title: Cost-effectiveness of transfers to centers with neurological intensive care units after intracerebral hemorrhage.
abstract: OBJECTIVE
  Our aim was to estimate the cost-effectiveness of transferring patients with intracerebral hemorrhage from centers without specialized neurological intensive care units (neuro-ICUs) to centers with neuro-ICUs.
  
  
  METHODS
  Decision analytic models were developed for the lifetime horizons. Model inputs were derived from the best available data, informed by a variety of previous cost-effectiveness models of stroke. The effect of neuro-ICU care on functional outcomes was modeled in 3 scenarios. A favorable outcomes scenario was modeled based on the best observational data and compared with moderately favorable and least-favorable outcomes scenarios. Health benefits were measured in quality-adjusted life years (QALYs), and costs were estimated from a societal perspective. Costs were combined with QALYs gained to generate incremental cost-effectiveness ratios. One-way sensitivity analysis and Monte Carlo simulations were performed to test robustness of the model assumptions.
  
  
  RESULTS
  Transferring patients to centers with neuro-ICUs yielded an incremental cost-effectiveness ratio for the lifetime horizon of $47,431 per QALY, $91,674 per QALY, and $380,358 per QALY for favorable, moderately favorable, and least-favorable scenarios, respectively. Models were robust at a willingness-to-pay threshold of $100,000 per QALY, with 95.5%, 75.0%, and 2.1% of simulations below the threshold for favorable, moderately favorable, and least-favorable scenarios, respectively.
  
  
  CONCLUSIONS
  Transferring patients with intracerebral hemorrhage to centers with specialized neuro-ICUs is cost-effective if observational estimates of the neuro-ICU-based functional outcome distribution are accurate. If future work confirms these functional outcome distributions, then a strong societal rationale exists to build systems of care designed to transfer intracerebral hemorrhage patients to specialized neuro-ICUs.
authors.affiliation: From the Departments of Neurosurgery (J.J.F., L.B.M.), Neurology (V.K., A.M.), Biostatistics (L.B.M.), Physical Medicine and Rehabilitation (M.P.), and the Stroke Program (L.B.M., J.F.B.), University of Michigan, Ann Arbor; and Department of Neurology, Bronson Methodist Hospital, Kalamazoo, MI (J.J.F.). fletchje@bronsonhg.org.
authors.forename: Jeffrey J
authors.initials: JJ
authors.lastname: Fletcher
authors.affiliation: From the Departments of Neurosurgery (J.J.F., L.B.M.), Neurology (V.K., A.M.), Biostatistics (L.B.M.), Physical Medicine and Rehabilitation (M.P.), and the Stroke Program (L.B.M., J.F.B.), University of Michigan, Ann Arbor; and Department of Neurology, Bronson Methodist Hospital, Kalamazoo, MI (J.J.F.).
authors.forename: Vikas
authors.initials: V
authors.lastname: Kotagal
authors.affiliation: From the Departments of Neurosurgery (J.J.F., L.B.M.), Neurology (V.K., A.M.), Biostatistics (L.B.M.), Physical Medicine and Rehabilitation (M.P.), and the Stroke Program (L.B.M., J.F.B.), University of Michigan, Ann Arbor; and Department of Neurology, Bronson Methodist Hospital, Kalamazoo, MI (J.J.F.).
authors.forename: Aaron
authors.initials: A
authors.lastname: Mammoser
authors.affiliation: From the Departments of Neurosurgery (J.J.F., L.B.M.), Neurology (V.K., A.M.), Biostatistics (L.B.M.), Physical Medicine and Rehabilitation (M.P.), and the Stroke Program (L.B.M., J.F.B.), University of Michigan, Ann Arbor; and Department of Neurology, Bronson Methodist Hospital, Kalamazoo, MI (J.J.F.).
authors.forename: Mark
authors.initials: M
authors.lastname: Peterson
authors.affiliation: From the Departments of Neurosurgery (J.J.F., L.B.M.), Neurology (V.K., A.M.), Biostatistics (L.B.M.), Physical Medicine and Rehabilitation (M.P.), and the Stroke Program (L.B.M., J.F.B.), University of Michigan, Ann Arbor; and Department of Neurology, Bronson Methodist Hospital, Kalamazoo, MI (J.J.F.).
authors.forename: Lewis B
authors.initials: LB
authors.lastname: Morgenstern
authors.affiliation: From the Departments of Neurosurgery (J.J.F., L.B.M.), Neurology (V.K., A.M.), Biostatistics (L.B.M.), Physical Medicine and Rehabilitation (M.P.), and the Stroke Program (L.B.M., J.F.B.), University of Michigan, Ann Arbor; and Department of Neurology, Bronson Methodist Hospital, Kalamazoo, MI (J.J.F.).
authors.forename: James F
authors.initials: JF
authors.lastname: Burke
mesh_terms: D000368:Aged; D002543:Cerebral Hemorrhage / Q000191:economics / Q000628:therapy*; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D006801:Humans; D007362:Intensive Care Units / Q000191:economics*; D008875:Middle Aged; D018803:Models, Economic; D009010:Monte Carlo Method; D009462:Neurology / Q000191:economics*; D010360:Patient Transfer / Q000191:economics*; D019057:Quality-Adjusted Life Years
keywords: cerebral hemorrhage; cost-effectiveness; mortality