LOS ANGELES — Endovascular thrombectomy is not only clinically the best option for many patients with acute, ischemic strokes involving a proximal occlusion in a large cerebral artery; it’s also highly cost effective, based on follow-up analyses of two of the five randomized trials published in 2015 that collectively established thrombectomy as standard of care for these patients.Thrombectomy plus administration of intravenous tissue plasminogen activator, compared with TPA only, “is highly cost effective and economically dominant with lower long-term cost and better outcomes,” Theresa I. Shireman, PhD, said at the International Stroke Conference.And in an independent analysis of data from a totally different trial, endovascular thrombectomy on average reduced patients’ acute length of hospitalization, improved their survival and quality of life, and was cost saving when compared with treatment with intravenous TPA only, which had previously been the standard of care, Bruce C.V. Campbell, PhD, reported at the meeting.The analysis presented by Dr. Shireman used data collected in the SWIFT-PRIME trial, which randomized 196 patients at centers in the United States and Europe to treatment with either intravenous TPA plus endovascular thrombectomy, or TPA alone. Average total costs during the index hospitalization ran to roughly $46,000 in the combined-treatment arm and about $29,000 in the TPA-only arm, a difference largely driven by a roughly $15,000 average incremental cost for the thrombectomy procedure, said Dr. Shireman, professor of health services research at Brown University in Providence, RI.However, the cost-effectiveness of thrombectomy began to kick in soon after. During the 90 days following index hospitalization, patients who underwent thrombectomy had substantial average reductions in their need for inpatient rehabilitation, time spent in skilled nursing facilities, and in outpatient rehabilitation. Overall, total medical costs during the first 90 days post discharge ran on average close to $5,000 less per patient following thrombectomy. In addition, based on their health status after 90 days, patients treated with thrombectomy were projected to have a greater than 1.7-year average life expectancy than those randomized to TPA only, with a projected net gain of 1.74 quality-adjusted life years (QALYs) per patient and with a projected average decrease of roughly $23,000 in total lifetime medical costs.Based on this average increase in QALYs and decreased long-term cost, adding thrombectomy to TPA for routine treatment of the types of patients enrolled in SWIFT-PRIME was economically dominant, Dr. Shireman said at the meeting, sponsored by the American Heart Association. She also projected that despite the higher upfront cost for adding thrombectomy to treatment, the eventual savings in long-term care meant that thrombectomy began producing a net savings once patients survived for more than 22 months following their index hospitalization.Dr. Campbell reported very similar findings in his analysis of data collected from the EXTEND-IA trial, which randomized 70 patients at 10 centers in Australia and New Zealand. During the first 90 days of treatment, including the index hospitalization, treatment with thrombectomy plus TPA saved an average of roughly $4,000 per patient, compared with TPA only, even though the average incremental cost for adding thrombectomy was nearly $11,000. The overall increased total 90-day costs with TPA only was largely driven by a substantially longer time spent hospitalized among the TPA-only patients, compared with those treated with thrombectomy plus TPA, said Dr. Campbell, a neurologist and head of hyperacute stroke at Royal Melbourne Hospital.In addition, adding thrombectomy resulted in a projected average 4-year increase in life expectancy, and an average gain of about 3 QALYs per patient. Thrombectomy “is an incredibly powerful procedure, not just in terms of clinical response but also in terms of economics,” he concluded. Even when judged by the worst-case scenario of the analysis, “there is a 100% probability that the cost-effectiveness per QALY is less than $10,000 U.S., which is incredible value,” Dr. Campbell said.Dr. Shireman and Dr. Campbell had no personal disclosures.Mitchel L. Zoleris with the Philadelphia bureau of Frontline Medical News. LOS ANGELES — Endovascular thrombectomy is not only clinically the best option for many patients with acute, ischemic strokes involving a proximal occlusion in a large cerebral artery; it’s also highly cost effective, based on follow-up analyses of two of the five randomized trials published in 2015 that collectively established thrombectomy as standard of care for these patients. Thrombectomy plus administration of intravenous tissue plasminogen activator, compared with TPA only, “is highly cost effective and economically dominant with lower long-term cost and better outcomes,” Theresa I. Shireman, PhD, said at the International Stroke Conference. And in an independent analysis of data from a totally different trial, endovascular thrombectomy on average reduced patients’ acute length of hospitalization, improved their survival and quality of life, and was cost saving when compared with treatment with intravenous TPA only, which had previously been the standard of care, Bruce C.V. Campbell, PhD, reported at the meeting. The analysis presented by Dr. Shireman used data collected in the SWIFT-PRIME trial, which randomized 196 patients at centers in