Economic evaluation of the Melbourne Mobile Stroke Unit

2020 ◽  
pp. 174749302092994 ◽  
Author(s):  
Joosup Kim ◽  
Damien Easton ◽  
Henry Zhao ◽  
Skye Coote ◽  
Garveeta Sookram ◽  
...  
Keyword(s):  
Stroke Unit ◽  
Standard Care ◽  
Stroke Care ◽  
Reperfusion Therapy ◽  
Sensitivity Analyses ◽  
Local Data ◽  
Endovascular Thrombectomy ◽  
Stroke Treatment ◽  
Mobile Stroke Unit ◽  
Life Years

Background The Melbourne Mobile Stroke Unit (MSU) is the first Australian service to provide prehospital acute stroke treatment, including thrombolysis and facilitated triage for endovascular thrombectomy. Aims To estimate the cost-effectiveness of the MSU during the first full year of operation compared with standard ambulance and hospital stroke care pathways (standard care). Methods The costs and benefits of the Melbourne MSU were estimated using an economic simulation model. Operational costs and service utilization data were obtained from the MSU financial and patient tracking reports. The health benefits were estimated as disability-adjusted life years (DALYs) avoided using local data on reperfusion therapy and estimates from the published literature on their effectiveness. Costs were presented in Australian dollars. The robustness of results was assessed using multivariable (model inputs varied simultaneously: 10,000 Monte Carlo iterations) and various one-way sensitivity analyses. Results In 2018, the MSU was dispatched to 1244 patients during 200 days of operation. Overall, 167 patients were diagnosed with acute ischemic stroke, and 58 received thrombolysis, endovascular thrombectomy, or both. We estimated 27.94 DALYs avoided with earlier access to endovascular thrombectomy (95% confidence interval (CI) 15.30 to 35.93) and 16.90 DALYs avoided with improvements in access to thrombolysis (95% CI 9.05 to 24.68). The MSU was estimated to cost an additional $30,982 per DALY avoided (95% CI $21,142 to $47,517) compared to standard care. Conclusions There is evidence that the introduction of MSU is cost-effective when compared with standard care due to earlier provision of reperfusion therapies.

scholarly journals Mobile Stroke Unit Hits the Road in Houston

US Neurology ◽  
2015 ◽  
Vol 11 (01) ◽  
pp. 59
Author(s):  
James C Grotta ◽  
Keyword(s):  
Symptom Onset ◽  
Stroke Unit ◽  
Quality Adjusted Life Years ◽  
Stroke Treatment ◽  
The Road ◽  
Standard Management ◽  
Mobile Stroke Unit ◽  
Life Years ◽  
Tissue Plasminogen ◽  
Quality Adjusted Life

After 1 year of preparation, the nation’s first Mobile Stroke Unit (MSU) delivering acute stroke treatment with tissue plasminogen activator (tPA) in the prehospital setting was launched in mid 2014. The unit is being operated as part of a clinical trial comparing MSU management to standard management to determine how much faster patients can be treated, how much better patients do if treated in the first hour after symptom onset than if treated later, if the physician on board the MSU can be replaced by a remote physician via telemedicine, and the costs and quality-adjusted life years saved by the MSU approach. We are treating on average over two patients per week with intravenous tPA, with more than 30 % treated within the first hour of symptom onset.

scholarly journals 011 Melbourne mobile stroke unit halves workflow for acute stroke reperfusion therapy

2019 ◽  
Vol 90 (e7) ◽  
pp. A4.3-A5
Author(s):  
Henry Zhao ◽  
Skye Coote ◽  
Francesca Langenberg ◽  
Damien Easton ◽  
Michael Stephenson ◽  
...  
Keyword(s):  
Stroke Unit ◽  
Reperfusion Therapy ◽  
Ct Scanner ◽  
Royal Melbourne Hospital ◽  
Prehospital Treatment ◽  
Endovascular Thrombectomy ◽  
Prehospital Thrombolysis ◽  
Golden Hour ◽  
Mobile Stroke Unit ◽  
Historical Controls

BackgroundThe Melbourne Mobile Stroke Unit (MSU) utilises a specialised ambulance with on-board CT scanner and multidisciplinary team to provide on-scene imaging, treatment and triage for central Melbourne, Australia. We describe the operational impact of the MSU on commencement of acute reperfusion therapy.MethodsData from the first 12 months of operation were collected for all patients receiving reperfusion therapy from November 2017. Workflow times were compared to contemporary published Australian data and historical controls from Royal Melbourne Hospital.ResultsIn the first calendar 12 months of operation, the Melbourne MSU operated 30.5 service weeks and provided prehospital thrombolysis (tPA) to n=52 patients (44% of eligible infarcts) and directed n=33 patients for endovascular thrombectomy, of which 48% required bypass from the closest non-thrombectomy hospital. The overall median onset-to-tPA for MSU patients was 97.5 mins compared to the Australian metropolitan median of 150 mins. Thrombolysis in the first ‘golden hour’ increased to 13.5% from 3.3% in-hospital. Median onset-to-groin for MSU patients receiving EVT was 162 mins compared to 234 mins from historical controls.DiscussionPrehospital treatment and triage using the Mobile Stroke Unit in metropolitan Melbourne resulted in substantial improvements in commencement of reperfusion therapy. Workflow times are approximately halved for thrombolysis and endovascular thrombectomy respectively. Prehospital thrombolysis also allowed a >400% increase in the proportion of treatment in the first ‘golden hour’.

