Patients' perceptions on outcomes after mechanical thrombectomy in acute ischemic stroke.

BACKGROUND: The modified Rankin Scale (mRS) is a clinician-reported scale that measures the degree of disability in patients who suffered a stroke. Patients' perception of a meaningful recovery from severe stroke, expected value of a stroke intervention, and the effect of disparities are largely unknown. METHODS: We conducted a survey of patients, their family members, and accompanying visitors to understand their personal preferences and expectations for acute strokes potentially eligible for acute endovascular intervention using a hypothetical scenario of a severe stroke in a standardized questionnaire. RESULTS: Of 164 survey respondents, 65 (39.6%) were the patient involved, 93 (56.7%) were a family member, and six (3.7%) were accompanied visitors (friends, other). Minimally acceptable disability after a stroke intervention was considered as mRS 2 by 42 respondents (25.6%), as mRS 3 by 79 (48.2%), and as mRS 4 by 43 (26.2%) respondents. Race was associated with different views on this question (p < 0.001; Hispanic and Black patients being more likely to accept disability than Caucasian and Asian patients), while sex (p = 0.333) and age (p = 0.560) were not. Sixty-three respondents (38.4%) viewed minimally acceptable probability of improvement with an intervention as over 50%, 57 (34.8%) as 10-50%, and 44 (26.8%) as less than 10%. CONCLUSIONS: A wide range of acceptable outcomes were reported regardless of gender or age. However, race was associated with different acceptable outcome. This is an important finding to demonstrate because of the persistent racial and ethnic disparities in the utilization of endovascular therapy for acute stroke in the United States.

Mechanical Thrombectomy Versus Best Medical Management for Acute Ischemic Stroke in Elderly Patients: A Cost-Effectiveness Analysis.

OBJECTIVE: To determine the cost-effectiveness of mechanical thrombectomy (MT) versus best medical management (BMM) in patients aged ≥80 years. METHODS: We performed a systematic literature review to identify comparative studies of MT versus BMM with or without intravenous tissue-type plasminogen activator (IV tPA) in patients ≥80 years. Clinical data including outcomes and mortality categorized as modified Rankin scale scores 0-2, 3-5, and 6, were collected from identified studies, and effectiveness scores were assigned to each outcome. Costs associated with stroke outcomes were derived from previous literature, including costs associated with initial and follow-up imaging, hospitalization, physicians/associated personnel, and MT. TreeAge Pro software was used to construct a cost-effectiveness analysis model of clinical data from studies and costs derived from the literature. RESULTS: The review identified 1 relevant comparative study. The cost model demonstrated total annual cumulative overall per-patient costs of $30,064.21 for BMM with IV tPA and $21,940.36 for BMM without IV tPA. Overall effectiveness scores were 0.61 and 0.62, respectively. MT had a cumulative total annual per-patient cost of $47,849.54 and an overall effectiveness score of 0.40. The cost-effectiveness ratios of total cumulative patient cost to overall outcome effectiveness score for the 3 treatments were as follows: BMM with IV tPA = $49,285.59, BMM without IV tPA = $35,387.58, and MT = $119,623.85. BMM with or without IV tPA was found to be more cost-effective than MT. CONCLUSIONS: This study utilized stroke outcomes data for patients aged ≥80 years to conduct a cost-effectiveness analysis. MT was found to be less cost-effective than BMM with and without IV tPA.

Is Endovascular Therapy for Stroke Cost-Effective Globally? A Systematic Review of the Literature.

OBJECTIVES: Cost-effectiveness of endovascular therapy (EVT) is a key consideration for broad use of this approach for emergent large vessel occlusion stroke. We evaluated the evidence on cost-effectiveness of EVT in comparison with best medical management from a global perspective. MATERIALS AND METHODS: This systematic review of studies published between January 2010 and May 2020 evaluated the cost effectiveness of EVT for patients with large vessel occlusion acute ischemic stroke. The gain in quality adjusted life year (QALY) and incremental cost-effectiveness ratio (ICER), expressed as cost per QALY resulting from EVT, were recorded. The study setting (country, economic perspective), decision model, and data sources used in economic models of EVT cost-effectiveness were recorded. RESULTS: Twenty-five original studies from 12 different countries were included in our review. Five of these studies were reported from a societal perspective; 18 were reported from a healthcare system perspective. Two studies used real-world data. The time horizon varied from 1 year to a lifetime; however, 18 studies reported a time horizon of >10 years. Twenty studies reported using outcome data from randomized, controlled clinical trials for their models. Nineteen studies reported using a Markov model. Incremental QALYs ranged from 0.09-3.5. All studies but 1 reported that EVT was cost-effective. CONCLUSIONS: Evidence from different countries and economic perspectives suggests that EVT for stroke treatment is cost-effective. Most cost-effectiveness studies are based on outcome data from randomized clinical trials. However, there is a need to study the cost-effectiveness of EVT based solely on real-world outcome data.