the United States and Europe to treatment with either intravenous TPA plus endovascular thrombectomy, or TPA alone. Average total costs during the index hospitalization ran to roughly $46,000 in the combined-treatment arm and about $29,000 in the TPA-only arm, a difference largely driven by a roughly $15,000 average incremental cost for the thrombectomy procedure, said Dr. Shireman, professor of health services research at Brown University in Providence, RI. However, the cost-effectiveness of thrombectomy began to kick in soon after. During the 90 days following index hospitalization, patients who underwent thrombectomy had substantial average reductions in their need for inpatient rehabilitation, time spent in skilled nursing facilities, and in outpatient rehabilitation. Overall, total medical costs during the first 90 days post discharge ran on average close to $5,000 less per patient following thrombectomy. In addition, based on their health status after 90 days, patients treated with thrombectomy were projected to have a greater than 1.7-year average life expectancy than those randomized to TPA only, with a projected net gain of 1.74 quality-adjusted life years (QALYs) per patient and with a projected average decrease of roughly $23,000 in total lifetime medical costs. Based on this average increase in QALYs and decreased long-term cost, adding thrombectomy to TPA for routine treatment of the types of patients enrolled in SWIFT-PRIME was economically dominant, Dr. Shireman said at the meeting, sponsored by the American Heart Association. She also projected that despite the higher upfront cost for adding thrombectomy to treatment, the eventual savings in long-term care meant that thrombectomy began producing a net savings once patients survived for more than 22 months following their index hospitalization. Dr. Campbell reported very similar findings in his analysis of data collected from the EXTEND-IA trial, which randomized 70 patients at 10 centers in Australia and New Zealand. During the first 90 days of treatment, including the index hospitalization, treatment with thrombectomy plus TPA saved an average of roughly $4,000 per patient, compared with TPA only, even though the average incremental cost for adding thrombectomy was nearly $11,000. The overall increased total 90-day costs with TPA only was largely driven by a substantially longer time spent hospitalized among the TPA-only patients, compared with those treated with thrombectomy plus TPA, said Dr. Campbell, a neurologist and head of hyperacute stroke at Royal Melbourne Hospital. In addition, adding thrombectomy resulted in a projected average 4-year increase in life expectancy, and an average gain of about 3 QALYs per patient. Thrombectomy “is an incredibly powerful procedure, not just in terms of clinical response but also in terms of economics,” he concluded. Even when judged by the worst-case scenario of the analysis, “there is a 100% probability that the cost-effectiveness per QALY is less than $10,000 U.S., which is incredible value,” Dr. Campbell said. Dr. Shireman and Dr. Campbell had no personal disclosures. Mitchel L. Zoleris with the Philadelphia bureau of Frontline Medical News. Editor’s NoteIt’s good to know that this combined intervention is pretty clearly superior. While most of us in post-acute/long-term care won’t be the ones making this decision on the front lines, we can hope that the stroke teams in our local hospitals are aware of it and adept at performing these. And at the risk of sounding like a broken record, I want to reiterate how important it is for us to ensure that our nursing staff are mindful that a possible stroke, with acute neurological deficits, is a medical emergency — a 911 emergency — and they should not wait half an hour for the doctor on call to get back to them. Even in residents who may not desire CPR in the event of a cardiac arrest, it’s usually going to be appropriate to consider them for brain-saving procedures in an acute CVA situation. Unless the resident’s goals of care are completely comfort-oriented, or when they are in the last few months of life, it is reasonable to proceed with aggressive clot-busting (and clot-removing) therapy that can save them from a markedly diminished quality of life.—Karl Steinberg, MD, CMDEditor in Chief It’s good to know that this combined intervention is pretty clearly superior. While most of us in post-acute/long-term care won’t be the ones making this decision on the front lines, we can hope that the stroke teams in our local hospitals are aware of it and adept at performing these. And at the risk of sounding like a broken record, I want to reiterate how important it is for us to ensure that our nursing staff are mindful that a possible stroke, with acute neurological deficits, is a medical emergency — a 911 emergency — and they should not wait half an hour for the doctor on call to get back to them. Even in residents who may not desire CPR in the event of a cardiac arrest, it’s usually going to be appropriate to consider them for brain-saving procedures in an acute CVA situation. Unless the resident’s goals of care are completely comfort-oriented, or when they are in the last few months of life, it is reasonable to proceed with aggressive clot-busting (and clot-removing) therapy that can save them from a markedly diminished quality of life. —Karl Steinberg, MD, CMD Editor in Chief
Search from 250 M+ research papersSearch from 250 M+ research papers
Mar 1, 2024
Alice Hung + 11
Open Access