Echocardiographic identification of cardiovascular sources of emboli to guide clinical management of stroke: a cost-effectiveness analysis.
BACKGROUND
No consensus exists about the use of imaging strategies to identify potential cardiovascular sources of emboli in patients who have had strokes.


OBJECTIVE
To determine the cost-effectiveness of various cardiac imaging strategies after stroke.


METHODS
A markov model decision analysis was used to evaluate the benefits and costs of nine diagnostic strategies, including transthoracic echocardiography, transesophageal echocardiography, sequential approaches, selective imaging, and no imaging.


METHODS
Simulated clinical practice in the United States.


METHODS
Hypothetical patients with a first stroke who were in normal sinus rhythm.


METHODS
Echocardiographic detection rates of potential sources of emboli were ascertained by doing a systematic review of the literature. Values for event rates, anticoagulation effects, utilities, and costs were obtained from the literature and Medicare data.


RESULTS
When visualized left atrial thrombus was used as the only indication for anticoagulation, transesophageal echocardiography performed only in patients with a history of cardiac problems cost $9000 per quality-adjusted life-year; transesophageal echocardiography in all patients cost $13,000 per quality-adjusted life-year. Cost savings and decreased morbidity and mortality rates associated with reduction in preventable recurrent strokes substantially offset examination costs and risks of anticoagulation. These results were moderately sensitive to efficacy of anticoagulation and incidence of intracranial bleeding during anticoagulation and were mildly sensitive to prevalence of left atrial thrombus, rate of recurrent stroke in patients with thrombus, quality of life after stroke, cost of transesophageal echocardiography, and specificity of transesophageal echocardiography. Transthoracic echocardiography, alone or in sequence with transesophageal echocardiography, was not cost-effective compared with transesophageal echocardiography.


CONCLUSIONS
Physicians should consider doing transesophageal echocardiography in all patients with new-onset stroke.
McNamara
R L
RL
Johns Hopkins Medical Institutions, Johns Hopkins University School of Hygiene and Public Health, Baltimore, Maryland, USA.
Lima
J A
JA
Whelton
P K
PK
Powe
N R
NR
D000368:Aged; D000925:Anticoagulants / Q000627:therapeutic use; D002318:Cardiovascular Diseases / Q000150:complications / Q000000981:diagnostic imaging* / Q000517:prevention & control; D002561:Cerebrovascular Disorders / Q000209:etiology* / Q000517:prevention & control; D015331:Cohort Studies; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D004452:Echocardiography / Q000191:economics / Q000379:methods*; D017548:Echocardiography, Transesophageal / Q000191:economics; D017048:Health Care Costs; D006801:Humans; D008390:Markov Chains; D019057:Quality-Adjusted Life Years; D012008:Recurrence; D012680:Sensitivity and Specificity; D013923:Thromboembolism / Q000150:complications / Q000000981:diagnostic imaging* / Q000517:prevention & control
D000925:Anticoagulants