S. Is stroke the most common cause of disability? J Stroke Cerebrovasc Dis. 2004;13:171–177. doi: 10.1016/j.jstrokecerebrovasdis.2004.06.003.
Crossref
PubMed
Google Scholar
2.
Truelsen T, Piechowski-Jóźwiak B, Bonita R, Mathers C, Bogousslavsky J, Boysen G. Stroke incidence and prevalence in Europe: a review of available data. Eur J Neurol. 2006;13:581–598. doi: 10.1111/j.1468-1331.2006.01138.x.
Crossref
PubMed
Google Scholar
3.
Saka O, McGuire A, Wolfe C. Cost of stroke in the United Kingdom. Age Ageing. 2009;38:27–32. doi: 10.1093/ageing/afn281.
Crossref
PubMed
Google Scholar
4.
Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, Blaha MJ, et al.; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics–2014 update: a report from the American Heart Association. Circulation. 2014;129:e28–e292. doi: 10.1161/01.cir.0000441139.02102.80.
Crossref
PubMed
Google Scholar
5.
Hacke W, Kaste M, Bluhmki E, Brozman M, Dávalos A, Guidetti D, et al.; ECASS Investigators. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008;359:1317–1329. doi: 10.1056/NEJMoa0804656.
Crossref
PubMed
Google Scholar
6.
Tissue plasminogen activator for acute ischemic stroke. The national institute of neurological disorders and stroke rt-pa stroke study group. N Engl J Med. 1995;333:1581–1587.
Crossref
PubMed
Google Scholar
7.
Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, et al.; MR CLEAN Investigators. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015;372:11–20. doi: 10.1056/NEJMoa1411587.
Crossref
PubMed
Google Scholar
8.
Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, et al.; ESCAPE Trial Investigators. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372:1019–1030. doi: 10.1056/NEJMoa1414905.
Crossref
PubMed
Google Scholar
9.
Campbell BC, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, et al.; EXTEND-IA Investigators. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015;372:1009–1018. doi: 10.1056/NEJMoa1414792.
Crossref
PubMed
Google Scholar
10.
Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, et al.; SWIFT PRIME Investigators. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med. 2015;372:2285–2295. doi: 10.1056/NEJMoa1415061.
Crossref
PubMed
Google Scholar
11.
Jovin TG, Chamorro A, Cobo E, de Miquel MA, Molina CA, Rovira A, et al.; REVASCAT Trial Investigators. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med. 2015;372:2296–2306. doi: 10.1056/NEJMoa1503780.
Crossref
PubMed
Google Scholar
12.
Rha JH, Saver JL. The impact of recanalization on ischemic stroke outcome: a meta-analysis. Stroke. 2007;38:967–973. doi: 10.1161/01.STR.0000258112.14918.24.
Crossref
PubMed
Google Scholar
13.
Mazighi M, Serfaty JM, Labreuche J, Laissy JP, Meseguer E, Lavallée PC, et al.; RECANALISE investigators. Comparison of intravenous alteplase with a combined intravenous-endovascular approach in patients with stroke and confirmed arterial occlusion (RECANALISE study): a prospective cohort study. Lancet Neurol. 2009;8:802–809. doi: 10.1016/S1474-4422(09)70182-6.
Crossref
PubMed
Google Scholar
14.
Smith WS, Sung G, Saver J, Budzik R, Duckwiler G, Liebeskind DS, et al.; Multi MERCI Investigators. Mechanical thrombectomy for acute ischemic stroke: final results of the Multi MERCI trial. Stroke. 2008;39:1205–1212. doi: 10.1161/STROKEAHA.107.497115.
Crossref
PubMed
Google Scholar
15.
Poisson SN, Nguyen-Huynh MN, Johnston SC, Furie KL, Lev MH, Smith WS. Intracranial large vessel occlusion as a predictor of decline in functional status after transient ischemic attack. Stroke. 2011;42:44–47. doi: 10.1161/STROKEAHA.110.591099.
Crossref
PubMed
Google Scholar
16.
