BACKGROUND: Recent studies, including the TENSION trial, support the use of endovascular thrombectomy (EVT) in acute ischemic stroke with large infarct (Alberta Stroke Program Early Computed Tomography Score (ASPECTS) 3-5). OBJECTIVE: To evaluate the cost-effectiveness of EVT compared with best medical care (BMC) alone in this population from a German healthcare payer perspective. METHODS: A short-term decision tree and a long-term Markov model (lifetime horizon) were used to compare healthcare costs and quality-adjusted life years (QALYs) between EVT and BMC. The effectiveness of EVT was reflected by the 90-day modified Rankin Scale (mRS) outcome from the TENSION trial. QALYs were based on published mRS-specific health utilities (EQ-5D-3L indices). Long-term healthcare costs were calculated based on insurance data. Costs (reported in 2022 euros) and QALYs were discounted by 3% annually. Cost-effectiveness was assessed using incremental cost-effectiveness ratios (ICERs). Deterministic and probabilistic sensitivity analyses were performed to account for parameter uncertainties. RESULTS: Compared with BMC, EVT yielded higher lifetime incremental costs (€24 257) and effects (1.41 QALYs), resulting in an ICER of €17 158/QALY. The results were robust to parameter variation in sensitivity analyses (eg, 95% probability of cost-effectiveness was achieved at a willingness to pay of >€22 000/QALY). Subgroup analyses indicated that EVT was cost-effective for all ASPECTS subgroups. CONCLUSIONS: EVT for acute ischemic stroke with established large infarct is likely to be cost-effective compared with BMC, assuming that an additional investment of €17 158/QALY is deemed acceptable by the healthcare payer.

Clinic of Radiology Jessenius Faculty of Medicine Comenius University Martin Slovakia

Department of Clinical Neurosciences Hotchkiss Brain Institute Health Science Centre University of Calgary and Foothills Medical Centre Calgary Alberta Canada

Department of Health Economics and Health Services Research University Medical Center Hamburg Eppendorf Hamburg Hamburg Germany

Department of Neurology Aarhus University Hospital Aarhus Denmark

Department of Neurology and Stroke Unit La Paz University Hospital Madrid Spain

Department of Neurology Oslo University Hospital Oslo Norway

Department of Neurology University Medical Center Hamburg Eppendorf Hamburg Hamburg Germany

Department of Neuroradiology Heidelberg University Hospital Heidelberg Germany

Department of Neuroradiology Hôpital Maison Blanche Université de Reims Champagne Ardenne Reims France

Department of Neuroradiology Medical University of Innsbruck Innsbruck Tirol Austria

Department of Radiology Faculty of Medicine in Hradec Kralove Charles University Hradec Kralove Czech Republic

Hamburg Center for Health Economics Hamburg Germany

Laboratoire de Biométrie et Biologie Évolutive Université Lyon 1 Villeurbanne France

Service de Biostatistique Hospices Civils de Lyon Lyon France

The Norwegian University of Science and Technology Trondheim Norway

Zobrazit více v PubMed

Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2019;50:e344–418. doi: 10.1161/STR.0000000000000211. PubMed DOI

Turc G, Bhogal P, Fischer U, et al. European Stroke Organisation (ESO) - European Society for Minimally Invasive Neurological Therapy (ESMINT) guidelines on mechanical thrombectomy in acute ischemic stroke. J Neurointerv Surg. 2023;15:e8. doi: 10.1136/neurintsurg-2018-014569. PubMed DOI

Yoshimura S, Sakai N, Yamagami H, et al. Endovascular therapy for acute stroke with a large ischemic region. N Engl J Med. 2022;386:1303–13. doi: 10.1056/NEJMoa2118191. PubMed DOI

Huo X, Ma G, Tong X, et al. Trial of endovascular therapy for acute ischemic stroke with large infarct. N Engl J Med. 2023;388:1272–83. doi: 10.1056/NEJMoa2213379. PubMed DOI

Sarraj A, Hassan AE, Abraham MG, et al. Trial of endovascular thrombectomy for large ischemic strokes. N Engl J Med. 2023;388:1259–71. doi: 10.1056/NEJMoa2214403. PubMed DOI

Bendszus M, Fiehler J, Subtil F, et al. Endovascular Thrombectomy for acute ischaemic stroke with established large infarct: Multicentre, open-label, randomised trial. Lancet. 2023;402:1753–63. doi: 10.1016/S0140-6736(23)02032-9. PubMed DOI

Li Q, Abdalkader M, Siegler JE, et al. Mechanical thrombectomy for large ischemic stroke: a systematic review and meta-analysis. Neurology. 2023;101:e922–32. doi: 10.1212/WNL.0000000000207536. PubMed DOI PMC

Chen M, Leslie-Mazwi TM, Hirsch JA, et al. Large core stroke thrombectomy: paradigm shift or futile exercise. J Neurointerv Surg. 2023;15:413–4. doi: 10.1136/jnis-2023-020219. PubMed DOI

Wu X, Payabvash S, Matouk CC, et al. Cost-effectiveness of Endovascular Thrombectomy in patients with low Alberta stroke program early CT scores (< 6) at presentation. J Neurosurg. 2021;135:1645–55. doi: 10.3171/2020.9.Jns202965. PubMed DOI

