Economic Evaluation of Endovascular Treatment for Acute Ischemic Stroke

Stroke ◽  
2021 ◽  
Author(s):  
Lucie A. van den Berg ◽  
Olvert A. Berkhemer ◽  
Puck S.S. Fransen ◽  
Debbie Beumer ◽  
Hester Lingsma ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Usual Care ◽  
Acute Ischemic Stroke ◽  
Intervention Group ◽  
Functional Independence ◽  
Quality Adjusted Life Year ◽  
Control Group ◽  
Unique Identifier ◽  
Quality Adjusted Life

Background and Purpose: Endovascular treatment for acute ischemic stroke has been proven clinically effective, but evidence of the cost-effectiveness based on real-world data is scarce. The aim of this study was to assess whether endovascular therapy plus usual care is cost-effective in comparison to usual care alone in acute ischemic stroke patients. Methods: An economic evaluation was performed from a societal perspective with a 2-year time horizon. Empirical data on health outcomes and the use of resources following endovascular treatment were gathered parallel to the MR CLEAN trial (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) and its 2-year follow-up study. Incremental cost-effectiveness ratios were calculated as the extra costs per additional patient with functional independence (modified Rankin Scale score 0–2) and the extra cost per quality-adjusted life year gained. Results: The mean costs per patient in the intervention group were $126 494 versus $143 331 in the control group (mean difference, −$16 839 [95% CI, −$38 113 to $5456]). Compared with patients in the control group, more patients in the intervention group achieved functional independence, 37.2% versus 23.9% (absolute difference, 13.3% [95% CI, 4.0%–22.0%]) and they generated more quality-adjusted life years, 0.99 versus 0.83 (mean difference of 0.16 [95% CI, 0.04–0.29]). Endovascular treatment dominated standard treatment with $18 233 saved per extra patient with a good outcome and $105 869 saved per additional quality-adjusted life year. Conclusions: Endovascular treatment added to usual care is clinically effective, and cost saving in comparison to usual care alone in patients with acute ischemic stroke. REGISTRATION: URL: https://www.trialregister.nl/trial/695 ; Unique identifier: NL695. https://www.isrctn.com/ISRCTN10888758 ; Unique identifier: ISRCTN10888758.

scholarly journals Early Mobilization in Ischemic Stroke: A Pilot Randomized Trial of Safety and Feasibility in a Public Hospital in Brazil

2015 ◽  
Vol 5 (1) ◽  
pp. 31-40 ◽  
Author(s):  
Simone Rosa Poletto ◽  
Letícia Costa Rebello ◽  
Maria Júlia Monteiro Valença ◽  
Daniele Rossato ◽  
Andrea Garcia Almeida ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Public Hospital ◽  
Controlled Trial ◽  
Pilot Trial ◽  
Intervention Group ◽  
Total Duration ◽  
Early Mobilization ◽  
Functional Independence ◽  
Control Group