Broussalis E, Trinka E, Hitzl W, Wallner A, Chroust V, Killer-Oberpfalzer M. Comparison of stent-retriever devices versus the Merci retriever for endovascular treatment of acute stroke. AJNR Am J Neuroradiol. 2013;34:366–372. doi: 10.3174/ajnr.A3195.
Crossref
PubMed
Google Scholar
17.
Saver JL, Jahan R, Levy EI, Jovin TG, Baxter B, Nogueira RG, et al.; SWIFT Trialists. Solitaire flow restoration device versus the Merci Retriever in patients with acute ischaemic stroke (SWIFT): a randomised, parallel-group, non-inferiority trial. Lancet. 2012;380:1241–1249. doi: 10.1016/S0140-6736(12)61384-1.
Crossref
PubMed
Google Scholar
18.
Nogueira RG, Lutsep HL, Gupta R, Jovin TG, Albers GW, Walker GA, et al.; TREVO 2 Trialists. Trevo versus Merci retrievers for thrombectomy revascularisation of large vessel occlusions in acute ischaemic stroke (TREVO 2): a randomised trial. Lancet. 2012;380:1231–1240. doi: 10.1016/S0140-6736(12)61299-9.
Crossref
PubMed
Google Scholar
19.
Castaño C, Dorado L, Guerrero C, Millán M, Gomis M, Perez de la Ossa N, et al. Mechanical thrombectomy with the Solitaire AB device in large artery occlusions of the anterior circulation: a pilot study. Stroke. 2010;41:1836–1840. doi: 10.1161/STROKEAHA.110.584904.
Crossref
PubMed
Google Scholar
20.
Costalat V, Machi P, Lobotesis K, Maldonado I, Vendrell JF, Riquelme C, et al. Rescue, combined, and stand-alone thrombectomy in the management of large vessel occlusion stroke using the solitaire device: a prospective 50-patient single-center study: timing, safety, and efficacy. Stroke. 2011;42:1929–1935. doi: 10.1161/STROKEAHA.110.608976.
Crossref
PubMed
Google Scholar
21.
Machi P, Costalat V, Lobotesis K, Maldonado IL, Vendrell JF, Riquelme C, et al. Solitaire FR thrombectomy system: immediate results in 56 consecutive acute ischemic stroke patients. J Neurointerv Surg. 2012;4:62–66. doi: 10.1136/jnis.2010.004051.
Crossref
PubMed
Google Scholar
22.
Turk AS, Campbell JM, Spiotta A, Vargas J, Turner RD, Chaudry MI, et al. An investigation of the cost and benefit of mechanical thrombectomy for endovascular treatment of acute ischemic stroke. J Neurointerv Surg. 2014;6:77–80. doi: 10.1136/neurintsurg-2012-010616.
Crossref
PubMed
Google Scholar
23.
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;42:2013–2018. doi: 10.1161/STROKEAHA.110.606889.
Crossref
PubMed
Google Scholar
24.
Nguyen-Huynh MN, Johnston SC. Is mechanical clot removal or disruption a cost-effective treatment for acute stroke? AJNR Am J Neuroradiol. 2011;32:244–249. doi: 10.3174/ajnr.A2329.
Crossref
PubMed
Google Scholar
25.
Patil CG, Long EF, Lansberg MG. Cost-effectiveness analysis of mechanical thrombectomy in acute ischemic stroke. J Neurosurg. 2009;110:508–513. doi: 10.3171/2008.8.JNS08133.
Crossref
PubMed
Google Scholar
26.
Morris S, Devlin N, Parkin D.Economic Analysis in Healthcare. Chichester, West Sussex, United Kingdom:Wiley; 2012:295–299.
Google Scholar
27.
National Institute for Health and Care Excellence. Guide to the methods of technology appraisal 2013. Published April 4, 2013. http://publications.nice.org.uk/guide-to-the-methods-of-technology-appraisal-2013-pmg9. Accessed June 1, 2014.
Google Scholar
28.
Purchasing power parties for gdp. http://www.oecd.org/std/ppp. Accessed December 1, 2014.
Google Scholar
29.
Curtis L.Unit Costs of Health and Social Care. Kent, UK: PSSRU, University of Kent; 2013:105–256.
Google Scholar
30.
Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJ, Demaerschalk BM, et al.; American Heart Association Stroke Council; Council on Cardiovascular Nursing; Council on Peripheral Vascular Disease; Council on Clinical Cardiology. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44:870–947. doi: 10.1161/STR.0b013e318284056a.
Crossref
PubMed
Google Scholar
32.
