Cost-effectiveness of an insertable cardiac monitor to detect atrial fibrillation in patients with cryptogenic stroke.

BACKGROUND AND AIMS: Documentation of atrial fibrillation is required to initiate oral anticoagulation therapy for recurrent stroke prevention. Atrial fibrillation often goes undetected with traditional electrocardiogram monitoring techniques. We evaluated whether atrial fibrillation detection using continuous long-term monitoring with an insertable cardiac monitor is cost-effective for preventing recurrent stroke in patients with cryptogenic stroke, in comparison to the standard of care. METHODS: A lifetime Markov model was developed to estimate the cost-effectiveness of insertable cardiac monitors from a UK National Health Service perspective using data from the randomized CRYSTAL-AF trial and other published literature. We also conducted scenario analyses (CHADS2 score) and probabilistic sensitivity analyses. All costs and benefits were discounted at 3.5%. RESULTS: Monitoring cryptogenic stroke patients with an insertable cardiac monitor was associated with fewer recurrent strokes and increased quality-adjusted life years compared to the standard of care (7.37 vs 7.22). Stroke-related costs were reduced in insertable cardiac monitor patients, but overall costs remained higher than the standard of care (£19,631 vs £17,045). The incremental cost-effectiveness ratio was £17,175 per quality-adjusted life years gained, compared to standard of care in the base-case scenario, which is below established quality-adjusted life years willingness-to-pay thresholds. When warfarin replaced non-vitamin-K oral anticoagulants as the main anticoagulation therapy, the incremental cost-effectiveness ratio was £13,296 per quality-adjusted life years gained. CONCLUSION: Insertable cardiac monitors are a cost-effective diagnostic tool for the prevention of recurrent stroke in patients with cryptogenic stroke. The cost-effectiveness results have relevance for the UK and across value-based healthcare systems that assess costs relative to outcomes.

Effectiveness of diagnostic strategies in suspected delayed cerebral ischemia: a decision analysis.

BACKGROUND AND PURPOSE: Delayed cerebral ischemia (DCI) is a serious complication after aneurysmal subarachnoid hemorrhage. If DCI is suspected clinically, imaging methods designed to detect angiographic vasospasm or regional hypoperfusion are often used before instituting therapy. Uncertainty in the strength of the relationship between imaged vasospasm or perfusion deficits and DCI-related outcomes raises the question of whether imaging to select patients for therapy improves outcomes in clinical DCI. METHODS: Decision analysis was performed using Markov models. Strategies were either to treat all patients immediately or to first undergo diagnostic testing by digital subtraction angiography or computed tomography angiography to assess for angiographic vasospasm, or computed tomography perfusion to assess for perfusion deficits. According to current practice guidelines, treatment consisted of induced hypertension. Outcomes were survival in terms of life-years and quality-adjusted life-years. RESULTS: When treatment was assumed to be ineffective in nonvasospasm patients, Treat All and digital subtraction angiography were equivalent strategies; when a moderate treatment effect was assumed in nonvasospasm patients, Treat All became the superior strategy. Treating all patients was also superior to selecting patients for treatment via computed tomography perfusion. One-way sensitivity analyses demonstrated that the models were robust; 2- and 3-way sensitivity analyses with variation of disease and treatment parameters reinforced dominance of the Treat All strategy. CONCLUSIONS: Imaging studies to test for the presence of angiographic vasospasm or perfusion deficits in patients with clinical DCI do not seem helpful in selecting which patients should undergo treatment and may not improve outcomes. Future directions include validating these results in prospective cohort studies.

Use of secondary stroke prevention medicines in Australia: national trends, 2003-2009.

OBJECTIVE: To examine recent trends in the use of secondary stroke prevention medicines by transient ischaemic attack (TIA) and ischaemic stroke survivors. DESIGN, SETTING AND PARTICIPANTS: Retrospective observational study of patients aged ≥ 65 years who were hospitalised with a TIA or ischaemic stroke between January 2000 and December 2009. Use of antihypertensive, antithrombotic and lipid-lowering medicines by patients was determined monthly, using claims data from the Australian Government Department of Veterans' Affairs, commencing in January 2003. MAIN OUTCOME MEASURE: Monthly prevalence of use of secondary stroke prevention medicines. RESULTS: Between 2003 and 2009, small increases in use (less than 2% relative increase annually) were observed for antihypertensive and antithrombotic medicines among 19 019 patients. There was a 9% relative increase in use of lipid-lowering therapy each year. The proportion of patients dispensed all three recommended medicine classes nearly doubled over the 7-year period. By December 2009, about 80% of patients were dispensed an antihypertensive, 75% received an antithrombotic and 60% were dispensed lipid-lowering therapy. Almost half of the population were dispensed all three recommended classes by the end of the study period. CONCLUSIONS: Increased use of secondary stroke prevention medicines was shown in this study, in accordance with national stroke guideline recommendations and initiatives supporting quality use of medicines in Australia. There may be opportunity to further increase use of these medicines among older Australians who have had a TIA or ischaemic stroke.

