title: Cost-effectiveness of recombinant tissue-type plasminogen activator within 3 hours of acute ischemic stroke: current evidence.
abstract: OBJECTIVE
  Despite the availability of results from multiple newer clinical trials and changing healthcare costs, the cost-effectiveness of recombinant tissue-type plasminogen activator (r-tPA) for treatment of acute ischemic stroke within 0 to 3 hours of symptom onset was last evaluated in 1998 for the United States Using current evidence, we evaluate the long-term cost-effectiveness of r-tPA administered 0 to 3 hours after acute ischemic stroke onset versus no r-tPA.
  
  
  METHODS
  A disease-based decision model to project lifetime outcomes of patients after acute ischemic stroke by r-tPA treatment status from the US payer perspective was developed. Model inputs were derived from a recent meta-analysis of r-tPA trials, cohort studies, and health state preference studies. Cost data, inflated to 2013 dollars, were based on drug wholesale acquisition cost and the literature. To compare r-tPA to no r-tPA, we calculated incremental total direct costs, incremental quality-adjusted life years, and incremental cost-effectiveness ratios. We performed 1-way and probabilistic sensitivity analyses to evaluate uncertainty in the results.
  
  
  RESULTS
  r-tPA resulted in a gain of 0.39 quality-adjusted life years (95% confidence range, 0.16-0.66) on average per patient and a lifetime cost-saving of $25,000 (95% confidence range, -$42,500 to -$11,000) compared with no r-tPA. In probabilistic sensitivity analyses, r-tPA was dominant compared with no r-tPA in ≈100% of simulations. The model was sensitive to inputs for r-tPA efficacy, healthcare costs for disabled patients, mortality rates for disabled and nondisabled patients, and quality of life estimates.
  
  
  CONCLUSIONS
  Our analysis supports earlier economic evaluations that r-tPA is a cost-effective method to treat stroke. Appropriate use of r-tPA should be prioritized nationally.
authors.affiliation: From the University of Washington, Seattle (D.M.B., G.F.G., D.L.V.); Genentech, Inc South San Francisco, CA (E.C., D.T.); Palo Alto Outcomes Research, CA (D.L.); and University of Georgia College of Pharmacy, Athens (S.C.F.). dboudrea@u.washington.edu.
authors.forename: Denise M
authors.initials: DM
authors.lastname: Boudreau
authors.affiliation: From the University of Washington, Seattle (D.M.B., G.F.G., D.L.V.); Genentech, Inc South San Francisco, CA (E.C., D.T.); Palo Alto Outcomes Research, CA (D.L.); and University of Georgia College of Pharmacy, Athens (S.C.F.).
authors.forename: Gregory F
authors.initials: GF
authors.lastname: Guzauskas
authors.affiliation: From the University of Washington, Seattle (D.M.B., G.F.G., D.L.V.); Genentech, Inc South San Francisco, CA (E.C., D.T.); Palo Alto Outcomes Research, CA (D.L.); and University of Georgia College of Pharmacy, Athens (S.C.F.).
authors.forename: Er
authors.initials: E
authors.lastname: Chen
authors.affiliation: From the University of Washington, Seattle (D.M.B., G.F.G., D.L.V.); Genentech, Inc South San Francisco, CA (E.C., D.T.); Palo Alto Outcomes Research, CA (D.L.); and University of Georgia College of Pharmacy, Athens (S.C.F.).
authors.forename: Deepa
authors.initials: D
authors.lastname: Lalla
authors.affiliation: From the University of Washington, Seattle (D.M.B., G.F.G., D.L.V.); Genentech, Inc South San Francisco, CA (E.C., D.T.); Palo Alto Outcomes Research, CA (D.L.); and University of Georgia College of Pharmacy, Athens (S.C.F.).
authors.forename: Darren
authors.initials: D
authors.lastname: Tayama
authors.affiliation: From the University of Washington, Seattle (D.M.B., G.F.G., D.L.V.); Genentech, Inc South San Francisco, CA (E.C., D.T.); Palo Alto Outcomes Research, CA (D.L.); and University of Georgia College of Pharmacy, Athens (S.C.F.).
authors.forename: Susan C
authors.initials: SC
authors.lastname: Fagan
authors.affiliation: From the University of Washington, Seattle (D.M.B., G.F.G., D.L.V.); Genentech, Inc South San Francisco, CA (E.C., D.T.); Palo Alto Outcomes Research, CA (D.L.); and University of Georgia College of Pharmacy, Athens (S.C.F.).
authors.forename: David L
authors.initials: DL
authors.lastname: Veenstra
mesh_terms: D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D005343:Fibrinolytic Agents / Q000191:economics* / Q000627:therapeutic use*; D006801:Humans; D019057:Quality-Adjusted Life Years; D020521:Stroke / Q000188:drug therapy*; D010959:Tissue Plasminogen Activator / Q000191:economics* / Q000627:therapeutic use*; D014481:United States
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator
keywords: cerebrovascular disorders; cost-effectiveness; quality of life; stroke; thrombolytic drugs