Evidence-Based Disparities in Stroke Care Metrics and Outcomes in the United States: A Systematic Review.

Stroke disproportionately affects racial minorities, and the level to which stroke treatment practices differ across races is understudied. Here, we performed a systematic review of disparities in stroke treatment between racial minorities and White patients. A systematic literature search was performed on PubMed to identify studies published from January 1, 2010, to April 5, 2021 that investigated disparities in access to stroke treatment between racial minorities and White patients. A total of 30 studies were included in the systematic review. White patients were estimated to use emergency medical services at a greater rate (59.8%) than African American (55.6%), Asian (54.7%), and Hispanic patients (53.2%). A greater proportion of White patients (37.4%) were estimated to arrive within 3 hours from onset of stroke symptoms than African American (26.0%) and Hispanic (28.9%) patients. A greater proportion of White patients (2.8%) were estimated to receive tPA (tissue-type plasminogen activator) as compared with African American (2.3%), Hispanic (2.6%), and Asian (2.3%) patients. Rates of utilization of mechanical thrombectomy were also lower in minorities than in the White population. As shown in this review, racial disparities exist at key points along the continuum of stroke care from onset of stroke symptoms to treatment. Beyond patient level factors, these disparities may be attributed to other provider and system level factors within the health care ecosystem.

Comparative cost analysis of liquid embolization systems for brain arteriovenous malformation using a real-world US hospital database: TRUFILL® versus OnyxTM.

BACKGROUND: Liquid embolic systems (LES) such as n-butyl cyanoacrylate-based TRUFILL® and ethylene vinyl-alcohol copolymer-based OnyxTM are widely used for the embolization of brain arteriovenous malformations (bAVMs). The purpose of this study was to compare hospital cost and length of stay (LOS) among unruptured bAVM patients undergoing embolization procedures with TRUFILL versus Onyx LES. METHODS: Adult patients with unruptured bAVMs undergoing endovascular embolization with TRUFILL or Onyx LES between January 1, 2010 and June 30, 2020 were identified from the Premier Healthcare Database. Baseline covariates among the two groups were balanced using propensity score matching. Outcomes including total procedure cost, supply cost, and LOS were examined. A Generalized Estimating Equation model was used to assess outcomes in the matched cohorts. RESULTS: A total of 1072 patients were included in the study; 140 embolized with TRUFILL (mean age 47.06 [15.72] years, 45.70% male) and 932 embolized with Onyx (mean age 46.80 [16.65] years, 52.30% male). In the post-match cohort, the total procedure costs were lower for the TRUFILL (n = 130) versus Onyx (n = 333) group, though not significantly ($36,798 vs. $40,988; odds ratio [OR] = 0.90, 95% confidence interval [CI]: 0.73-1.10; p = 0.30). However, supply cost was significantly lower for hospitalizations with TRUFILL compared to Onyx use ($13,281 vs. $16,371, OR = 0.81, 95% CI: 0.68, 0.98; p = 0.026). Hospital LOS was similar in these two groups (TRUFILL: 4.05 vs. Onyx: 4.06 days; OR = 1.00, 95% CI: 0.70, 1.42; p = 0.99). CONCLUSIONS: In a large, multi-center, real-world sample of patients undergoing bAVM embolization, TRUFILL use was associated with significantly lower supply cost compared to Onyx use.

Estimating the impact of balloon guide catheter with mechanical thrombectomy for acute ischemic stroke: A U.S. cost analysis.

BACKGROUND: Balloon guide catheters (BGCs) can be used adjunctively during mechanical thrombectomy (MT) for acute ischemic stroke (AIS). Evaluating the potential economic impact associated with adjunctive BGC use is an important consideration for resource allocation. METHODS: Decision tree models were used to estimate the economic value of BGC use in MT through its impact on functional outcomes. Healthcare utilization cost estimates in the short- and long-term for patients with different 90-day mRS scores were analyzed for MT-only and MT + BGC scenarios. Deterministic (one-way) and probabilistic sensitivity analyses were performed to evaluate the robustness and uncertainty of model parameters. RESULTS: Per-patient index hospitalization cost was estimated at $65,260 for MT-only and $62,883 for MT + BGC scenarios. Per-patient one-year post-index hospitalization cost was estimated at $27,569 for MT-only and $24,830 for MT + BGC. MT + BGC had a total cost savings of $5117 compared with MT-only. Deterministic (one-way) sensitivity analysis demonstrated that cost saving per patient was most sensitive to the proportion of patients in the mRS 0-2 category in both MT + BGC and MT-only. In a probabilistic sensitivity analysis, mean per-patient costs for the index hospitalization were estimated at $63,737 for MT-only and $61,425 for MT + BGC. Mean per-patient cost estimates one-year post-index hospitalization was $27,445 for MT-only and $24,715 for MT + BGC. MT + BGC had a total cost savings of $5043 compared with MT-only. CONCLUSION: Mechanical thrombectomy with adjunctive BGC use may reduce short-term and long-term patient costs due to improved functional outcomes when compared to MT treatment alone for AIS.