National Institute for Health and Care Excellence. Submission by Boehringer Ingelheim to support the single technology appraisal by nice of alteplase for the treatment of acute ischaemic stroke (review of technology appraisal 122). September 2012. https://www.nice.org.uk/guidance/ta264/resources/guidance-alteplase-for-treating-acute-ischaemic-stroke-review-of-technology-appraisal-guidance-122-pdf. Accessed June 1, 2014.
Google Scholar
33.
ScHARR. Alteplase for the treatment of acute ischaemic stroke (review of technology appraisal 122). http://www.nice.org.uk/guidance/ta264/resources/guidance-alteplase-for-treating-acute-ischaemic-stroke-review-of-technology-appraisal-guidance-122-pdf. Accessed July 1, 2014.
Google Scholar
34.
Morris S, Hunter R, Davie C, Thompson A, Walker H, Thomson N, Mountford J. Cost-effectiveness analysis of the london stroke service. University College London Report. London, UK:University College London; 2011:1–62.
Google Scholar
35.
Dorman PJ, Waddell F, Slattery J, Dennis M, Sandercock P. Is the EuroQol a valid measure of health-related quality of life after stroke? Stroke. 1997;28:1876–1882.
Crossref
PubMed
Google Scholar
36.
Neuro C. Codman Neuro revive SE thrombectomy device list price. 2013. http://www.depuysynthes.com/about/codman-neuro. Accessed June 1, 2014.
Google Scholar
37.
Neuro C. Codman Neuro revive se budget impact model detailed assumptions. 2013. http://www.depuysynthes.com/about/codman-neuro. Accessed June 1, 2014.
Google Scholar
38.
van Swieten JC, Koudstaal PJ, Visser MC, Schouten HJ, van Gijn J. Interobserver agreement for the assessment of handicap in stroke patients. Stroke. 1988;19:604–607.
Crossref
PubMed
Google Scholar
39.
Royal College of Physicians. Sentinel Stroke National Audit Programme (SSNAP) Clinical Audit January-March 2014 Public Report. https://www.strokeaudit.org/results/national-results.aspx. Accessed October 2014.
Google Scholar
40.
Sandercock P, Berge E, Dennis M, Forbes J, Hand P, Kwan J, et al. A systematic review of the effectiveness, cost-effectiveness and barriers to implementation of thrombolytic and neuroprotective therapy for acute ischaemic stroke in the NHS. Health Technol Assess. 2002;6:1–112.
Crossref
PubMed
Google Scholar
41.
Wahlgren N, Ahmed N, Dávalos A, Ford GA, Grond M, Hacke W, et al.; SITS-MOST investigators. Thrombolysis with alteplase for acute ischaemic stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST): an observational study. Lancet. 2007;369:275–282. doi: 10.1016/S0140-6736(07)60149-4.
Crossref
PubMed
Google Scholar
42.
Briggs A, Sculpher M, Claxton K.Decision Modelling for Health Economic Evaluation. UK:Oxford University Press; 2006:78–118.
Google Scholar
43.
Luengo-Fernandez R, Yiin GS, Gray AM, Rothwell PM. Population-based study of acute- and long-term care costs after stroke in patients with AF. Int J Stroke. 2013;8:308–314. doi: 10.1111/j.1747-4949.2012.00812.x.
Crossref
PubMed
Google Scholar
44.
Fields JD, Lutsep HL, Smith WS; MERCI Multi MERCI Investigators. Higher degrees of recanalization after mechanical thrombectomy for acute stroke are associated with improved outcome and decreased mortality: pooled analysis of the MERCI and Multi MERCI trials. AJNR Am J Neuroradiol. 2011;32:2170–2174. doi: 10.3174/ajnr.A2709.
Crossref
PubMed
Google Scholar
45.
Poisson SN, Glidden D, Johnston SC, Fullerton HJ. Deaths from stroke in US young adults, 1989–2009. Neurology. 2014;83:2110–2115. doi: 10.1212/WNL.0000000000001042.
Crossref
PubMed
Google Scholar
46.
Aarnio K, Haapaniemi E, Melkas S, Kaste M, Tatlisumak T, Putaala J. Long-term mortality after first-ever and recurrent stroke in young adults. Stroke. 2014;45:2670–2676. doi: 10.1161/STROKEAHA.114.005648.
Crossref
PubMed
Google Scholar