Background: The effect of early mobilization after acute stroke is still unclear, although some studies have suggested improvement in outcomes. We conducted a randomized, single-blind, controlled trial seeking to evaluate the feasibility, safety, and benefit of early mobilization for patients with acute ischemic stroke treated in a public teaching hospital in Southern Brazil. This report presents the feasibility and safety findings for the pilot phase of this trial. Methods: The primary outcomes were time to first mobilization, total duration of mobilization, complications during early mobilization, falls within 3 months, mortality within 3 months, and medical complications of immobility. We included adult patients with CT- or MRI-confirmed ischemic stroke within 48 h of symptom onset who were admitted from March to November 2012 to the acute vascular unit or general emergency unit of a large urban emergency department (ED) at the Hospital de Clínicas de Porto Alegre. The severity of the neurological deficit on admission was assessed by the National Institutes of Health Stroke Scale (NIHSS). The NIHSS and modified Rankin Scale (mRS, functional outcome) scores were assessed on day 14 or at discharge as well as at 3 months. Activities of daily living (ADL) were measured with the modified Barthel Index (mBI) at 3 months. Results: Thirty-seven patients (mean age 65 years, mean NIHSS score 11) were randomly allocated to an intervention group (IG) or a control group (CG). The IG received earlier (p = 0.001) and more frequent (p < 0.0001) mobilization than the CG. Of the 19 patients in the CG, only 5 (26%) underwent a physical therapy program during hospitalization. No complications (symptomatic hypotension or worsening of neurological symptoms) were observed in association with early mobilization. The rates of complications of immobility (pneumonia, pulmonary embolism, and deep vein thrombosis) and mortality were similar in the two groups. No statistically significant differences in functional independence, disability, or ADL (mBI ≥85) were observed between the groups at the 3-month follow-up. Conclusions: This pilot trial conducted at a public hospital in Brazil suggests that early mobilization after acute ischemic stroke is safe and feasible. Despite some challenges and limitations, early mobilization was successfully implemented, even in the setting of a large, complex ED, and without complications. Patients from the IG were mobilized much earlier than controls receiving the standard care provided in most Brazilian hospitals.

Abstract WMP1: Cost Effectiveness Analysis of Mechanical Thrombectomy: the THRACE Randomized Trial

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Hamza Achit ◽  
Francis guillemin ◽  
Marc Soudant ◽  
Kossar Hosseini ◽  
Aurelie Bannay ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Randomized Trial ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Intravenous Thrombolysis ◽  
Cost Effective ◽  
Functional Independence ◽  
Quality Adjusted Life Year ◽  
Significant Difference ◽  
Quality Adjusted Life

Background and purpose: The benefit of mechanical thrombectomy added to intravenous thrombolysis in patients with acute ischemic stroke has been largely demonstrated. However, evidence on economic incentive of this strategy is still limited, especially in the context of randomized trial. The purpose of this study is to analyze whether the combination of mechanical thrombectomy with intravenous thrombolysis is more cost-effective than implementing intravenous thrombolysis alone. Patients and methods: Individual-level cost and outcome data were collected in the THRACE randomized clinical trial, including patients with acute ischaemic stroke and proximal cerebral artery occlusion. Patients were assigned to either intravenous thrombolysis (IVT; n = 208) or intravenous thrombolysis plus intra-arterial thrombectomy (IVMT; n=204). The primary outcomes were both modified Rankin scale of functional independence at 90 days (score 0-2) and the EuroQol-5D score of quality of life. This study considered the perspective of the National Health Security System in France. Results: Bridging therapy increased by 10.9% the rate of functional independence compared to IVT (53% vs 42,1%) at an increased cost of 1909 є, with no significant difference in mortality (12% vs 13%) or symptomatic intracranial haemorrhage (2% vs 2%). Cost per one averted case of disability was consequently estimated at 17,480 є. The incremental cost per quality-adjusted life year gained was 13,423 є. Sensitivity analysis showed that combined approach had 84.1% probability of being cost-effective regarding cases of averted disability and 92.2% probability regarding quality-adjusted life year outcome. The national implementation of this new strategy would result in additional cost of 12.9 million є and avoid about 737 cases of death or disability. Conclusions: Based on randomized trial, this study demonstrates that intravenous thrombolysis plus mechanical intra-arterial thrombectomy for treating acute ischemic stroke is more cost-effective than intravenous thrombolysis alone.

scholarly journals Workflow Intervals and Outcomes of Endovascular Treatment for Acute Large-Vessel Occlusion During On-Vs. Off-hours in China: The ANGEL-ACT Registry

2021 ◽  
Vol 12 ◽  
Author(s):  
Yunlong Ding ◽  
Feng Gao ◽  
Yong Ji ◽  
Tingting Zhai ◽  
Xu Tong ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Functional Independence ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Unique Identifier ◽  
Vessel Occlusion ◽  
Clinical Trial Registration ◽  
Logistic Regression Models