Economic analysis of n-butyl cyanoacrylate compared with ethylene vinyl alcohol copolymer liquid embolic embolization of brain arteriovenous malformations (bAVMs) from a US hospital perspective.

BACKGROUND: In US hospitals, the liquid embolic systems (LESs) n-butyl cyanoacrylate (n-BCA) and ethylene vinyl alcohol copolymer (EVOH) are used for brain arteriovenous malformation (bAVM) embolization to achieve presurgical devascularization. The aim of this study was to perform an economic analysis comparing four techniques for bAVM embolization based on LES, ancillary device, and angiography suite time costs. METHODS: An economic model was developed comparing the embolization costs for n-BCA, EVOH with the plug and push technique, EVOH with detachable-tip microcatheters, and EVOH with balloon microcatheters. Per procedure costs were calculated for bAVMs with one to four pedicles. Annual cohort analyses were performed to evaluate the potential impact for low and high-volume centers. Sensitivity analyses were performed to determine cost drivers. RESULTS: The analyses showed that the n-BCA technique was the least costly of the four techniques. Total per procedure costs for one to four embolized pedicles ranged from $5941 to $10,074 for the n-BCA technique, $8428 to $30,345 for the EVOH balloon microcatheter technique, $12,711 to $47,477 for the EVOH plug and push technique, and $13,900 to $52,233 for the EVOH detachable-tip microcatheter technique. Cohort analyses costs for 52 annual cases ranged from $308,953 to $523,838 with the n-BCA technique and from $722,816 to $2,716,096 with the EVOH detachable-tip microcatheter technique. CONCLUSIONS: Procedure costs associated with n-BCA are lower than those with each of the three EVOH techniques examined. Future cost analyses should compare the costs of new LES products once available.

Real-world outcomes associated with the use of the EmboTrap revascularization device for ischemic stroke in the United States.

BACKGROUND: Mechanical thrombectomy (MT) has become the standard of care for the treatment of acute ischemic stroke (AIS). The EmboTrap revascularization device (CERENOVUS, Johnson & Johnson Medical Devices, Irvine, California, USA) has an innovative, dual layer feature designed to facilitate thrombus retrieval. OBJECTIVE: To investigate the real-world clinical and economic outcomes among patients with AIS undergoing MT using the EmboTrap device in the United States (US). METHODS: Adult patients (≥18 years) who underwent MT for AIS using the EmboTrap device between July 2018 and December 2020 were identified from the Premier Healthcare Database. Patient outcomes included discharge status (including in-hospital mortality), mean length of stay (LOS), intracranial hemorrhage (ICH), mean hospital costs, and 30-day readmissions (all-cause, cardiovascular (CV)-related, and AIS-related). RESULTS: A total of 318 patients (mean age 68.5±14.6 years) with AIS treated with the EmboTrap device as the only stent retriever used were identified. Approximately 25% of patients were discharged to home/home health organization, and the in-hospital mortality rate was 10.7%. The rate of ICH was 16.7%. Mean hospital LOS was 9.9±11.3 days, and the mean hospital costs were US$47 367±30 297. The 30-day readmission rate was 9.6% for all-causes, 5.9% for CV-related causes, and 2.6% for AIS-related causes. CONCLUSIONS: This is the first study in the US to report real-world outcomes sourced by retrospective database analysis among patients with AIS undergoing MT using the EmboTrap device. Further research is needed to better understand performance of the EmboTrap device in real-world settings.

Endovascular treatment with the Enterprise stent versus the Neuroform or Low-Profile Visualized Intraluminal Support stent for unruptured aneurysms.

Aim: To compare outcomes among patients undergoing endovascular treatment for unruptured intracranial aneurysm (UIA) with the Enterprise stent versus the Neuroform or Low-Profile Visualized Intraluminal Support (LVIS) stent. Patients & methods: Patients undergoing endovascular procedure for UIA were classified into Enterprise stent and Neuroform or LVIS stent group. Groups were propensity-score matched and generalized estimating equations were used for outcomes assessment. Results: There were no significant between-group differences in length of stay or mortality. The Enterprise group had significantly lower odds of UIA-related inpatient readmissions versus the Neuroform/LVIS group (odds ratio: 0.62; 95% CI: 0.42-0.91). Conclusion: Enterprise stent use was associated with significantly lower readmissions versus competitor stent, with no difference in other study outcomes.

Influence of neurovascular embolic coil primary wind diameter on aneurysm packing density and case costs.