eLetters(0)

eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. Authors of the article cited in the comment will be invited to reply, as appropriate.

Comments and feedback on AHA/ASA Scientific Statements and Guidelines should be directed to the AHA/ASA Manuscript Oversight Committee via its Correspondence page.

Sign In to Submit a Response to This Article

Information & Authors

Information

Published In

Go to Stroke
Go to Stroke

The image is taken from an article in this issue, “Minimally Invasive Microsurgery for Cerebral Aneurysms” by Wong et al (Stroke. 2015;46:2699–2706).

The image is Figure 2D.

Stroke
Volume 46 • Number 9 • September 2015
Pages: 2591 - 2598
PubMed: 26251241

Copyright

© 2015 The Authors. Stroke is published on behalf of the American Heart Association, Inc., by Wolters Kluwer. This is an open access article under the terms of the Creative Commons Attribution Non-Commercial-NoDervis License, which permits use, distribution, and reproduction in any medium, provided that the original work is properly cited, the use is noncommercial, and no modifications or adaptations are made.

Versions

You are viewing the most recent version of this article.

History

Received: 28 March 2015
Revision received: 16 June 2015
Accepted: 19 June 2015
Published online: 6 August 2015
Published in print: September 2015

Permissions

Request permissions for this article.

Keywords

  1. cost-effectiveness
  2. stents
  3. stroke
  4. thrombectomy
  5. tissue-type plasminogen activator