Background: There may be a delay in or a poor outcome of endovascular treatment (EVT) among acute ischemic stroke (AIS) patients with large-vessel occlusion (LVO) during off-hours. By using a prospective, nationwide registry, we compared the workflow intervals and radiological/clinical outcomes between patients with acute LVO treated with EVT presenting during off- and on-hours.Methods: We analyzed prospectively collected Endovascular Treatment Key Technique and Emergency Work Flow Improvement of Acute Ischemic Stroke (ANGEL-ACT) data. Patients presenting during off-hours were defined as those presenting to the emergency department from Monday to Friday between 17:30 and 08:00, on weekends (from 17:30 on Friday to 08:00 on Monday), and on national holidays. We used logistic regression models with adjustment for potential confounders to determine independent associations between the time of presentation and outcomes.Results: Among 1,788 patients, 1,079 (60.3%) presented during off-hours. The median onset-to-door time and onset-to-reperfusion time were significantly longer during off-hours than during on-hours (165 vs. 125 min, P = 0.002 and 410 vs. 392 min, P = 0.027). The rates of successful reperfusion and symptomatic intracranial hemorrhage were similar in both groups. The adjusted odds ratio (OR) for the 90-day modified Rankin Scale score was 0.892 [95% confidence interval (CI), 0.748–1.064]. The adjusted OR for the occurrence of functional independence was 0.892 (95% CI, 0.724–1.098), and the adjusted OR for mortality was 1.214 (95% CI, 0.919–1.603).Conclusions: Off-hours presentation in the nationwide real-world registry was associated with a delay in the visit and reperfusion time of EVT in patients with AIS. However, this delay was not associated with worse functional outcomes or higher mortality rates.Clinical Trial Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03370939.

Abstract TMP2: Reduction of Time to Endovascular Treatment and Improved Outcomes After Ischemic Stroke in Routine Clinical Practice: Comparison of the MR CLEAN Registry First and Second Cohorts

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Kars C Compagne ◽  
Manon Kappelhof ◽  
Robert-Jan B Goldhoorn ◽  
Charles B Majoie ◽  
Yvo B Roos ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Ischemic Stroke ◽  
Clinical Practice ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Functional Independence ◽  
Routine Clinical Practice ◽  
Anterior Circulation ◽  
Time To Treatment ◽  
Mr Clean

Introduction: Outcomes after endovascular treatment (EVT) for acute ischemic stroke are highly time dependent, but whether active reduction of time to treatment leads to better outcome has not been demonstrated. We compared data of the two subsequent MR CLEAN Registry cohorts, comprising all patients in the Netherlands who had EVT for acute ischemic stroke from 2014-2017, for a trend in time to treatment and its association with outcome. Methods: We compared workflow, successful reperfusion (eTICI 2B-3), NIHSS at 24h, functional outcome (mRS) at 90 days, occurrence of symptomatic intracranial hemorrhage (sICH) and mortality in patients with ischemic stroke and a proximal intracranial occlusion in the anterior circulation included in the second cohort of the Registry (June 2016-November 2017; n = 1779) to those in patients included in the first cohort (March 2014-June 2016; n = 1526) using logistic regression. Results: Baseline NIHSS was 16 in both cohorts. Times from onset-to-groin and onset-to-reperfusion were shorter in the second cohort than in the first (185 versus 210 minutes; p<0.01 and 238 versus 270 minutes; p<0.01, respectively) (Figure 1). Successful reperfusion was achieved more often in the second than in the first cohort (72% versus 58%; p<0.01). Rates of sICH and mortality did not differ (5.9% versus 5.7%; p=0.94 and 29% versus 29%; p=0.60). However, follow-up NIHSS was lower (median 10 versus 11; p<0.001) and more patients achieved functional independence at 90 days (42.6% versus 38.9%; p = 0.012) in the second cohort (Figure 1). In a logistic regression model, the difference in good outcome between the two cohorts (aOR 1.27; 95%CI 1.08-1.50) was reduced after additional adjustment for time to reperfusion (aOR 1.15; 95%CI 0.96-1.36) as well as successful reperfusion (aOR 1.16; 95%CI 0.95-1.41). Discussion: Our data show that outcomes after EVT in routine clinical practice are improving, likely attributable to improved workflow and experience.