The right to know: ethical implications of antibody testing for healthcare workers and overlooked societal implications.

After the initial surge in cases of coronavirus (COVID-19), the outbreak has been managed differently in different countries. In the USA, it has been managed in many different ways between states, cities and even counties. This disparity is slowly becoming more and more pronounced with the advent of antibody testing. Although many argue over the potential merits of antibody testing as an immunity passport to allow the economy to restart, there are other implications that stand at the heart of the bioethical debate that are often overlooked. Particularly with COVID-19, there are many uncertainties and the discourse alone of antibodies presumes misinformation that may outweigh the epidemiological benefits of antibody testing. Although this paper does not seek to eliminate antibody testing, it does highlight the need for appropriate counselling both on a personal level with each patient but on a more global level. This moral standard of appropriate education is key to allowing the continued autonomy needed during this pandemic.

"Strokenomics": bending the cost curve in stroke care.

OBJECTIVE: The mortality rates for stroke are decreasing, yet it remains a leading cause of disability and the principal neurological diagnosis in patients discharged to nursing homes. The societal and economic burdens of stroke are substantial, with the total annual health care costs of stroke expected to reach $240.7 billion by 2030. Mechanical thrombectomy has been shown to improve functional outcomes compared to medical therapy alone. Despite an incremental cost of $10,840 compared to medical therapy, the improvement in functional outcomes and decreased disability have contributed to the cost-effectiveness of the procedure. In this study the authors describe a physician-led device bundle purchase program implemented for the delivery of stroke care. METHODS: The authors retrospectively reviewed the clinical and radiographic data and device-associated charges of 45 consecutive patients in whom a virtual "stroke bundle" model was used to purchase mechanical thrombectomy devices. RESULTS: Use of the stroke bundle to purchase mechanical thrombectomy devices resulted in an average savings per case of $2900.93. Compared to the traditional model of charging for devices à la carte, this represented an average savings of 25.2% per case. The total amount of savings for these initial 45 cases was $130,542.00. Thrombolysis in Cerebral Infarction scale grade 2b or 3 recanalization occurred in 38 patients (84.4%) using these devices. CONCLUSIONS: Purchasing devices through a bundled model resulted in substantial cost savings while maintaining the therapeutic efficacy of the procedure, further pushing the already beneficial long-term cost-benefit curve in favor of thrombectomy.

Versatile use of catheter systems for deployment of the Pipeline embolization device: a comparison of biaxial and triaxial catheter systems.

BACKGROUND: A Pipeline embolization device (PED; Medtronic, Dublin, Ireland) can be deployed using either a biaxial or a triaxial catheter delivery system. OBJECTIVE: To compare the use of these two catheter delivery systems for intracranial aneurysm treatment with the PED. METHODS: A retrospective study of patients undergoing PED deployment with biaxial or triaxial catheter systems between 2014 and 2016 was conducted. Experienced neurointerventionalists performed the procedures. Patients who received multiple PEDs or adjunctive coils were excluded. The two groups were compared for PED deployment time, total fluoroscopy time, patient radiation exposure, complications, and cost. RESULTS: Eighty-two patients with 89 intracranial aneurysms were treated with one PED each. In 49 cases, PEDs were deployed using biaxial access; triaxial access was used in 33 cases. Time (min) from guide catheter run to PED deployment was significantly shorter in the biaxial group (24.0±18.7 vs 38.4±31.1, P=0.006) as was fluoroscopy time (28.8±23.0 vs 50.3±27.1, P=0.001). Peak radiation skin exposure (mGy) in the biaxial group was less than in the triaxial group (1243.7±808.2 vs 2074.6±1505.6, P=0.003). No statistically significant differences were observed in transient and permanent complication rates or modified Rankin Scale scores at 30 days. The triaxial access system cost more than the biaxial access system (average $3285 vs $1790, respectively). Occlusion rates at last follow-up (mean 6 months) were similar between the two systems (average 88.1%: biaxial, 89.2%: triaxial). CONCLUSION: Our results indicate near-equivalent safety and effectiveness between biaxial and triaxial approaches. Some reductions in cost and procedure time were noted with the biaxial system.