Peer-reviewed general biomedical journal
Health economics
Medwave 2021;21(03):e8152 doi: 10.5867/medwave.2021.03.8152
Cost-utility analysis: Mechanical thrombectomy plus thrombolysis in ischemic stroke due to large vessel occlusion in the public sector in Chile
Rony Lenz-Alcayaga, Daniela Paredes-Fernández, Karla Hernández-Sánchez, Juan E. Valencia-Zapata
Key Words: economic evaluation, stroke, brain ischemia, chile
Abstract
Introduction
Several studies demonstrate the therapeutic superiority of thrombolysis plus mechanical thrombectomy versus thrombolysis alone to treat stroke.
Objective
To analyze the cost-utility of thrombolysis plus mechanical thrombectomy versus thrombolysis in patients with ischemic stroke due to large vessel occlusion.
Methods
Cost-utility analysis. The model used is blended: Decision Tree (first 90 days) and Markov in the long term, of seven health states based on a disease-specific scale, from the Chilean public insurance and societal perspective. Quality-Adjusted Life-Years and costs are evaluated. Deterministic (DSA) and probabilistic (PSA) analyses were carried out.
Results
From the public insurance perspective, in the base case, mechanical thrombectomy is associated with lower costs in a lifetime horizon, and with higher benefits (2.63 incremental QALYs, and 1.19 discounted incremental life years), at a Net Monetary Benefit (NMB) of CLP 37,289,874, and an Incremental Cost-Utility Ratio (ICUR) of CLP 3,807,413/QALY. For the scenario that incorporates access to rehabilitation, 2.54 incremental QALYs and 1.13 discounted life years were estimated, resulting in an NMB of CLP 35,670,319 and ICUR of CLP 3,960,624/QALY. In the scenario that incorporates access to long-term care from a societal perspective, the ICUR falls to CLP 951,911/QALY, and the NMB raises to CLP 43,318,072, improving the previous scenarios. In the DSA, health states, starting age, and relative risk of dying were the variables with the greatest influence. The PSA for the base case corroborated the estimates.
Conclusions
Thrombolysis plus mechanical thrombectomy adds quality of life at costs acceptable for decision-makers versus thrombolysis alone. The results are consistent with international studies.
This article does not have an English translation available.
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Introducción
Diversos estudios demuestran la superioridad terapéutica de la trombólisis más trombectomía mecánica, versus trombólisis sola, en el tratamiento del accidente vascular cerebral.
Objetivos
Analizar el costo utilidad de la trombólisis más trombectomía versus trombólisis sola en pacientes con accidente vascular cerebral isquémico con oclusión de grandes vasos.
Métodos
Evaluación de costo utilidad. Se ha utilizado un modelo mixto: árbol de decisión (primeros 90 días) y Markov en el largo plazo, de siete estados de salud definidos en escala específica de enfermedad, desde la perspectiva del seguro público chileno y societal. Se evalúan costos y años de vida ajustados por calidad. Se realizó análisis de incertidumbre determinístico y probabilístico.
Resultados
Bajo la perspectiva de seguro público, en el caso base la trombectomía mecánica se relaciona con menores costos en un horizonte de por vida, con mayores beneficios (2,63 años de vida ajustados por calidad incrementales, y 1,19 años de vida incrementales descontados), a un beneficio monetario neto de $37 289 874 pesos chilenos, y una razón incremental de costo utilidad de $3 807 413 pesos por años de vida ajustados por calidad. Para el escenario que agrega acceso a rehabilitación se estimaron 2,54 años de vida ajustados por calidad incremental y 1,13 años de vida descontados, resultando en un beneficio monetario neto de $35 670 319 pesos y razón incremental de costo utilidad de $3 960 624 pesos por años de vida ajustados por calidad. En el escenario que agrega el efecto de acceso a cuidados de larga duración con perspectiva societal, la razón incremental de costo utilidad cae hasta $951 911 pesos por años de vida ajustados por calidad y el beneficio monetario neto se eleva a $43 318 072 pesos, superando las estimaciones anteriores. En el análisis de incertidumbre determinístico, los estados de salud, edad de inicio de la cohorte y riesgo relativo de morir, fueron las variables con mayor influencia. El análisis de incertidumbre probabilístico para el caso base, corroboró las estimaciones.
Conclusiones
La trombólisis más trombectomía mecánica agrega calidad de vida a costos aceptables por el tomador de decisión, versus trombólisis sola. Los resultados son consistentes con los estudios internacionales.