scholarly journals Effect of Huoxiang Zhengqi Pill on Early Neurological Deterioration in Patients with Acute Ischemic Stroke Undergoing Recanalization Therapy and Predictive Effect of Essen Score

2020 ◽  
Vol 2020 ◽  
pp. 1-6
Author(s):  
Zhi-Xin Huang ◽  
Jianguo Lin ◽  
Cheng Zhang ◽  
Ying-Yi Dai ◽  
Songbin Lin ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Primary Outcome ◽  
Univariate Analysis ◽  
Intervention Group ◽  
Clinical Event ◽  
Control Group ◽  
Early Neurological Deterioration ◽  
Treatment Measures ◽  
Risk Patients

Early neurologic deterioration (END) in the acute phase of ischemic stroke is a serious clinical event, which is closely related to poor prognosis. Therefore, it is important to identify presentation features that predict END and take relevant treatment measures, as they could help to prevent the deterioration of high-risk patients. The prospective intervention study was carried out from January 2018 to December 2019. We included consecutive patients hospitalized for acute ischemic stroke (AIS) within 6 hours of onset. Patients were randomly assigned (1 : 1) to recanalization therapy plus Huoxiang Zhengqi Pill (HXZQ) (intervention group) or standard recanalization therapy alone (control group). The primary outcome was the development of END according to predefined criteria within the first 1 week of stroke onset. Poisson regression was used to identify predictors for END. Of the 155 patients enrolled in the study (age, 63 ± 11 years; 28.4% female), 20 (12.9%) developed END. Univariate analysis showed that the use of HXZQ and Essen stroke risk score (ESRS) (low risk group) were protective factors for END, while advanced age was a risk factor for END. However, in multivariate analysis, only ESRS (OR, 0.232; 95%CI, 0.058–0.928; P=0.039) and the use of HXZQ (OR, 0.297; 95%CI, 0.096–0.917; P=0.035) were statistically significant. ESRS can be used as the prediction factor of END. HXZQ has small side effects and wide indication. It could be used in the treatment of AIS.

scholarly journals Effect of Interhospital Transfer on Endovascular Treatment for Acute Ischemic Stroke

Stroke ◽  
2019 ◽  
Vol 50 (4) ◽  
pp. 923-930 ◽  
Author(s):  
Esmee Venema ◽  
Adrien E. Groot ◽  
Hester F. Lingsma ◽  
Wouter Hinsenveld ◽  
Kilian M. Treurniet ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Functional Independence ◽  
Modified Rankin Scale ◽  
Interhospital Transfer ◽  
Primary Stroke Center ◽  
Transferred Patients ◽  
Stroke Center

Background and Purpose— To assess the effect of inter-hospital transfer on time to treatment and functional outcome after endovascular treatment (EVT) for acute ischemic stroke, we compared patients transferred from a primary stroke center to patients directly admitted to an intervention center in a large nationwide registry. Methods— MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry is an ongoing, prospective, observational study in all centers that perform EVT in the Netherlands. We included adult patients with an acute anterior circulation stroke who received EVT between March 2014 to June 2016. Primary outcome was time from arrival at the first hospital to arterial groin puncture. Secondary outcomes included the 90-day modified Rankin Scale score and functional independence (modified Rankin Scale score of 0–2). Results— In total 821/1526 patients, (54%) were transferred from a primary stroke center. Transferred patients less often had prestroke disability (227/800 [28%] versus 255/699 [36%]; P =0.02) and more often received intravenous thrombolytics (659/819 [81%] versus 511/704 [73%]; P <0.01). Time from first presentation to groin puncture was longer for transferred patients (164 versus 104 minutes; P <0.01, adjusted delay 57 minutes [95% CI, 51–62]). Transferred patients had worse functional outcome (adjusted common OR, 0.75 [95% CI, 0.62–0.90]) and less often achieved functional independence (244/720 [34%] versus 289/681 [42%], absolute risk difference −8.5% [95% CI, −8.7 to −8.3]). Conclusions— Interhospital transfer of patients with acute ischemic stroke is associated with delay of EVT and worse outcomes in routine clinical practice, even in a country where between-center distances are short. Direct transportation of patients potentially eligible for EVT to an intervention center may improve functional outcome.