Subjects

  1. Treatment

Authors

Affiliations

Jeban Ganesalingam, MBBS, MRCP (Neuro), PhD*
From the Department of Stroke Medicine, Imperial College Healthcare NHS Trust, London, UK (J.G., D.A.); Department of Applied Health Research, University College London, London, UK (E.P., S.M.); Department of Market Access, Pricing and Outcomes Research, Boehringer Ingelheim Ltd, Bracknell, Berks, UK (T.S.); and Imaging Department, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK (K.L.).
View all articles by this author
Elena Pizzo, PhD*
From the Department of Stroke Medicine, Imperial College Healthcare NHS Trust, London, UK (J.G., D.A.); Department of Applied Health Research, University College London, London, UK (E.P., S.M.); Department of Market Access, Pricing and Outcomes Research, Boehringer Ingelheim Ltd, Bracknell, Berks, UK (T.S.); and Imaging Department, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK (K.L.).
View all articles by this author
Stephen Morris, PhD
From the Department of Stroke Medicine, Imperial College Healthcare NHS Trust, London, UK (J.G., D.A.); Department of Applied Health Research, University College London, London, UK (E.P., S.M.); Department of Market Access, Pricing and Outcomes Research, Boehringer Ingelheim Ltd, Bracknell, Berks, UK (T.S.); and Imaging Department, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK (K.L.).
View all articles by this author
Tom Sunderland, MSc
From the Department of Stroke Medicine, Imperial College Healthcare NHS Trust, London, UK (J.G., D.A.); Department of Applied Health Research, University College London, London, UK (E.P., S.M.); Department of Market Access, Pricing and Outcomes Research, Boehringer Ingelheim Ltd, Bracknell, Berks, UK (T.S.); and Imaging Department, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK (K.L.).
View all articles by this author
Diane Ames, MBBS, FRCP
From the Department of Stroke Medicine, Imperial College Healthcare NHS Trust, London, UK (J.G., D.A.); Department of Applied Health Research, University College London, London, UK (E.P., S.M.); Department of Market Access, Pricing and Outcomes Research, Boehringer Ingelheim Ltd, Bracknell, Berks, UK (T.S.); and Imaging Department, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK (K.L.).
View all articles by this author
Kyriakos Lobotesis, MBBS, FRCR
From the Department of Stroke Medicine, Imperial College Healthcare NHS Trust, London, UK (J.G., D.A.); Department of Applied Health Research, University College London, London, UK (E.P., S.M.); Department of Market Access, Pricing and Outcomes Research, Boehringer Ingelheim Ltd, Bracknell, Berks, UK (T.S.); and Imaging Department, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK (K.L.).
View all articles by this author

Notes

The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR, the Department of Health, or Boehringer Ingelheim Ltd.
*
Drs Ganesalingam and Pizzo contributed equally.
The online-only Data Supplement is available with this article at http://stroke.ahajournals.org/lookup/suppl/doi:10.1161/STROKEAHA.115.009396/-/DC1.
Correspondence to Kyriakos Lobotesis, MBBS, FRCR, Consultant Neuroradiologist, Imaging Department, Imperial College Healthcare NHS Trust, Charing Cross Hospital, Fulham Palace Rd, London W6 8RF, UK. E-mail [email protected]

Disclosures

T. Sunderland is a permanent employee of Boehringer Ingleheim. The other authors report no conflicts.

Sources of Funding

The research was supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care North Thames at Barts Health National Health Service (NHS) Trust.

Metrics & Citations

Metrics

Citations

Download Citations

If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Select your manager software from the list below and click Download.

