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. 2021 Jan;38(1):33-39.
doi: 10.1136/emermed-2019-209039. Epub 2020 Nov 10.

Secondary transfer of emergency stroke patients eligible for mechanical thrombectomy by air in rural England: economic evaluation and considerations

Diarmuid Coughlan  1 , Peter McMeekin  2 , Darren Flynn  3 , Gary A Ford  4   5 , Hannah Lumley  5 , David Burgess  6 , Joyce Balami  7 , Andrew Mawson  8 , Dawn Craig  1 , Stephen Rice  1 , Phil White  9
Affiliations

Secondary transfer of emergency stroke patients eligible for mechanical thrombectomy by air in rural England: economic evaluation and considerations

Diarmuid Coughlan et al. Emerg Med J. 2021 Jan.

Abstract

Background: Mechanical thrombectomy (MT) is a time-sensitive emergency procedure for patients who had ischaemic stroke leading to improved health outcomes. Health systems need to ensure that MT is delivered to as many patients as quickly as possible. Using decision modelling, we aimed to evaluate the cost-effectiveness of secondary transfer by helicopter emergency medical services (HEMS) compared with ground emergency medical services (GEMS) of rural patients eligible for MT in England.

Methods: The model consisted of (1) a short-run decision tree with two branches, representing secondary transfer transportation strategies and (2) a long-run Markov model for a theoretical population of rural patients with a confirmed ischaemic stroke. Strategies were compared by lifetime costs: quality-adjusted life years (QALYs), incremental cost per QALY gained and net monetary benefit. Sensitivity and scenario analyses explored uncertainty around parameter values.

Results: We used the base case of early-presenting (<6 hours to arterial puncture) patient aged 75 years who had stroke to compare HEMS and GEMS. This produced an incremental cost-effectiveness ratio (ICER) of £28 027 when a 60 min reduction in travel time was assumed. Scenario analyses showed the importance of the reduction in travel time and futile transfers in lowering ICERs. For late presenting (>6 hours to arterial puncture), ground transportation is the dominant strategy.

Conclusion: Our model indicates that using HEMS to transfer patients who had stroke eligible for MT from remote hospitals in England may be cost-effective when: travel time is reduced by at least 60 min compared with GEMS, and a £30 000/QALY threshold is used for decision-making. However, several other logistic considerations may impact on the use of air transportation.

Keywords: emergency ambulance systems; emergency care systems; helicopter retrieval; management; remote and rural medicine; stroke; thromboembolic diseasex.

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Conflict of interest statement

Competing interests: This paper summarises independent research funded by the NIHR under its Programme Grant for Applied Research Programme (RP-PG-1211-20012). PW is the co-principal investigator for two randomised thrombectomy trials (PISTE and STABILISE) in acute stroke. Start-up phase of PISTE was mainly funded by the Stroke Association but was also part-funded by unrestricted educational grants from Covidien (now Medtronic) and Codman who manufacture stroke thrombectomy devices. STABILISE is part-funded by Microvention grant to Newcastle University. PW has undertaken consultancy work for Stryker, Codman and Microvention who manufacture stroke thrombectomy devices. GAF’s previous institution has received research grants from Boehringer Ingelheim (manufacturer of alteplase), and honoraria from Lundbeck for stroke-related activities. GAF has also received personal remuneration for educational and advisory work from Boehringer Ingelheim and Lundbeck.

Figures

Figure 1
Figure 1
Simplified structure of lifetime economic model with decision tree of transport options along with base-case values for first 3 months (L) and lifetime Markov model of health states. CTA, CT angiography; GEMS, ground emergency medical services; HEMS, helicopter emergency medical services; IV-tPA, intraveneous thrombolysis; LVO, large vessel occulsion; mRS, modified Rankin Scale; MT, mechanical thrombectomy.
Figure 2
Figure 2
Cost-effectiveness acceptability curve for early presenters by transportation strategy. GEMS, ground emergency medical services; HEMS, helicopter emergency medical services; QALY, quality-adjusted life years.
See this image and copyright information in PMC

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