Abstract 137: Endovascular Intervention versus Standard Medical Therapy for Patients Presenting with Large Acute Ischemic Strokes - A Large Single Center Experience

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Maxim Mokin ◽  
Peter Kan ◽  
Adib Abla ◽  
Travis Dumont ◽  
Shady Jahshan ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Clinical Outcomes ◽  
Medical Therapy ◽  
Endovascular Therapy ◽  
Intervention Group ◽  
Medical Group ◽  
Standard Medical Therapy ◽  
Best Medical Therapy

Objective. Endovascular interventions for acute ischemic stroke have been widely adopted on the basis of single-arm registries that reported high recanalization rates with limited complications. We conducted a retrospective cohort study to compare the clinical outcomes in acute ischemic stroke patients who underwent endovascular treatment with patients who were treated with standard medical therapy alone at our institution. Methods. The study group consisted of two cohorts of patients with acute ischemic stroke over a 4-year period: 260 patients underwent endovascular treatment and 597 patients were treated with best medical therapy alone. All patients from the medical group presented with a NIHSS score of >8 and were ineligible for IV tPA. Clinical outcomes at discharge and at 3 months were compared. Results. Compared with the medical group, the endovascular group had a significantly greater proportion of patients who were discharged home (21.2% vs 8.7%, p<0.001) and who could ambulate independently at discharge (32.1% vs 16.8%, p<0.001). Of the patients with follow-up, the proportion of patients with a good outcome (mRS score of <=2) at 3 months was also significantly higher in the endovascular group (51.9% vs 35.7%, p<0.05). Conversely, the endovascular group had a significantly smaller proportion of patients who was discharged to nursing home (11.9% vs 24.1%, p<0.01) and hospice (6.9% vs 14.1%, p=0.003). Mortality rate at discharge was not different (21.2% vs 18.9%, p=0.451). The rate of symptomatic ICH was 9.2% in the intervention group. Conclusion. In our study, endovascular therapy provides a better functional outcome compared with standard medical therapy in select patients. Ultimately, determination of efficacy of endovascular therapy for acute ischemic stroke compared with best medical therapy will depend on results of randomized trials.

Abstract WP67: Ultra-early Institution of Statin Treatment is Associated With Improved Outcomes Among Acute Ischemic Stroke Patients Receiving Thrombolytic Treatment

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Adnan I Qureshi ◽  
Muhammad A Saleem
Keyword(s):  
Ischemic Stroke ◽  
Activities Of Daily Living ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Daily Living ◽  
Recombinant Tissue Plasminogen Activator ◽  
Statin Treatment ◽  
Functional Independence ◽  
Stroke Patients ◽  
Statin Use

