Cost-effectiveness of echocardiography to identify intracardiac thrombus among patients with first stroke or transient ischemic attack.
OBJECTIVE
Echocardiography to select stroke patients for targeted treatments, such as anticoagulation (AC), to reduce recurrent stroke risk is controversial. The authors' objective was to evaluate the cost-effectiveness of imaging strategies that use transthoracic (TTE) and transesophageal (TEE) echocardiography for identifying intracardiac thrombus in new stroke patients.


METHODS
Model-based cost-effectiveness analysis of 7 echocardiographic imaging strategies and 2 nontesting strategies with model parameters based on systematic evidence review related to effectiveness of echocardiography in newly diagnosed ischemic stroke patients (white males aged 65 years in base case). Primary outcome was cost per quality-adjusted life year (QALY).


RESULTS
All strategies containing TTE were dominated by others and were eliminated from the analysis. Assuming that AC reduces recurrent stroke risk from intracardiac thrombus by 43% over 1 year, TEE generated a cost per QALY of $137,000 (relative to standard treatment) among patients with 5% thrombus prevalence. Cost per QALY dropped to $50,000 in patients with at least 15% intracardiac thrombus prevalence, or, if an 86% relative risk reduction with AC is assumed, in patients with thrombus prevalence of at least 6%. Probabilistic analyses indicate considerable uncertainty around the cost-effectiveness of echocardiography across a wide range of intracardiac thrombus prevalence (pretest probability).


CONCLUSIONS
Current evidence on cost-effectiveness is insufficient to justify widespread use of echocardiography in stroke patients. Additional research on recurrent stroke risk in patients with intracardiac thrombus and on the efficacy of AC in reducing that risk may contribute to a better understanding of the circumstances under which echocardiography will be cost-effective.
Meenan
Richard T
RT
Oregon Health & Science University Evidence-based Practice Center, Portland, USA. Richard.meenan@kpchr.org
Saha
Somnath
S
Chou
Roger
R
Swarztrauber
Karleen
K
Pyle Krages
Kathryn
K
O'Keeffe-Rosetti
Maureen C
MC
McDonagh
Marian
M
Chan
Benjamin K S
BK
Hornbrook
Mark C
MC
Helfand
Mark
M
D000368:Aged; D000925:Anticoagulants / Q000191:economics / Q000627:therapeutic use; D003328:Coronary Thrombosis / Q000000981:diagnostic imaging*; D003362:Cost-Benefit Analysis; D003657:Decision Making; D003663:Decision Trees; D004452:Echocardiography / Q000191:economics; D006801:Humans; D002546:Ischemic Attack, Transient / Q000191:economics* / Q000628:therapy; D008297:Male; D008390:Markov Chains; D009010:Monte Carlo Method; D019057:Quality-Adjusted Life Years; D055502:Secondary Prevention; D020521:Stroke / Q000191:economics* / Q000628:therapy
D000925:Anticoagulants