Sarraj A, Pizzo E, Lobotesis K, et al. Endovascular thrombectomy in patients with large core ischemic stroke: a cost-effectiveness analysis from the SELECT study. J Neurointerv Surg. 2021;13:875–82. doi: 10.1136/neurintsurg-2020-016766. PubMed DOI

Sanmartin MX, Katz JM, Wang J, et al. Cost-effectiveness of endovascular thrombectomy in acute stroke patients with large ischemic core. J Neurointerv Surg. 2023;15:e166–71. doi: 10.1136/jnis-2022-019460. PubMed DOI

Ospel JM, Kunz WG, McDonough RV, et al. Cost-effectiveness of endovascular treatment for acute stroke with large infarct: a United States perspective. Radiology. 2023;309:e223320. doi: 10.1148/radiol.223320. PubMed DOI

Pan Y, Huo X, Jin A, et al. Cost-effectiveness of endovascular therapy for acute ischemic stroke with large infarct in China. J Neurointerv Surg. 2024;16:453–8. doi: 10.1136/jnis-2023-020466. PubMed DOI

Moreu M, Scarica R, Pérez-García C, et al. Mechanical thrombectomy is cost-effective versus medical management alone around Europe in patients with low ASPECTS. J Neurointerv Surg. 2023;15:629–33. doi: 10.1136/jnis-2022-019849. PubMed DOI PMC

Kim Y, Lee S, Abdelkhaleq R, et al. Utilization and availability of advanced imaging in patients with acute ischemic stroke. Circ Cardiovasc Qual Outcomes. 2021;14:e006989. doi: 10.1161/CIRCOUTCOMES.120.006989. PubMed DOI

Husereau D, Drummond M, Augustovski F, et al. Consolidated Health Economic Evaluation Reporting Standards 2022 (CHEERS 2022) statement: updated reporting guidance for health economic evaluations. Value Health. 2022;25:3–9. doi: 10.1016/j.jval.2021.11.1351. PubMed DOI

Ramos MCP, Barton P, Jowett S, et al. A systematic review of research guidelines in decision-analytic modeling. Value Health. 2015;18:512–29. doi: 10.1016/j.jval.2014.12.014. PubMed DOI

Bendszus M, Bonekamp S, Berge E, et al. A randomized controlled trial to test efficacy and safety of thrombectomy in stroke with extended lesion and extended time window. Int J Stroke. 2019;14:87–93. doi: 10.1177/1747493018798558. PubMed DOI PMC

Lin B, Zhang Z, Mei Y, et al. Cumulative risk of stroke recurrence over the last 10 years: a systematic review and meta-analysis. Neurol Sci. 2021;42:61–71. doi: 10.1007/s10072-020-04797-5. PubMed DOI

Federal Statistical Office Germany Life table (period life table): Germany, period of years, sex, completed age [code: 12621-0001], 2020/22

Slot KB, Berge E, Sandercock P, et al. Causes of death by level of dependency at 6 months after ischemic stroke in 3 large cohorts. Stroke. 2009;40:1585–9. doi: 10.1161/STROKEAHA.108.531533. PubMed DOI

Muntendorf L-K, Konnopka A, König H-H, et al. Cost-effectiveness of magnetic resonance imaging-guided thrombolysis for patients with stroke with unknown time of onset. Value Health. 2021;24:1620–7. doi: 10.1016/j.jval.2021.05.005. PubMed DOI

Ali M, MacIsaac R, Quinn TJ, et al. Dependency and health utilities in stroke: data to inform cost-effectiveness analyses. Eur Stroke J . 2017;2:70–6. doi: 10.1177/2396987316683780. PubMed DOI PMC

Sanders GD, Neumann PJ, Basu A, et al. Recommendations for conduct, methodological practices, and reporting of cost-effectiveness analyses: second panel on cost-effectiveness in health and medicine. JAMA. 2016;316:1093–103. doi: 10.1001/jama.2016.12195. PubMed DOI

Pichon-Riviere A, Drummond M, Palacios A, et al. Determining the efficiency path to universal health coverage: cost-effectiveness thresholds for 174 countries based on growth in life expectancy and health expenditures. Lancet Glob Health. 2023;11:e833–42. doi: 10.1016/S2214-109X(23)00162-6. PubMed DOI

Federal Statistical Office Germany National accounts - gross value added, gross domestic product (nominal/price-adjusted): Germany, years [code: 81000-0001] 2023

Standfield L, Comans T, Scuffham P. Markov modeling and discrete event simulation in health care: a systematic comparison. Int J Technol Assess Health Care. 2014;30:165–72. doi: 10.1017/S0266462314000117. PubMed DOI

Karnon J, Haji Ali Afzali H. When to use discrete event simulation (DES) for the economic evaluation of health technologies? A review and critique of the costs and benefits of DES. Pharmacoeconomics. 2014;32:547–58. doi: 10.1007/s40273-014-0147-9. PubMed DOI

de Havenon A, Tirschwell DL, Heitsch L, et al. Variability of the modified Rankin Scale score between day 90 and 1 year after ischemic stroke. Neurol Clin Pract. 2021;11:e239–44. doi: 10.1212/CPJ.0000000000000954. PubMed DOI PMC

Goyal M, Menon BK, van Zwam WH, et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016;387:1723–31. doi: 10.1016/S0140-6736(16)00163-X. PubMed DOI