Costs and health effects of CT perfusion-based selection for endovascular thrombectomy within 6 hours of stroke onset: a model-based health economic evaluation

Voorst, H. van; Hoving, J.W.; Koopman, M.S.; Daems, J.D.; Peerlings, D.; Buskens, E.; Lingsma, H.; Marquering, H.A.; Jong, H.W.A.M. de; Berkhemer, O.A.; Zwam, W.H. van; Walderveen, M.A.A. van; Wijngaard, I.R. van den; Dippel, D.W.J.; Yoo, A.J.; Campbell, B.; Kunz, W.G.; Majoie, C.B.; Emmer, B.J.; CLEOPATRA; MR CLEAN Registry; CONTRAST Consortium Investigators

doi:doi:10.1136/jnnp-2023-331862

BackgroundAlthough CT perfusion (CTP) is often incorporated in acute stroke workflows, it remains largely unclear what the associated costs and health implications are in the long run of CTP-based patient selection for endovascular treatment (EVT) in patients presenting within 6 hours after symptom onset with a large vessel occlusion.MethodsPatients with a large vessel occlusion were included from a Dutch nationwide cohort (n=703) if CTP imaging was performed before EVT within 6 hours after stroke onset. Simulated cost and health effects during 5 and 10 years follow-up were compared between CTP based patient selection for EVT and providing EVT to all patients. Outcome measures were the net monetary benefit at a willingness-to-pay of euro80 000 per quality-adjusted life year, incremental cost-effectiveness ratio), difference in costs from a healthcare payer perspective (Delta Costs) and quality-adjusted life years (Delta QALY) per 1000 patients for 1000 model iterations as outcomes...Show moreBackgroundAlthough CT perfusion (CTP) is often incorporated in acute stroke workflows, it remains largely unclear what the associated costs and health implications are in the long run of CTP-based patient selection for endovascular treatment (EVT) in patients presenting within 6 hours after symptom onset with a large vessel occlusion.MethodsPatients with a large vessel occlusion were included from a Dutch nationwide cohort (n=703) if CTP imaging was performed before EVT within 6 hours after stroke onset. Simulated cost and health effects during 5 and 10 years follow-up were compared between CTP based patient selection for EVT and providing EVT to all patients. Outcome measures were the net monetary benefit at a willingness-to-pay of euro80 000 per quality-adjusted life year, incremental cost-effectiveness ratio), difference in costs from a healthcare payer perspective (Delta Costs) and quality-adjusted life years (Delta QALY) per 1000 patients for 1000 model iterations as outcomes.ResultsCompared with treating all patients, CTP-based selection for EVT at the optimised ischaemic core volume (ICV >= 110 mL) or core-penumbra mismatch ratio (MMR <= 1.4) thresholds resulted in losses of health (median Delta QALYs for ICV >= 110 mL: -3.3 (IQR: -5.9 to -1.1), for MMR <= 1.4: 0.0 (IQR: -1.3 to 0.0)) with median Delta Costs for ICV >= 110 mL of -euro348 966 (IQR: -euro712 406 to -euro51 158) and for MMR <= 1.4 of euro266 513 (IQR: euro229 403 to euro380 110)) per 1000 patients. Sensitivity analyses did not yield any scenarios for CTP-based selection of patients for EVT that were cost-effective for improving health, including patients aged >= 80 yearsConclusionIn EVT-eligible patients presenting within 6 hours after symptom onset, excluding patients based on CTP parameters was not cost-effective and could potentially harm patients.Show less

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Costs and health effects of CT perfusion-based selection for endovascular thrombectomy within 6 hours of stroke onset: a model-based health economic evaluation