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Cost-effectiveness of multimodal CT for evaluating acute stroke.

ABSTRACT: Multimodal CT, including noncontrast CT (NCCT), CT with contrast, CT angiography (CTA), and perfusion CT (CTP), is increasingly used in acute stroke patients to identify candidates for endovascular therapy. Our goal is to explore the cost-effectiveness of multimodal CT as a diagnostic test.A Markov model compared multimodal CT to NCCT in a hypothetical cohort of nonhemorrhagic stroke patients presenting within 3 hours of symptom onset who were potential IV tPA candidates. Patients who failed to improve after IV tPA or in whom IV tPA was contraindicated were candidates for endovascular therapy. Direct costs (2008 USD), outcomes, and probabilities were obtained from the literature.For the 3-month time horizon, multimodal CT had lower costs (-$1,716), had greater quality-adjusted life-years (QALYs, 0.004), and was the cost-effective choice 100% of the time for a willingness-to-pay of $100,000/QALY (probabilistic sensitivity analysis). The number needed to screen with multimodal CT to avoid 1 diagnostic angiogram was 2. Over a lifetime, multimodal CT had lower costs (-$2,058), had greater QALYs (0.008), and was cost-effective, with a 90.1% likelihood, for a willingness-to-pay of $100,000/QALY.Multimodal CT appears to be a cost-saving screening tool over the short term. However, additional data regarding clinical outcomes following multimodal CT-guided intra-arterial treatment are needed before the long-term cost-effectiveness can be suitably addressed. This analysis can be incorporated into future discussions of multimodal CT as a diagnostic test for unselected patients, within and beyond the 3-hour IV tPA time window.

SUBMITTER: Young KC

PROVIDER: S-EPMC3033607 | biostudies-other | 2010 Nov

REPOSITORIES: biostudies-other

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Cost-effectiveness of multimodal CT for evaluating acute stroke.

Young Kate C KC Benesch Curtis G CG Jahromi Babak S BS

Neurology 20101006 19

<h4>Objective</h4>Multimodal CT, including noncontrast CT (NCCT), CT with contrast, CT angiography (CTA), and perfusion CT (CTP), is increasingly used in acute stroke patients to identify candidates for endovascular therapy. Our goal is to explore the cost-effectiveness of multimodal CT as a diagnostic test.<h4>Methods</h4>A Markov model compared multimodal CT to NCCT in a hypothetical cohort of nonhemorrhagic stroke patients presenting within 3 hours of symptom onset who were potential IV tPA c ...[more]

PMID: 20926786

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Project description:PurposeNational guidelines recommend prompt identification of candidates for acute ischemic stroke (AIS) treatment, requiring timely neuroimaging with CT and/or MRI. CT is often preferred because of its widespread availability and rapid acquisition. Despite higher diagnostic accuracy of MRI, it commonly involves complex workflows that could potentially cause treatment time delays. The purpose of this study was to analyze the impact on outcomes of imaging utilization before treatment decisions at comprehensive stroke centers for patients presenting with suspected AIS in the anterior circulation with last-known-well-to-arrival time 0 to 24 hours.MethodsA decision simulation model based on the American Heart Association's recommendations for AIS care pathways was developed from a health care perspective to compare initial imaging strategies: (1) stepwise-CT: noncontrast CT (NCCT) at the time of presentation, with CT angiography (CTA) ± CT perfusion (CTP) only in select patients (initial imaging to exclude hemorrhage and extensive ischemia) for mechanical thrombectomy (MT) evaluation; (2) stepwise-hybrid: NCCT at the time of presentation, with MR angiography (MRA) ± MR perfusion (MRP) only for MT evaluation; (3) stepwise-advanced: NCCT + CTA at presentation, with MR diffusion-weighted imaging (MR DWI) + MRP only for MT evaluation; (4) comprehensive-CT: NCCT + CTA + CTP at the time of presentation; and (5) comprehensive-MR: MR DWI + MRA + MRP at the time of presentation. Model parameters were defined using evidence-based data. Cost-effectiveness and sensitivity analyses were performed.ResultsThe cost-effectiveness analyses revealed that comprehensive-CT and comprehensive-MR yield the highest lifetime quality-adjusted life-years (QALYs) (4.81 and 4.82, respectively). However, the incremental cost-effectiveness ratio of comprehensive-MR is $233,000/QALY compared with comprehensive-CT. Stepwise-CT, stepwise-hybrid, and stepwise-advanced strategies are dominated, yielding lower QALYs and higher costs compared with comprehensive-CT.ConclusionsPerforming comprehensive-CT at presentation is the most cost-effective initial imaging strategy at comprehensive stroke centers.