scholarly journals A Cost-Utility Analysis of Endovascular Thrombectomy in a Real-World Setting

2019 ◽  
Vol 47 (1) ◽  
pp. 50-60
Author(s):  
Prosper S. Koto ◽  
Sherry X. Hu ◽  
Karim Virani ◽  
Wendy L. Simpkin ◽  
Christine A. Christian ◽  
...  
Keyword(s):  
Cost Effectiveness ◽  
Real World ◽  
Standard Care ◽  
Cost Effective ◽  
Sensitivity Analyses ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Real World Setting ◽  
Life Years

ABSTRACT:Objective:Endovascular thrombectomy (EVT) is efficacious for ischemic stroke caused by proximal intracranial large-vessel occlusion involving the anterior cerebral circulation. However, evidence of its cost-effectiveness, especially in a real-world setting, is limited. We assessed whether EVT ± tissue plasminogen activator (tPA) was cost-effective when compared with standard care ± tPA at our center.Method:We identified patients treated with EVT ± tPA after the Endovascular treatment for Small Core and Anterior circulation Proximal occlusion with Emphasis on minimizing computed tomography to recanalization times trial from our prospective stroke registry from February 1, 2013 to January 31, 2017. Patients admitted before February 2013 and treated with standard care ± tPA constitute the controls. The sample size was 88. Cost-effectiveness was assessed using the net monetary benefit (NMB). Differences in average costs and quality-adjusted life years (QALYs) were estimated using the augmented inverse probability weighted estimator. We accounted for sampling and methodological uncertainty in sensitivity analyses.Results:Patients treated with EVT ± tPA had a net gain of 2.89 [95% confidence interval (CI): 0.93–4.99] QALYs at an additional cost of $22,200 (95% CI: −28,902–78,244) per patient compared with the standard care ± tPA group. The NMB was $122,300 (95% CI: −4777–253,133) with a 0.85 probability of being cost-effective. The expected savings to the healthcare system would amount to $321,334 per year.Conclusion:EVT ± tPA had higher costs and higher QALYs compared with the control, and is likely to be cost-effective at a willingness-to-pay threshold of $50,000 per QALY.

Abstract P354: Assessment of Phased Implementation of a Mobile Stroke Unit for Acute Ischemic Stroke Treatment

Circulation ◽  
2018 ◽  
Vol 137 (suppl_1) ◽  
Author(s):  
Soraya Sanchez Molero ◽  
Cynthia Diaz ◽  
James Boozan ◽  
Michael F Stiefel
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Stroke Unit ◽  
Stroke Care ◽  
Tissue Type ◽  
Retrospective Case ◽  
Stroke Treatment ◽  
Mobile Stroke Unit ◽  
Significant Difference ◽  
The Impact

Introduction: The timing of administering tissue-type plasminogen activator (tPA) in patients with an ischemic stroke is directly related to clinical outcomes. The use of a mobile stroke unit (MSU) is a strategy to provide acute ischemic stroke assessment and treatment in a more rapid fashion compared to standard stroke transport and management. Our program initiated the use of a MSU in 2017 as a part of a phased implementation program. We sought to determine the impact of the MSU on the timing of stroke care in the region as it related to proximity to the hospital. Methods: We collected data during the first 9 months of 2017 on patients who were transported to the hospital as pre-hospital stroke alerts (PHSA) via conventional ambulance or via the MSU. Using a retrospective case-controlled design we compared process metrics associated with the phased implementation of the MSU with conventional pre-hospital stroke alerts as standard of care (SOC). Results: There was a total of 178 stroke alert patients; 72 in the MSU group and 106 in the PHSA group. 35 patients received tPA, 16 in the MSU, 19 in SOC. There was no significant difference in age, body weight, race, gender, and length of stay in the hospital in the two groups. The time from 911 call to arrival on scene was 12.06 min versus 20.4 min in the PHSA and MSU groups, respectively. Despite a longer time for arrival TPA administration for patients within a 5 miles radius of the hospital was 89 ± 25 mins in the SOC group and 78±12 mins in the MSU group (p=0.11). For 911 calls originating 10-20 miles from the hospital, the time for 911 call to tPA was 106 ± 23 mins in the PHSA group (n = 4) and 86 ± 2 mins in the MSU group (n = 4). Conclusion: Our initial results are comparable with previously reported data . Our data suggests the MSU may have a greater impact on reducing time to tPA for those further from the hospital or where transport time is delayed. The role of the MSU for non tPA patients such as mechanical thrombectomy, intracerebral hemorrhage and subarachnoid hemorrhage warrants further investigation.