Cost-effectiveness analysis of the neuroprotective agent edaravone for noncardioembolic cerebral infarction.

BACKGROUND: The free radical scavenger edaravone has been reported useful for improvement in activities of daily living and for prevention of recurrent stroke in the edaravone versus sodium ozagrel in acute noncardioembolic ischemic stroke (EDO) trial. The aim of this report was to evaluate the cost-effectiveness of edaravone compared to the intravenous antiplatelet drug ozagrel sodium (ozagrel) for noncardioembolic stroke (non-CES) based on the EDO trial data. METHODS: A cost-effectiveness analysis was performed using the Markov model, which also incorporated the long-term course after the acute stage of non-CES. From the perspective of a health care payer, direct medical costs and nursing care costs were taken into account in the cost analysis. The quality-adjusted life year (QALY) served as an indicator of effectiveness. Simulation at 5 and 10 years after the onset of non-CES was carried out. The study involved 68-year-old patients with non-CES, selected against the EDO trial subject selection criteria. A 14-day treatment with edaravone 60 mg/day or ozagrel 160 mg/day was assumed as acute treatment for non-CES. RESULTS: The use of edaravone was associated with a reduction in total costs (0.51 million yen [$6,374] at 5 years and 0.64 million yen [$8,039]) at 10 years after the onset of non-CES) and improvement in QALYs (0.23 at 5 years and 0.38 at 10 years). Compared to ozagrel therapy, edaravone therapy was a cost-saving strategy for treating non-CES. CONCLUSIONS: Compared to ozagrel therapy, edaravone therapy for non-CES is not only useful from a clinical viewpoint, but also valuable from a socioeconomic perspective.

Shoulder arthroscopy positioning: lateral decubitus versus beach chair.

Since the introduction of the beach chair position for shoulder arthroscopy, orthopaedic surgeons have debated whether the beach chair or lateral decubitus is superior. Most surgeons use the same patient position to perform all of their arthroscopic shoulder procedures, regardless of the pathology. Each position has its advantages and disadvantages. The evidence regarding the efficiency, efficacy, and risks of the lateral decubitus and the beach chair positions for shoulder arthroscopy does not show one position to be superior. This review presents a comparison of these positions with regard to setup, surgical visualization, access, and patient risk.

[Assessment of proximal aortic anastomosis device in coronary artery bypass grafting].

The aim of this study was to assess the feasibility and safety of a new proximal anastomotic device (PAD) "Enclose II" in coronary artery bypass grafting (CABG). PAD enables the construction of a proximal aortic anastomosis without the use of partial clamp of the ascending aorta, thus reduces the incidence of adverse perioperative neurologic injury related to atheroembolic events. This device was used in 41 off-pump CABG and 11 on-pump beating heart CABG patients for performing 46 radial artery (RA) and 9 vein anastomoses to the aorta. The subjects were 43 males and 9 females, with a mean age of 63.6 years. Thirteen (25%) patients had severe atherosclerotic cerebrovascular lesions preoperatively. The mean flow in the RA graft was 52.4 +/- 26.9 ml/min and that of saphenous vein graft (SVG) was 61.1 +/- 31.9 ml/min. Angiography showed all grafts patent. There was no procedure-related adverse events or cerebrovascular complication. Enclose II device can be a valuable tool to perform RA and vein anastomoses in CABG.

Success of carotid endarterectomy in veterans: high medical risk does not equate with high surgical risk.