AIMS: Endovascular coiling is a common modality for treating intracranial aneurysms; however, recanalization occurs in approximately 1 in 5 cases, with downstream consequences of regrowth and rupture. Aneurysm packing density >24% reduces recanalization risk; packing density can be increased by inserting additional coils or by using coils with larger volumetric filling. Coil volume depends on length and primary wind diameter (PWD). This study evaluated the influence of PWD on packing density and total case costs. MATERIALS AND METHODS: Two hypothetical scenarios and one case study were analyzed. In scenario one, the number of coils required to achieve packing density >24% in a hypothetical aneurysm was determined for 0.012″ vs. 0.010″ PWD coils. In scenario two, the total length of 0.010″ vs. 0.012″ PWD coils required to achieve a packing density >24% was analyzed relative to aneurysm volume. In the case study, packing densities with one 0.012″ PWD coil (actual scenario) and one 0.010″ PWD coil (theoretical scenario) were compared. RESULTS: In scenario one, cost savings would be realized by using four 0.012″ PWD coils vs. seven 0.010″ PWD coils to achieve packing density >24%. In scenario two, greater volumetric filling of 0.012″ vs. 0.010″ PWD coils was correlated with lower total length of coil required. In the case study, a 0.012″ PWD coil achieved packing density >24%, whereas an equivalent length 0.010″ PWD coil would not. LIMITATIONS: Theoretical modeling was used to explore the impact of coil PWD on aneurysm packing density. In clinical practice, packing density depends not only on PWD but on its length, shape, distribution within an aneurysm, and other recanalization risk factors. CONCLUSIONS: Coil PWD influences packing density, the number of coils required to achieve a specific packing density, and total case costs. Using 0.012″ PWD coils may provide cost and procedural efficiencies.

Health economic impact of first-pass success among patients with acute ischemic stroke treated with mechanical thrombectomy: a United States and European perspective.

BACKGROUND: First-pass effect (FPE), restoring complete or near complete reperfusion (modified Thrombolysis in Cerebral Infarction (mTICI) 2c-3) in a single pass, is an independent predictor for good functional outcomes in the endovascular treatment of acute ischemic stroke. The economic implications of achieving FPE have not been assessed. OBJECTIVE: To assess the economic impact of achieving complete or near complete reperfusion after the first pass. METHODS: Post hoc analyses were conducted using ARISE II study data. The target population consisted of patients in whom mTICI 2c-3 was achieved, stratified into two groups: (1) mTICI 2c-3 achieved after the first pass (FPE group) or (2) after multiple passes (non-FPE group). Baseline characteristics, clinical outcomes, and healthcare resource use were compared between groups. Costs from peer-reviewed literature were applied to assess cost consequences from the perspectives of the United States (USA), France, Germany, Italy, Spain, Sweden, and United Kingdom (UK). RESULTS: Among patients who achieved mTICI 2c-3 (n=172), FPE was achieved in 53% (n=91). A higher proportion of patients in the FPE group reached good functional outcomes (90-day modified Rankin Scale score 0-2 80.46% vs 61.04%, p<0.01). The patients in the FPE group had a shorter mean length of stay (6.10 vs 9.48 days, p<0.01) and required only a single stent retriever, whereas 35% of patients in the non-FPE group required at least one additional device. Driven by improvement in clinical outcomes, the FPE group had lower procedural/hospitalization-related (24-33% reduction) and annual care (11-27% reduction) costs across all countries. CONCLUSIONS: FPE resulted in improved clinical outcomes, translating into lower healthcare resource use and lower estimated costs.

Outcomes associated with endovascular treatment among patients with acute ischemic stroke in the USA.

BACKGROUND: Few studies have examined the trends in clinical and economic outcomes of patients with acute ischemic stroke (AIS) who receive endovascular therapy (ET) in the real-world setting. OBJECTIVE: To evaluate characteristics and trends in clinical and economic outcomes among commercially insured patients with AIS undergoing ET between 2011 and 2017. METHODS: Patients with AIS undergoing ET from January 1, 2011 to June 30, 2017 were identified from administrative claims contained in the IBM MarketScan Commercial and Medicare Supplemental databases. The Mann-Kendall trend test was performed to examine clinical and economic trends.Between 2011 and 2017, 3411 patients (mean age 62.85±15 years) with a primary diagnosis of AIS underwent ET (coverage: Commercial 59%, n=2008; Medicare Supplemental 41%, n=1403). In the Commercial cohort, discharge to home increased significantly (from 29.54% to 39.18%, p<0.05). Length of stay declined significantly among the overall cohort (from 10.96 to 9.05 days, p<0.01) and the Medicare Supplemental cohort (from 10.03 to 8.43 days, p<0.05). All-cause 365-day readmission decreased significantly among the overall cohort (from 47.5% to 36.7%, p<0.05) and the Commercial cohort (from 51.54% to 36.43%, p<0.05) but remained unchanged in the Medicare Supplemental cohort. While index procedure cost did not change significantly ($93 955 to $87 906, p=0.8806), total cost significantly declined in the overall cohort (from $166 922 to $130 678, p<0.05). CONCLUSIONS: Although with some variation across the samples studied, outcomes including discharge to home, length of stay, readmission, and total cost associated with endovascular stroke therapy seemed to have improved between 2011 and 2017. Index admission cost remained unchanged.