Retrospective Review and Proof of Concept of Asia’s First Mobile Stroke Unit Experience in Kovai Medical Center and Hospital

2020 ◽  
Vol 3 (2) ◽  
pp. 116-123
Author(s):  
Mathew Cherian ◽  
Pankaj Mehta ◽  
Shriram Varadharajan ◽  
Santosh Poyyamozhi ◽  
Elango Swamiappan ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Retrospective Review ◽  
Stroke Unit ◽  
Care Pathway ◽  
Clinical Care ◽  
Stroke Care ◽  
First Year ◽  
Proof Of Concept ◽  
Mobile Stroke Unit ◽  
Clinical Care Pathway

Background: We review our initial experience of India’s and Asia’s first mobile stroke unit (MSU) following the completion of its first year of operation. We outline the clinical care pathway integrating the MSU services using a case example taking readers along our clinical care workflow while highlighting the challenges faced in organizing and optimizing such services in India. Methods: Retrospective review of data collected for all patients from March 2018 to February 2019 transported and treated within the MSU during the first year of its operation. Recent case example is reviewed highlighting complete comprehensive acute clinical care pathway from prehospital MSU services to advanced endovascular treatment with focus on challenges faced in developing nation for stroke care. Results: The MSU was dispatched and utilized for 14 patients with clinical symptoms of acute stroke. These patients were predominantly males (64%) with median age of 59 years. Ischemic stroke was seen in 7 patients, hemorrhagic in 6, and 1 patient was classified as stroke mimic. Intravenous tissue plasminogen activator was administered to 3 patients within MSU. Most of the patients’ treatment was initiated within 2 h of symptom onset and with the median time of patient contact (rendezvous) following stroke being 55 mins. Conclusion: Retrospective review of Asia’s first MSU reveals its proof of concept in India. Although the number of patients availing treatment in MSU is low as compared to elsewhere in the world, increased public awareness with active government support including subsidizing treatment costs could accelerate development of optimal prehospital acute stroke care policy in India.

scholarly journals Stroke Care During the First and the Second Waves of the COVID-19 Pandemic in a Community Hospital

2021 ◽  
Vol 12 ◽  
Author(s):  
Piotr Sobolewski ◽  
Wiktor Szczuchniak ◽  
Danuta Grzesiak-Witek ◽  
Jacek Wilczyński ◽  
Karol Paciura ◽  
...  
Keyword(s):  
Retrospective Study ◽  
Stroke Unit ◽  
Community Hospital ◽  
Intravenous Thrombolysis ◽  
Stroke Care ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Staff Members ◽  
Second Wave

Objective: The coronavirus disease 2019 (COVID-19) infection may alter a stroke course; thus, we compared stroke course during subsequent pandemic waves in a stroke unit (SU) from a hospital located in a rural area.Methods: A retrospective study included all patients consecutively admitted to the SU between March 15 and May 31, 2020 (“first wave”), and between September 15 and November 30, 2020 (“second wave”). We compared demographic and clinical data, treatments, and outcomes of patients between the first and the second waves of the pandemic and between subjects with and without COVID-19.Results: During the “first wave,” 1.4% of 71 patients were hospitalized due to stroke/TIA, and 41.8% of 91 during the “second wave” were infected with SARS-CoV-2 (p < 0.001). During the “second wave,” more SU staff members were infected with COVID-19 than during the “first wave” (45.6 vs. 8.7%, p < 0.001). Nevertheless, more patients underwent intravenous thrombolysis (26.4 vs. 9.9%, p < 0.008) and endovascular thrombectomy (5.3 vs. 0.0%, p < 0.001) during the second than the first wave. Large vessel occlusion (LVO) (OR 8.74; 95% CI 1.60–47.82; p = 0.012) and higher 30-day mortality (OR 6.01; 95% CI 1.04–34.78; p = 0.045) were associated with patients infected with COVID-19. No differences regarding proportions between ischemic and hemorrhagic strokes and TIAs between both waves or subgroups with and without COVID-19 existed.Conclusion: Despite the greater COVID-19 infection rate among both SU patients and staff during the “second wave” of the pandemic, a higher percentage of reperfusion procedures has been performed then. COVID-19 infection was associated with a higher rate of the LVO and 30-day mortality.