BACKGROUND: The safety and efficacy of carotid endarterectomy (CEA) in stroke prevention has been well documented. But "high-risk" patients have traditionally been excluded from these studies and may be offered alternate therapies. We examined the safety of CEA in veterans, a medically high-risk group with multiple comorbidities. STUDY DESIGN: The records of all patients having CEAs performed between 1995 and 1999 in the Connecticut Veterans Affairs (VA) hospital were reviewed. Survival and freedom from stroke were determined using Kaplan-Meier survival analysis. The effects of risk factors on outcomes were analyzed with Cox regression. RESULTS: There were 128 CEAs performed in 120 patients, with a mean followup of 8.5 years. Most patients were symptomatic preoperatively and had a high incidence of hypertension (83%), coronary artery disease (64%), diabetes (37%), and pulmonary disease (22%). Incidences of perioperative (30-day) mortality (0.8%), stroke (1.6%), and myocardial infarction (0.8%) were low. Survival rates at 8.9 and 12 years were 50% and 13%, respectively, with 90% patient followup. Freedom from ipsilateral stroke was 90% at 12 years. Age (hazards ratio [HR] 1.1, p=0.004), hypertension (HR 2.6, p=0.04), and elevated creatinine (HR 3.7, p=0.001) were significant risk factors for mortality. Age (HR 0.8, p=0.07) and diastolic blood pressure (HR 1.2, p=0.06) were predictive of ipsilateral stroke. CONCLUSIONS: Despite poor health and symptomatic presentation, patients treated with CEA achieved excellent perioperative outcomes and were protected from stroke for the remainder of their lives. Multiple medical comorbidities should not be used as exclusion criteria for CEA.

Pharmacoeconomic analysis of cilostazol for the secondary prevention of cerebral infarction.

BACKGROUND: The antiplatelet agent, cilostazol, is known to reduce the risk of subsequent cerebral infarction. However, the cost effectiveness of such treatment in comparison to aspirin has not been studied. METHODS AND RESULTS: A Markov model was developed to calculate the health outcomes and associated costs for 65-year-old patients with cerebral infarction who were treated with 200 mg/day cilostazol or 81 mg/day aspirin. Cilostazol was more effective, but also more expensive than aspirin. Cilostazol would extend quality-adjusted life years (QALY) by 0.64, while increasing life-time costs by approximately Yen 1.1 million. The incremental cost-effectiveness ratio of cilostazol in comparison with aspirin was estimated to be Yen 1.8 million per QALY. CONCLUSIONS: The use of cilostazol to prevent recurrence of cerebral infarction appears to be cost effective.

Cost analysis of aprotinin for coronary artery bypass patients: analysis of the randomized trials.

BACKGROUND: The full kallikrein-inhibiting dose of aprotinin has been shown to reduce blood loss, transfusion requirements, and the systemic inflammatory response associated with cardiopulmonary bypass graft surgery (CABG). A half-dose regimen, although having a reduced delivery cost, inhibits plasmin and fibrinolysis without substantially effecting kallikrein-mediated inflammation associated with bypass surgery. The differing pharmacologic effects of the two regimens impact the decision-making process. The current study assessed the medical cost offset of full-dose and half-dose aprotinin from short- and long-term perspectives to provide a rational decision-making framework for clinicians. METHODS: To estimate CABG admission costs, resource utilization and clinical data from aprotinin clinical trials were combined with unit costs estimated from a Duke University-based cost model. Lifetime medical costs of stroke and acute myocardial infarction were based on previous research. RESULTS: Relative to placebo, the differences in total perioperative cost for primary CABG patients receiving full-dose or half-dose aprotinin were not significant. When lifetime medical costs of complications were considered, total costs in full-dose and half-dose aprotinin-treated patients were not different relative to that of placebo. Total perioperative cost was significantly lower for repeat CABG patients treated with aprotinin, with savings of $2,058 for full-dose and $2,122 for half-dose patients when compared with placebo. Taking lifetime costs of stroke and acute myocardial infarction into consideration, the cost savings estimates were $6,044 for full-dose patients and $4,483 for half-dose patients, due to substantially higher lifetime stroke costs incurred by the placebo patients. CONCLUSIONS: Using this cost model, use of full-dose and half-dose aprotinin in primary CABG patients was cost neutral during hospital admission, whereas both dosing regimens were significantly cost saving in reoperative CABG patients. Additional lifetime cost savings were realized relative to placebo due to reduced complication costs, particularly with the full-dose regimen. As the full kallikrein-inhibiting dose of aprotinin has been shown to be safe and effective, the current results support its use in both primary and repeat CABG surgery. No demonstrable economic advantage was observed with the half-dose aprotinin regimen.

[Hypertensive female patients often undertreated or treated too late. Therapy of hypertension needs women's initiative]. / Hypertonikerinnen oft unzureichend oder zu spät behandelt. Die Hochdrucktherapie braucht eine Frauenbewegung.

Both the cardiovascular risk profile and the incidence of arterial hypertension are known to show gender-specific differences. In postmenopausal women, the cardiovascular risk is clearly elevated. At particular risk are women with diabetes mellitus, overweight and hypertriglyceridemia. In numerous clinical studies on the treatment of arterial hypertension, however, the percentage of women involved is small, and not representative. Furthermore, studies on the confirmation of the diagnosis and treatment show that treatment of hypertension in female patients has often been less effective and less rigorously applied than in men. At the same time, it is known that the success of rigorous risk reduction is independent of gender.

