title: Cost-Effectiveness of Endovascular Stroke Therapy: A Patient Subgroup Analysis From a US Healthcare Perspective.
abstract: OBJECTIVE
  Endovascular therapy in addition to standard care (EVT+SC) has been demonstrated to be more effective than SC in acute ischemic large vessel occlusion stroke. Our aim was to determine the cost-effectiveness of EVT+SC depending on patients' initial National Institutes of Health Stroke Scale (NIHSS) score, time from symptom onset, Alberta Stroke Program Early CT Score (ASPECTS), and occlusion location.
  
  
  METHODS
  A decision model based on Markov simulations estimated lifetime costs and quality-adjusted life years (QALYs) associated with both strategies applied in a US setting. Model input parameters were obtained from the literature, including recently pooled outcome data of 5 randomized controlled trials (ESCAPE [Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke], EXTEND-IA [Extending the Time for Thrombolysis in Emergency Neurological Deficits-Intra-Arterial], MR CLEAN [Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands], REVASCAT [Randomized Trial of Revascularization With Solitaire FR Device Versus Best Medical Therapy in the Treatment of Acute Stroke Due to Anterior Circulation Large Vessel Occlusion Presenting Within 8 Hours of Symptom Onset], and SWIFT PRIME [Solitaire With the Intention for Thrombectomy as Primary Endovascular Treatment]). Probabilistic sensitivity analysis was performed to estimate uncertainty of the model results. Net monetary benefits, incremental costs, incremental effectiveness, and incremental cost-effectiveness ratios were derived from the probabilistic sensitivity analysis. The willingness-to-pay was set to $50 000/QALY.
  
  
  RESULTS
  Overall, EVT+SC was cost-effective compared with SC (incremental cost: $4938, incremental effectiveness: 1.59 QALYs, and incremental cost-effectiveness ratio: $3110/QALY) in 100% of simulations. In all patient subgroups, EVT+SC led to gained QALYs (range: 0.47-2.12), and mean incremental cost-effectiveness ratios were considered cost-effective. However, subgroups with ASPECTS ≤5 or with M2 occlusions showed considerably higher incremental cost-effectiveness ratios ($14 273/QALY and $28 812/QALY, respectively) and only reached suboptimal acceptability in the probabilistic sensitivity analysis (75.5% and 59.4%, respectively). All other subgroups had acceptability rates of 90% to 100%.
  