    • Li Wang,
    • Yuhong Zeng,
    • Limei Zhou,
    • Ping Xu,
    • Xianbin Guo,
    • Yu Xie,
    • Junxiu Cai,
    • Min Pan,
    • Jie Tang,
    • Qingtao Gong,
    • Rong Su,
    • Yan Liu,
    • Yake Lou,
    Cost-effectiveness of tirofiban for acute ischemic stroke without large or medium-sized vessel occlusion: A Markov modelling analysis from the Chinese and United States perspectives, PLOS ONE, 19, 2, (e0297939), (2024).https://doi.org/10.1371/journal.pone.0297939
    Crossref
    • Lu Han,
    • Kuixu Lan,
    • Dejian Kou,
    • Zehua Meng,
    • Jin Feng,
    • Elizabeth Maitland,
    • Stephen Nicholas,
    • Jian Wang,
    Cost-effectiveness of endovascular treatment for acute ischemic stroke in China: evidence from Shandong Peninsula, Health Economics Review, 14, 1, (2024).https://doi.org/10.1186/s13561-024-00513-7
    Crossref
    • Joyce S. Balami,
    • Gary A. Ford,
    • Alastair M. Buchan,
    • Alastair Gray,
    • Andrea Francesconi,
    • Paolo Collini,
    • Paolo Candio,
    Extending mechanical thrombectomy service provision to 24/7: a break-even analysis, BMC Health Services Research, 24, 1, (2024).https://doi.org/10.1186/s12913-024-11290-8
    Crossref
    • Benjamin P. Sugar,
    • Nathan E. Drasler,
    • Jonathan Lee,
    • Bryce D. Beutler,
    • Alastair E. Moody,
    • John Jay P. Cadavona,
    • Lisa Leung,
    • Burton J. Tabaac,
    Utility of Thrombectomy in Nonagenarians: A Scoping Review, European Neurology, 87, 3, (122-129), (2024).https://doi.org/10.1159/000539789
    Crossref
    • Hal Rice,
    • Laetitia de Villiers,
    • Raffaelle Scarica,
    • Anne‐Laure Bocquet,
    • Kelly Dargan,
    • Thomas Barthe,
    Health budget implications of mechanical thrombectomy for acute ischaemic stroke in Australia, Journal of Medical Imaging and Radiation Oncology, 68, 5, (564-569), (2024).https://doi.org/10.1111/1754-9485.13652
    Crossref
    • Adrián Martín-Gutiérrez,
    • Luis Leal-Vega,
    • María Begoña Coco-Martín,
    • Juan F. Arenillas-Lara,
    A systematic review of the socioeconomic impact of mechanical thrombectomy for acute ischemic stroke, Journal of Stroke and Cerebrovascular Diseases, 33, 11, (107906), (2024).https://doi.org/10.1016/j.jstrokecerebrovasdis.2024.107906
    Crossref
    • Bill Hum,
    • Kamil Taneja,
    • Sean Bunachita,
    • Hadi Ashor,
    • Jeeyong Shin,
    • Anshel Bright,
    • Ryan Wang,
    • Karan Patel,
    Unveiling the evolving landscape of stroke care costs: A time-driven analysis, Journal of Stroke and Cerebrovascular Diseases, 33, 6, (107663), (2024).https://doi.org/10.1016/j.jstrokecerebrovasdis.2024.107663
    Crossref
    • Aravind Ganesh,
    • Anand Viswanathan,
    Acute Medical Therapies for Persons Living with Physical or Cognitive Disability, The Palgrave Encyclopedia of Disability, (1-19), (2024).https://doi.org/10.1007/978-3-031-40858-8_190-1
    Crossref
    • Li Wang,
    • Ying Yu,
    • Limei Zhou,
    • Ping Xu,
    • Xianbin Guo,
    • Yu Xie,
    • Junxiu Cai,
    • Min Pan,
    • Jie Tang,
    • Qingtao Gong,
    • Rong Su,
    • Yake Lou,
    • Yan Liu,
    Endovascular treatment for basilar artery occlusion: a cost-effectiveness analysis based on a meta-analysis, Frontiers in Neurology, 14, (2023).https://doi.org/10.3389/fneur.2023.1267554
    Crossref
    • І. А. Костюк,
    • Т. С. Міщенко,
    • Є. Є. Шалабін,
    Pharmacoeconomic analysis of the use of combinations of complex electrolyte compounds with citicoline in the treatment of patients with acute ischemic stroke in Ukraine, Farmatsevtychnyi zhurnal, 4, (62-79), (2023).https://doi.org/10.32352/0367-3057.4.23.06
    Crossref
  11. See more

View Options

View options

PDF and All Supplements

Download PDF and All Supplements

PDF/EPUB

View PDF/EPUB
Login options

Check if you have access through your login credentials or your institution to get full access on this article.

Personal login Institutional Login
Save for later Item saved, go to cart
Purchase Options

Purchase this article to access the full text.

Purchase access to this article for 24 hours

Cost-Utility Analysis of Mechanical Thrombectomy Using Stent Retrievers in Acute Ischemic Stroke
Stroke
  • Vol. 46
  • No. 9

Purchase access to this journal for 24 hours

Stroke
  • Vol. 46
  • No. 9
Restore your content access

Enter your email address to restore your content access:

Note: This functionality works only for purchases done as a guest. If you already have an account, log in to access the content to which you are entitled.

Media

Figures

Other

Tables

Share

Share

Share article link

Share

View full text|Download PDF

Comment Response