Campanha de prevenção ao derrame cerebral: infarto cerebral; hemorragia cerebral / Pense Bem

O Programa Nacional de Prevenção ao Derrame Cerebral é um movimento institucional idealizado por neurocirurgiões brasileiros através da Sociedade Brasileira de Neurocirurgia para coordenar ações de promoção da saúde, prevenção secundária e reabilitação das lesões vasculares cerebrais. O programa foi criado para atender a uma crescente necessidade médica e social, verificada pelos estudos epidemiológicos nacionais. O projeto segue parâmetros de programas internacionais, associados ao aproveitamento de modelos regionais já existentes, que levam em consideração as diferentes realidades dos estados brasileiros. (AU)

[Cost effectiveness of clopidogrel in secondary cardiovascular prevention: a cost-effectiveness analysis based on the Caprie Study]. / Die Wirtschaftlichkeit von Clopidogrel in der kardiovaskulären Sekundärprävention: eine Kosten-Effektivitäts-Analyse auf der Grundlage der Caprie-Studie.

As a result of medical progress each year numerous new therapies are introduced to the medical community, and each of them must prove its usefulness in two arenas. Firstly, does the new therapy improve outcomes relative to conventional therapy? If this test is passed, the second question is: are the improved outcomes worth the extra costs? Controlled clinical trials answer the first question and economic analysis, the second. The CARPIE-Study has proven, that Clopidogrel, a new antiplatelet drug, was superior in secondary prevention of cardiovascular events to aspirin. On the basis of this study we conducted a cost-effectiveness analysis from the perspective of Swiss third party payers. The following costs were included in the analysis: treatment costs of aspirin and clopidogrel, myocardial infarction, ischaemic stroke and primary non-fatal intracranial haemorrhage. For the calculation of the years of life gained the DEALE-method was applied. The net costs of treating 1000 patients, i.e. incremental drug costs less savings of treatment costs, are Fr. 1.5 Mio. The intervention with Clopidogrel lead to an additional gain of 63 life years in compared to aspirin. At additional yearly cost of Fr. 722.--per patient the analysis yield a cost-effectiveness of CHF 24,164 (nominal) Fr. 22,837 (discounted) per additional year of live saved. The results suggest that the cost-effectiveness of Clopidogrel in secondary prevention lie well within the range of other preventive cardiovascular interventions. Therefore, from an economic perspective the use of Clopidogrel in secondary prevention of major cardiovascular events in patients with atherosclerotic vascular disease is justifiable.

Protective effect of FK506 in the reperfusion model after short-term occlusion of middle cerebral artery in the rat: assessment by autoradiography using [125I]PK-11195.

The protective effect of the immunosuppressant agent FK506 in the reperfusion after short-term occlusion of the middle cerebral artery in the rat model was evaluated using [125I]PK-11195 autoradiography. FK506 0.5 mg kg-1 day-1 was administered intramurally to Wistar rats weighing 260-300 g from one day prior to ischemia to seven days after ischemia. Reperfusion was performed after 30 or 60 min occlusion. Infarct area was evaluated by [125I]PK-11195 autoradiography on the seventh day following occlusion. FK506 significantly reduced the infarct area in the caudate nucleus following 30 and 60 min occlusion, but significantly reduced the infarct area in the cortex only following 60 min occlusion. These results suggest that FK506 has a protective effect against reperfusion after short-term occlusion of the middle cerebral artery.

[Intraoperative assessment of the ascending aorta by echogram during the CABG operation for the prevention of cerebral infarction].

While coronary artery bypass grafting operations (CABG), we started to use the echogram to evaluate the ascending aorta intraoperatively from December 1993. During a period from January, 1990, to June, 1995, 379 patients were treated with CABG. Intraoperative echogram was used in 127 cases (group I) and 252 cases unused (group II). The sites of the aorta for evaluation were following: site of cannulation, aortic clamping, and proximal anastomosis respectively. Depending on the echographical findings the operative procedures were changed as required. The incidence of postoperative cerebral embolism in group I was 0.8% (one patient) and in group II, 2.4% (6 patients). Although no significant difference was found in the cohort, rate of incidence in the group II was high. There were 4 cases who had significant atheromatous lesions clearly evaluated by echogram, which were not detected by palpation. We conclude that the intraoperative assessment of the ascending aorta by echogram is beneficial in prevention of cerebral infarction.