Abstract TP291: Melbourne Mobile Stroke Unit Increases Stroke Treatment Rates and Treatment Opportunities

Stroke ◽  
2019 ◽  
Vol 50 (Suppl_1) ◽  
Author(s):  
Skye Coote ◽  
Henry Zhao ◽  
Lauren Pesavento ◽  
Francesca Langenberg ◽  
Patricia Desmond ◽  
...  
Keyword(s):  
Stroke Unit ◽  
Stroke Treatment ◽  
Mobile Stroke Unit

scholarly journals Mobile Stroke Unit Computed Tomography Angiography Substantially Shortens Door-to-Puncture Time

Stroke ◽  
2020 ◽  
Vol 51 (5) ◽  
pp. 1613-1615 ◽  
Author(s):  
Alexandra L. Czap ◽  
Noopur Singh ◽  
Ritvij Bowry ◽  
Amanda Jagolino-Cole ◽  
Stephanie A. Parker ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Computed Tomography Angiography ◽  
Stroke Unit ◽  
Interquartile Range ◽  
National Institutes Of Health ◽  
Unique Identifier ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Unit Management ◽  
Mobile Stroke Unit

Background and Purpose— Endovascular thrombectomy (ET) door-to-puncture time (DTPT) is a modifiable metric. One of the most important, yet time-consuming steps, is documentation of large vessel occlusion by computed tomography angiography (CTA). We hypothesized that obtaining CTA on board a Mobile Stroke Unit and direct alert of the ET team shortens DTPT by over 30 minutes. Methods— We compared DTPT between patients having CTA onboard the Mobile Stroke Unit then subsequent ET from September 2018 to November 2019 and patients in Mobile Stroke Unit from August 2014 to August 2018, when onboard CTA was not yet being used. We also correlated DTPT with change in National Institutes of Health Stroke Scale between baseline and 24 hours. Results— Median DTPT was 53.5 (95% CI, 35–67) minutes shorter with onboard CTA and direct ET team notification: 41 minutes (interquartile range, 30.0–63.5) versus 94.5 minutes (interquartile range, 69.8–117.3; P <0.001). Median on-scene time was 31.5 minutes (interquartile range, 28.8–35.5) versus 27.0 minutes (interquartile range, 23.0–31.0) ( P <0.001). Shorter DTPT correlated with greater improvement of National Institutes of Health Stroke Scale (correlation=−0.2, P =0.07). Conclusions— Prehospital Mobile Stroke Unit management including on-board CTA and ET team alert substantially shortens DTPT. Registration— URL: https://clinicaltrials.gov ; Unique identifier: NCT02190500.

Cost-Effectiveness of Skin Surveillance Through a Specialized Clinic for Patients at High Risk of Melanoma

2017 ◽  
Vol 35 (1) ◽  
pp. 63-71 ◽  
Author(s):  
Caroline G. Watts ◽  
Anne E. Cust ◽  
Scott W. Menzies ◽  
Graham J. Mann ◽  
Rachael L. Morton
Keyword(s):  
Cost Effectiveness ◽  
High Risk ◽  
Standard Care ◽  
Sensitivity Analyses ◽  
Model Parameters ◽  
System Perspective ◽  
Life Years ◽  
The Mean ◽  
Quality Adjusted Life ◽  
High Risk Clinic

Purpose Clinical guidelines recommend that people at high risk of melanoma receive regular surveillance to improve survival through early detection. A specialized High Risk Clinic in Sydney, Australia was found to be effective for this purpose; however, wider implementation of this clinical service requires evidence of cost-effectiveness and data addressing potential overtreatment of suspicious skin lesions. Patients and Methods A decision-analytic model was built to compare the costs and benefits of specialized surveillance compared with standard care over a 10-year period, from a health system perspective. A high-risk standard care cohort was obtained using linked population data, comprising the Sax Institute’s 45 and Up cohort study, linked to Medicare Benefits Schedule claims data, the cancer registry, and hospital admissions data. Benefits were measured in quality-adjusted life-years gained. Sensitivity analyses were undertaken for all model parameters. Results Specialized surveillance through the High Risk Clinic was both less expensive and more effective than standard care. The mean saving was A$6,828 (95% CI, $5,564 to $8,092) per patient, and the mean quality-adjusted life-year gain was 0.31 (95% CI, 0.27 to 0.35). The main drivers of the differences were detection of melanoma at an earlier stage resulting in less extensive treatment and a lower annual mean excision rate for suspicious lesions in specialized surveillance (0.81; 95% CI, 0.72 to 0.91) compared with standard care (2.55; 95% CI, 2.34 to 2.76). The results were robust when tested in sensitivity analyses. Conclusion Specialized surveillance was a cost-effective strategy for the management of individuals at high risk of melanoma. There were also fewer invasive procedures in specialized surveillance compared with standard care in the community.

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