Background: There is preliminary evidence that early statin use may improve the outcomes of acute ischemic stroke patients following endovascular treatment. Methods: We analyzed data from subjects treated with intravenous (IV) recombinant tissue plasminogen activator (rt-PA) alone or in combination with endovascular treatment the Interventional Management of Stroke III trial. We compared the rates of functional independence (defined by modified Rankin scale of 0-2) and minimal impairment of activities of daily living (Barthel index at 90 days 95-100)at 3 and 12 months among subjects with ultra-early institution of statin treatment (on Day 0) with those in whom statin treatment was not initiated and in those in whom statins were initiated between Day 1-discharge (delayed institution)after adjusting for age and baseline National Institutes of Health Stroke Scale score strata, history of hyperlipidemia; and statin use at baseline Results: Of the 656 subjects who were recruited in the trial, ultra-early institution of statin treatment and delayed institution occurred in 51 and 387 subjects, respectively. At 3 months post randomization, the adjusted rates of independent functional outcome (odds ratio [OR] 2.3; 95 % confidence interval [CI] 1.2-4.5; P = 0.015) and minimal impairment of activities of daily living (OR 2.2; 95 % CI 1.1-4.3; P = 0.022) were higher among subjects with ultra-early institution of statin treatment compared with those without any statin treatment. The adjusted rates of functional independence (OR 2.7; 95 % CI 1.4-5.2; P = 0.004) continued to higher among subjects with ultra-early institution of statin treatment at 12 months post randomization. The adjusted rates of functional independence and minimal impairment of activities of daily living were higher among subjects with ultra-early institution of statin treatment compared with those without any statin treatment in subjects randomized to endovascular treatment. Conclusions: Ultra-early institution of statin treatment in acute ischemic stroke patients treated with IV rt-PA with or without endovascular treatment was associated with improved outcome at both 3 and 12 months

Endovascular treatment for calcified cerebral emboli in patients with acute ischemic stroke

2021 ◽  
pp. 1-11
Author(s):  
Agnetha A. E. Bruggeman ◽  
Manon Kappelhof ◽  
Nerea Arrarte Terreros ◽  
Manon L. Tolhuisen ◽  
Praneeta R. Konduri ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
The Netherlands ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Functional Independence ◽  
First Line ◽  
Multicenter Randomized Controlled Trial ◽  
Intravenous Alteplase ◽  
Mr Clean

OBJECTIVE Calcified cerebral emboli (CCE) are a rare cause of acute ischemic stroke. The authors aimed to assess the association of CCE with functional outcome, successful reperfusion, and mortality. Furthermore, they aimed to assess the effectiveness of intravenous alteplase treatment and endovascular treatment (EVT), as well as the best first-line EVT approach in patients with CCE. METHODS The Multicenter Randomized Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) Registry is a prospective, observational multicenter registry of patients treated with EVT for acute ischemic stroke in 16 intervention hospitals in the Netherlands. The association of CCE with functional outcome, reperfusion, and mortality was evaluated using logistic regression models. Univariable comparisons were made to determine the effectiveness of intravenous alteplase treatment and the best first-line EVT approach in CCE patients. RESULTS The study included 3077 patients from the MR CLEAN Registry. Fifty-five patients (1.8%) had CCE. CCE were not significantly associated with worse functional outcome (adjusted common OR 0.71, 95% CI 0.44–1.15), and 29% of CCE patients achieved functional independence. An extended Thrombolysis in Cerebral Infarction score ≥ 2B was significantly less often achieved in CCE patients compared to non-CCE patients (adjusted OR [aOR] 0.52, 95% CI 0.28–0.97). Symptomatic intracranial hemorrhage occurred in 8 CCE patients (15%) vs 171 of 3022 non-CCE patients (6%; p = 0.01). The median improvement on the National Institutes of Health Stroke Scale (NIHSS) was 2 in CCE patients versus 4 in non-CCE patients (p = 0.008). CCE were not significantly associated with mortality (aOR 1.16, 95% CI 0.64–2.12). Intravenous alteplase use in CCE patients was not associated with functional outcome or reperfusion. In CCE patients with successful reperfusion, stent retrievers were more often used as the primary treatment device (p = 0.04). CONCLUSIONS While patients with CCE had significantly lower reperfusion rates and less improvement on the NIHSS after EVT, CCE were not significantly associated with worse functional outcome or higher mortality rates. Therefore, EVT should still be considered in this specific group of patients.

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