  
  CONCLUSIONS
  EVT+SC is cost-effective in most subgroups. In patients with ASPECTS ≤5 or with M2 occlusions, cost-effectiveness remains uncertain based on current data.
authors.affiliation: From the Institute for Clinical Radiology (W.G.K., W.H.S., S.E.B., F.G.M., S.W., M.F.R., B.E.-W., K.M.T.) and Department of Neuroradiology (F.D.), LMU Munich, Munich, Germany; Departments of Radiology (M.G.M.H.) and Epidemiology (M.G.M.H.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Center for Health Decision Sciences, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA (M.G.M.H.). wolfgang.kunz@med.lmu.de.
authors.forename: Wolfgang G
authors.initials: WG
authors.lastname: Kunz
authors.affiliation: From the Institute for Clinical Radiology (W.G.K., W.H.S., S.E.B., F.G.M., S.W., M.F.R., B.E.-W., K.M.T.) and Department of Neuroradiology (F.D.), LMU Munich, Munich, Germany; Departments of Radiology (M.G.M.H.) and Epidemiology (M.G.M.H.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Center for Health Decision Sciences, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA (M.G.M.H.).
authors.forename: M G Myriam
authors.initials: MG
authors.lastname: Hunink
authors.affiliation: From the Institute for Clinical Radiology (W.G.K., W.H.S., S.E.B., F.G.M., S.W., M.F.R., B.E.-W., K.M.T.) and Department of Neuroradiology (F.D.), LMU Munich, Munich, Germany; Departments of Radiology (M.G.M.H.) and Epidemiology (M.G.M.H.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Center for Health Decision Sciences, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA (M.G.M.H.).
authors.forename: Wieland H
authors.initials: WH
authors.lastname: Sommer
authors.affiliation: From the Institute for Clinical Radiology (W.G.K., W.H.S., S.E.B., F.G.M., S.W., M.F.R., B.E.-W., K.M.T.) and Department of Neuroradiology (F.D.), LMU Munich, Munich, Germany; Departments of Radiology (M.G.M.H.) and Epidemiology (M.G.M.H.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Center for Health Decision Sciences, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA (M.G.M.H.).
authors.forename: Sebastian E
authors.initials: SE
authors.lastname: Beyer
authors.affiliation: From the Institute for Clinical Radiology (W.G.K., W.H.S., S.E.B., F.G.M., S.W., M.F.R., B.E.-W., K.M.T.) and Department of Neuroradiology (F.D.), LMU Munich, Munich, Germany; Departments of Radiology (M.G.M.H.) and Epidemiology (M.G.M.H.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Center for Health Decision Sciences, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA (M.G.M.H.).
authors.forename: Felix G
authors.initials: FG
authors.lastname: Meinel
authors.affiliation: From the Institute for Clinical Radiology (W.G.K., W.H.S., S.E.B., F.G.M., S.W., M.F.R., B.E.-W., K.M.T.) and Department of Neuroradiology (F.D.), LMU Munich, Munich, Germany; Departments of Radiology (M.G.M.H.) and Epidemiology (M.G.M.H.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Center for Health Decision Sciences, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA (M.G.M.H.).
authors.forename: Franziska
authors.initials: F
authors.lastname: Dorn
authors.affiliation: From the Institute for Clinical Radiology (W.G.K., W.H.S., S.E.B., F.G.M., S.W., M.F.R., B.E.-W., K.M.T.) and Department of Neuroradiology (F.D.), LMU Munich, Munich, Germany; Departments of Radiology (M.G.M.H.) and Epidemiology (M.G.M.H.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Center for Health Decision Sciences, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA (M.G.M.H.).
authors.forename: Stefan
authors.initials: S
authors.lastname: Wirth
authors.affiliation: From the Institute for Clinical Radiology (W.G.K., W.H.S., S.E.B., F.G.M., S.W., M.F.R., B.E.-W., K.M.T.) and Department of Neuroradiology (F.D.), LMU Munich, Munich, Germany; Departments of Radiology (M.G.M.H.) and Epidemiology (M.G.M.H.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Center for Health Decision Sciences, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA (M.G.M.H.).
authors.forename: Maximilian F
authors.initials: MF
authors.lastname: Reiser
authors.affiliation: From the Institute for Clinical Radiology (W.G.K., W.H.S., S.E.B., F.G.M., S.W., M.F.R., B.E.-W., K.M.T.) and Department of Neuroradiology (F.D.), LMU Munich, Munich, Germany; Departments of Radiology (M.G.M.H.) and Epidemiology (M.G.M.H.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Center for Health Decision Sciences, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA (M.G.M.H.).
authors.forename: Birgit
authors.initials: B
authors.lastname: Ertl-Wagner
authors.affiliation: From the Institute for Clinical Radiology (W.G.K., W.H.S., S.E.B., F.G.M., S.W., M.F.R., B.E.-W., K.M.T.) and Department of Neuroradiology (F.D.), LMU Munich, Munich, Germany; Departments of Radiology (M.G.M.H.) and Epidemiology (M.G.M.H.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Center for Health Decision Sciences, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA (M.G.M.H.).
authors.forename: Kolja M
authors.initials: KM
authors.lastname: Thierfelder
mesh_terms: D002545:Brain Ischemia / Q000188:drug therapy* / Q000191:economics*; D003362:Cost-Benefit Analysis; D006801:Humans; D015233:Models, Statistical; D019057:Quality-Adjusted Life Years; D016032:Randomized Controlled Trials as Topic / Q000706:statistics & numerical data*; D012720:Severity of Illness Index; D020521:Stroke / Q000188:drug therapy* / Q000191:economics*; D015912:Thrombolytic Therapy / Q000191:economics* / Q000706:statistics & numerical data
keywords: cost-effectiveness; economics; stroke; thrombectomy; thrombolysis