title: Stroke: Effect of implementing an evaluation and treatment protocol compliant with NINDS recommendations.
abstract: OBJECTIVE
  To evaluate--relative to routine clinical practice--the potential cost-effectiveness of implementing a strategy compliant with National Institute of Neurological Disorders and Stroke (NINDS) recommendations for care of patients presenting with signs and symptoms of acute ischemic stroke.
  
  
  METHODS
  A discrete-event simulation model of the process of stroke care from symptom onset through administration of tissue plasminogen activator (tPA) was constructed. A literature review was performed to determine process times, performance of computed tomography (CT), health outcomes, and cost estimates. The following were compared: (a) a "base-case" strategy determined on the basis of findings in the literature and (b) a NINDS-compliant strategy (ie, evaluation by emergency physician in less than 10 minutes, interpretation of CT scans within 45 minutes, and administration of tPA within 1 hour after presentation). Strategies were compared with regard to cost and effectiveness. Sensitivity analyses were performed for all relevant cost, timing, and resource parameters. Outcomes of concern were quality-adjusted life years and number of patients treated within a 3-hour therapeutic window.
  
  
  RESULTS
  The NINDS-compliant strategy resulted in an average quality-adjusted life years value of 3.64, versus 3.63 for the base case, at an approximate cost of 434 US dollars per patient. The NINDS-compliant strategy increased the proportion of treatable patients from 1.4% to 3.7% and remained cost-effective for expenditures of up to 450 US dollars per patient. Assuming base-case parameters are used, increasing the number of CT scanners from two to eight raised the proportion of treatable patients to 1.5%. Increasing the number of available neurologists from four to eight raised the proportion to 1.44%. Reducing the time from stroke onset to emergency department arrival by 30 minutes raised the proportion to up to 7.7%.
  
  
  CONCLUSIONS
  Applying NINDS recommendations is potentially cost-effective, although reducing the time from stroke onset to emergency department arrival may be even more so.
authors.affiliation: Institute for Technology Assessment and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Zero Emerson Bldg, Suite 2H, Boston, MA 02114, USA. james@mgh-ita.org
authors.forename: James E
authors.initials: JE
authors.lastname: Stahl
authors.forename: Karen L
authors.initials: KL
authors.lastname: Furie
authors.forename: Suzanne
authors.initials: S
authors.lastname: Gleason
authors.forename: G Scott
authors.initials: GS
authors.lastname: Gazelle
mesh_terms: D002985:Clinical Protocols; D003362:Cost-Benefit Analysis; D004630:Emergencies; D006801:Humans; D008962:Models, Theoretical; D009316:National Institutes of Health (U.S.); D020521:Stroke / Q000191:economics / Q000628:therapy*; D013997:Time Factors; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014481:United States
chemical_list: D010959:Tissue Plasminogen Activator