Quantified health and cost effects of faster endovascular treatment for large vessel ischemic stroke patients in the Netherlands

Abstract

Background: The effectiveness of endovascular treatment (EVT) for large vessel occlusion (LVO) stroke severely depends on time to treatment. However, it remains unclear what the value of faster treatment is in the years after index stroke. The aim of this study was to quantify the value of faster EVT in terms of health and healthcare costs for the Dutch LVO stroke population.

Methods: A Markov model was used to simulate 5-year follow-up functional outcome, measured with the modified Rankin Scale (mRS), of 69-year-old LVO patients. Post-treatment mRS was extracted from the MR CLEAN Registry (n=2892): costs per unit of time and Quality-Adjusted Life Years (QALYs) per mRS sub-score were retrieved from follow-up data of the MR CLEAN trial (n=500). Net Monetary Benefit (NMB) at a willingness to pay of €80 000 per QALY was reported as primary outcome, and secondary outcome measures were days of disability-free life gained and costs.

Results: EVT administered 1 min faster resulted in a median NMB of €309 (IQR: 226;389), 1.3 days of additional disability-free life (IQR: 1.0;1.6), while cumulative costs remained largely unchanged (median: -€15, IQR: -65;33) over a 5-year follow-up period. As costs over the follow-up period remained stable while QALYs decreased with longer time to treatment, which this results in a near-linear decrease of NMB. Since patients with faster EVT lived longer, they incurred more healthcare costs.

Conclusion: One-minute faster EVT increases QALYs while cumulative costs remain largely unaffected. Therefore, faster EVT provides better value of care at no extra healthcare costs.

Keywords: artery; economics; intervention; stroke; thrombectomy.

Figure 1

Markov model architecture: Pane A: Short-term model used for each hour to simulate 90-day mRS (modified Rankin Scale). In this example, 0–60 minutes of onset time to groin puncture was presented. Pane B: Long-term model for patients (example for mRS 3 at 90-days' post-index stroke). After recurrent stroke an equal or higher mRS score can be achieved. After stroke recurrence, death (mRS 6) is not possible to prevent duplicate mortality rates in the model. mRS after stroke recurrence was based on normalized values from the MR CLEAN trial control arm.

Figure 2

Data and inclusion. In this study data from the MR CLEAN Registry (part 1 and 2), MR CLEAN trial, and 2-year follow-up from the MR CLEAN trial were used. For this study, additional exclusion criteria were formulated for the MR CLEAN Registry data. EVT, endovascular treatment; mRS, modified Rankin Scale.

Figure 3

Probabilistic sensitivity analysis results per hour of delay from onset to groin puncture: Costs (A), quality-adjusted life-year (QALY) (B), and Net Monetary Value (C) per hour time from onset to groin puncture.