Project description:BackgroundThrombolytic treatment (tissue-type plasminogen activator [tPA]) is only recommended for acute ischemic stroke patients with stroke onset time <4.5 hours. tPA is not recommended when stroke onset time is unknown. Diffusion-weighted MRI (DWI) and fluid attenuated inversion recovery (FLAIR) MRI mismatch information has been found to approximate stroke onset time with some accuracy. Therefore, we developed a micro-simulation model to project health outcomes and costs of MRI-based treatment decisions versus no treatment for acute wake-up stroke patients.Methods and findingsThe model assigned simulated patients a true stroke onset time from a specified probability distribution. DWI-FLAIR mismatch estimated stroke onset <4.5 hours with sensitivity and specificity of 0.62 and 0.78, respectively. Modified Rankin Scale (mRS) scores reflected tPA treatment effectiveness accounting for patients' true stroke onset time. Discounted lifetime costs and benefits (quality-adjusted life years [QALYs]) were projected for each strategy. Incremental cost-effectiveness ratios (ICERs) were calculated for the MRI-based strategy in base-case and sensitivity analyses. With no treatment, 45.1% of simulated patients experienced a good stroke outcome (mRS score 0-1). Under the MRI-based strategy, in which 17.0% of all patients received tPA despite stroke onset times >4.5 hours, 46.3% experienced a good stroke outcome. Lifetime discounted QALYs and costs were 5.312 and $88,247 for the no treatment strategy and 5.342 and $90,869 for the MRI-based strategy, resulting in an ICER of $88,000/QALY. Results were sensitive to variations in patient- and provider-specific factors such as sleep duration, hospital travel and door-to-needle times, as well as onset probability distribution, MRI specificity, and mRS utility values.ConclusionsOur model-based findings suggest that an MRI-based treatment strategy for this population could be cost-effective and quantifies the impact that patient- and provider-specific factors, such as sleep duration, hospital travel and door-to-needle times, could have on the optimal decision for wake-up stroke patients.

Project description:BACKGROUND:Statins are effective in the primary prevention of atherosclerotic cardiovascular disease. The 2013 American College of Cardiology/American Heart Association (ACC/AHA) guideline expands recommended statin use, but its cost-effectiveness has not been compared with other guidelines. METHODS:We used the Cardiovascular Disease Policy Model to estimate the cost-effectiveness of the ACC/AHA guideline relative to current use, Adult Treatment Panel III guidelines, and universal statin use in all men 45 to 74 years of age and women 55 to 74 years of age over a 10-year horizon from 2016 to 2025. Sensitivity analyses varied costs, risks, and benefits. Main outcomes were incremental cost-effectiveness ratios and numbers needed to treat for 10 years per quality-adjusted life-year gained. RESULTS:Each approach produces substantial benefits and net cost savings relative to the status quo. Full adherence to the Adult Treatment Panel III guideline would result in 8.8 million more statin users than the status quo, at a number needed to treat for 10 years per quality-adjusted life-year gained of 35. The ACC/AHA guideline would potentially result in up to 12.3 million more statin users than the Adult Treatment Panel III guideline, with a marginal number needed to treat for 10 years per quality-adjusted life-year gained of 68. Moderate-intensity statin use in all men 45 to 74 years of age and women 55 to 74 years of age would result in 28.9 million more statin users than the ACC/AHA guideline, with a marginal number needed to treat for 10 years per quality-adjusted life-year gained of 108. In all cases, benefits would be greater in men than women. Results vary moderately with different risk thresholds for instituting statins and statin toxicity estimates but depend greatly on the disutility caused by daily medication use (pill burden). CONCLUSIONS:At a population level, the ACC/AHA guideline for expanded statin use for primary prevention is projected to treat more people, to save more lives, and to cost less compared with Adult Treatment Panel III in both men and women. Whether individuals benefit from long-term statin use for primary prevention depends more on the disutility associated with pill burden than their degree of cardiovascular risk.

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Cost-effectiveness of multimodal CT for evaluating acute stroke.

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Cost-effectiveness of multimodal CT for evaluating acute stroke.

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