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Drive-the-doctor paradigm in acute ischaemic stroke for improving regional stroke care networks: a cost-effectiveness
Chi Phuong Nguyen1,2,3, Maarten Uyttenboogaart4,5, Willemijn J Maas2,4
1Department of Operations, Faculty of Economics and Business, University of Groningen, Groningen, The Netherlands p.nguyen@umcg.nl.
Insights
The drive-the-doctor (DD) paradigm for large vessel occlusion (LVO) stroke is cost-effective. This model, with an interventionalist traveling to primary stroke centers, offers improved outcomes and is a promising evolution for stroke networks.
Area of Science:
- Neuroscience and Neurology
- Health Economics and Outcomes Research
Background:
- The drive-the-doctor (DD) paradigm involves interventionalists traveling from comprehensive stroke centers (CSCs) to primary stroke centers (PSCs) for endovascular thrombectomy (EVT) in acute ischemic stroke due to large vessel occlusion (LVO).
- This model aims to reduce delays in treatment initiation and improve recanalization times compared to the drip-and-ship (DS) paradigm.
Purpose of the Study:
- To analyze the cost-effectiveness of the DD paradigm compared to the DS paradigm for LVO patients in the northern Netherlands.
- To identify the optimal DD strategy considering variations in the number of upgraded PSCs and transportation modalities.
Main Methods:
- Economic evaluation using a simulation model, decision tree, and Markov model.
- Analysis of a hypothetical cohort of 100,000 LVO patients (average age 70) over a 15-year horizon from a Dutch healthcare provider perspective.
- Testing DD paradigms with one or two upgraded PSCs, assessing transportation by car, ambulance, and helicopter, and using an ICER threshold of €50,000.
Main Results:
- The DD paradigm utilizing car transport and two upgraded PSCs emerged as the optimal strategy, yielding the lowest incremental cost-effectiveness ratio (ICER).
- This optimal strategy resulted in an additional 0.13 quality-adjusted life years (QALYs) at an incremental cost of €2367, with an ICER of €18,306.
- Probabilistic sensitivity analyses indicated a 72% preference for the DD paradigm with two PSCs using car transport.
Conclusions:
- The DD paradigm is a cost-effective approach for managing LVO patients.
- This model represents a promising advancement for optimizing regional stroke networks and improving patient outcomes.
Background And Objective:
In a drive-the-doctor (DD) paradigm, an interventionalist travels from a comprehensive stroke centre (CSC) to primary stroke centres (PSCs) to perform endovascular thrombectomy (EVT) for acute ischaemic stroke due to large vessel occlusion (LVO). The DD paradigm may reduce time delays from onset to recanalisation. This study aimed to analyse the cost-effectiveness of the DD paradigm versus a drip-and-ship (DS) paradigm, where LVO patients are transferred from PSCs to a CSC for EVT in the northern Netherlands.
Design:
Economic evaluation was performed using a simulation model combined with a decision tree and a Markov model.
Setting:
Stroke centres in the northern Netherlands.
Participants:
A hypothetical cohort of 100 000 LVO patients with an average age of 70 years.
Interventions:
Two strategies were tested, including the DD paradigm with one upgraded PSC and the DD paradigm with two upgraded PSCs.
Main Outcome Measures:
Total costs and quality-adjusted life years (QALYs) were measured over a 15-year time horizon from a Dutch healthcare provider perspective. An incremental cost-effectiveness ratio (ICER) of €50 000 was used as a willingness-to-pay threshold. One-way sensitivity, probabilistic sensitivity and scenario analyses (interventionalist transportation by car, ambulance and helicopter) were conducted to examine parameter uncertainty.
Results:
The DD paradigm using car as a transport modality and two PSCs was the optimal strategy, resulting in the lowest ICER. This strategy provided an additional 0.13 QALYs at incremental costs of €2367, yielding an ICER of €18 306 compared with current practice. The DD paradigm with two PSCs reduced ICERs compared with the scenario with one PSC when varying transportation modalities (car, ambulance and helicopter). Probabilistic sensitivity analyses showed that the DD paradigm with two PSCs using car was preferred in 72% of 10 000 Monte Carlo simulations.
Conclusions:
The DD paradigm appeared cost-effective for LVO patients and may be considered a promising evolution for a regional stroke network.
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01:15Ischemic Stroke ll: Pathophysiology