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Mechanical thrombectomy in patients with acute ischemic stroke: a cost-utility analysis
Xuanqian Xie1, Anna Lambrinos1, Brian Chan1
1Health Quality Ontario (Xie, Lambrinos, Chan, Dhalla, Sikich); Toronto Health Economics and Technology Assessment Collaborative (Xie), Leslie Dan Pharmacy, University of Toronto; Departments of Medical Imaging and Surgery (Krings, Pereira), University of Toronto; University Health Network - Toronto Western Hospital (Krings, Casaubon); Department of Medicine (Casaubon), Division of Neurology, University of Toronto; Stroke Outcomes Research Centre (Saposnik), St. Michael's Hospital, University of Toronto; Division of Neuroradiology (Bharatha), Department of Medical Imaging, St. Michael's Hospital, University of Toronto; Ontario Stroke Network (O'Callaghan, Kelloway), Toronto, Ont.; Ottawa Hospital Research Institute and Diagnostic Imaging - Interventional Neuroradiology (Lum), The Ottawa Hospital, University of Ottawa; Division of Neurology (Stotts), The Ottawa Hospital, Ottawa, Ont.; Department of Clinical Neurosciences (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta.
Background:
The beneficial effects of endovascular treatment with new-generation mechanical thrombectomy devices compared with intravenous thrombolysis alone to treat acute large-artery ischemic stroke have been shown in randomized controlled trials (RCTs). This study aimed to estimate the cost utility of mechanical thrombectomy compared with the established standard of care.
Methods:
We developed a Markov decision process analytic model to assess the cost-effectiveness of treatment with mechanical thrombectomy plus intravenous thrombolysis versus treatment with intravenous thrombolysis alone from the public payer perspective in Canada. We conducted comprehensive literature searches to populate model inputs. We estimated the efficacy of mechanical thrombectomy plus intravenous thrombolysis from a meta-analysis of 5 RCTs, and we used data from the Oxford Vascular Study to model long-term clinical outcomes. We calculated incremental cost-effectiveness ratios (ICER) using a 5-year time horizon.
Results:
The base case analysis showed the cost and effectiveness of treatment with mechanical thrombectomy plus intravenous thrombolysis to be $126 939 and 1.484 quality-adjusted life-years (QALYs), respectively, and the cost and effectiveness of treatment with intravenous thrombolysis alone to be $124 419 and 1.273 QALYs, respectively. The mechanical thrombectomy plus intravenous thrombolysis strategy was associated with an ICER of $11 990 per QALY gained. Probabilistic sensitivity analysis showed that the probability of treatment with mechanical thrombectomy plus intravenous thrombolysis being cost-effective was 57.5%, 89.7% and 99.6% at thresholds of $20 000, $50 000 and $100 000 per QALY gained, respectively. The main factors influencing the ICER were time horizon, extra cost of mechanical thrombectomy treatment and age of the patient.
Interpretation:
Mechanical thrombectomy as an adjunct therapy to intravenous thrombolysis is cost-effective compared with treatment with intravenous thrombolysis alone for patients with acute large-artery ischemic stroke.
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