Cost-effective analysis of mechanical thrombectomy alone in the treatment of acute ischaemic stroke: a Markov modelling study

Abstract

Objective: Recently, a randomised controlled trial (DIRECT-MT) demonstrated that mechanical thrombectomy (MT) was non-inferior to MT with intravenous alteplase as to the functional outcomes. This study aims to investigate whether MT alone is cost-effective compared with MT with alteplase in China.

Methods: A Markov decision analytic model was built from the Chinese healthcare perspective using a lifetime horizon. Probabilities, costs and outcomes data were obtained from the DIRECT-MT trial and other most recent/comprehensive literature. Base case calculation was conducted to compare the costs and effectiveness between MT alone and MT with alteplase. One-way and probabilistic sensitivity analyses were performed to evaluate the robustness of the results.

Results: MT alone had a lower cost and higher effectiveness compared with MT with alteplase. The probabilistic sensitivity analysis demonstrated that, over a lifetime horizon, MT alone had a 99.5% probability of being cost-effective under the willingness-to-pay threshold of 1× gross domestic product per capita in China based on data obtained from the DIRECT-MT trial. These results remained robust under one-way sensitivity analysis.

Conclusions: MT alone was cost-effective compared with MT with alteplase in China. However, cautions are needed to extend this conclusion to regions outside of China.

Keywords: HEALTH ECONOMICS; Neurosurgery; Stroke.

Figure 1

Structure of the decision tree model (left) and Markov model (right). AIS, acute ischaemic stroke; mRS, modified Rankin Score; MT, mechanical thrombectomy.

Figure 2

Tornado diagram depicting results of one-way sensitivity analyses. Effects of parameters variations on the ICER of mechanical thrombectomy alone versus mechanical thrombectomy with alteplase were presented. EV, expected value; ICER, incremental cost-effectiveness ratio; mRS, modified Rankin Score

Figure 3

Probabilistic sensitivity analysis over the long-run model (30 years horizon). Incremental cost-effectiveness scatters plot of mechanical thrombectomy alone versus mechanical thrombectomy with alteplase. The dotted line represents a WTP threshold of CNY66 006/QALY. Each dot represents a simulation run (10 000 iterations). CNY, Chinese yuan renminbi; QALY, quality-adjusted life-year; WTP, willingness-to-pay.

Figure 4

Cost-effectiveness plane according to probabilistic sensitivity analysis over the long-run model (30 years horizon) based on different trials. (A) The result was based on the DIRECT-MT trial. (B) The result was based on the trial of Bellwald et al. (C) The result was based on the trial of Coutinho et al.