Authors:
Rony Lenz-Alcayaga[1,2], Daniela Paredes-Fernández[1], Karla Hernández-Sánchez[3], Juan E. Valencia-Zapata[4]
Affiliation:
[1] Núcleo Académico Instituto de Salud Pública, Universidad Nacional Andrés Bello, Santiago, Chile
[2] Lenz Consultores, Santiago, Chile
[3] Unidad de Revisión de Evidencia, Lenz Consultores, Santiago, Chile
[4] Economía de la Salud y Reembolso, Medtronic Latinoamérica
E-mail: dm_paredes@ug.uchile.cl
Author address:
[1] Fernández Concha #700, Las Condes Santiago, Chile
Citation: Lenz-Alcayaga R, Paredes-Fernández D, Hernández-Sánchez K, Valencia-Zapata JE. Cost-utility analysis: Mechanical thrombectomy plus thrombolysis in ischemic stroke due to large vessel occlusion in the public sector in Chile. Medwave 2021;21(03):e8152 doi: 10.5867/medwave.2021.03.8152
Submission date: 11/11/2020
Acceptance date: 15/3/2021
Publication date: 13/4/2021
Origin: Not commissioned
Type of review: Externally peer-reviewed by three reviewers, double-blind
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Chile - Institute for Health Metrics and Evaluation. 2019;:1. [On line] | Link |Ministerio de Salud. Guía Clínica Accidente Cerebro Vascular Isquémico, en personas de 15 años y más. 2013;:130. [On line] | Link |Lavados PM, Sacks C, Prina L, Escobar A, Tossi C, Araya F, et al. Incidence, 30-day case-fatality rate, and prognosis of stroke in Iquique, Chile: a 2-year community-based prospective study (PISCIS project). Lancet. 2005 Jun 25-Jul 1;365(9478):2206-15. | CrossRef | PubMed |Beume LA, Hieber M, Kaller CP, Nitschke K, Bardutzky J, Urbach H, et al. Large Vessel Occlusion in Acute Stroke. Stroke. 2018 Oct;49(10):2323-2329. | CrossRef | PubMed |Rennert RC, Wali AR, Steinberg JA, Santiago-Dieppa DR, Olson SE, Pannell JS, et al. Epidemiology, Natural History, and Clinical Presentation of Large Vessel Ischemic Stroke. Neurosurgery. 2019 Jul 1;85(suppl_1):S4-S8. | CrossRef | PubMed |Malhotra K, Gornbein J, Saver JL. Ischemic Strokes Due to Large-Vessel Occlusions Contribute Disproportionately to Stroke-Related Dependence and Death: A Review. Front Neurol. 2017 Nov 30;8:651. | CrossRef | PubMed |MINSALUD, COLCIENCIAS, Colombia UN de. Guía de práctica clínica de diagnóstico, tratamiento y rehabilitación del episodio agudo del ataque cerebrovascular isquémico en población mayor de 18 años. Bogotá: : Ministerio de Salud y Protección Social – Colciencias 2015. | Link |Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al.Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2019 Dec;50(12):e344-e418. | CrossRef | PubMed |National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995 Dec 14;333(24):1581-7. | CrossRef | PubMed |Chiumente M, Gianino MM, Minniti D, Mattei TJ, Spass B, Kamal KM, et al. Burden of stroke in Italy: an economic model highlights savings arising from reduced disability following thrombolysis. Int J Stroke. 2015 Aug;10(6):849-55. | CrossRef | PubMed |Angerova Y, Marsalek P, Chmelova I, Gueye T, Uherek S, Briza J, et al. Cost and cost-effectiveness of early inpatient rehabilitation after stroke varies with initial disability: the Czech Republic perspective. Int J Rehabil Res. 2020 Dec;43(4):376-382. | CrossRef | PubMed |Sweid A, Hammoud B, Ramesh S, Wong D, Alexander TD, Weinberg JH, et al. Acute ischaemic stroke interventions: large vessel occlusion and beyond. Stroke Vasc Neurol. 2019 Nov 28;5(1):80-85. | CrossRef | PubMed |Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, et al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med. 2015 Jun 11;372(24):2285-95. | CrossRef | PubMed |Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2018 Mar;49(3):e46-e110. | CrossRef | PubMed |Jovin TG, Chamorro A, Cobo E, de Miquel MA, Molina CA, Rovira A, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med. 2015 Jun 11;372(24):2296-306. | CrossRef | PubMed |Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015 Mar 12;372(11):1019-30. | CrossRef | PubMed |Campbell BC, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. 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July 2022, Vol 22, Issue 6
Research papers
Association of biomarkers and severity of COVID-19: A crosssectional study
Systematization of initiatives in sexual and reproductive health about good practices criteria in response to the COVID-19 pandemic in primary health care in Chile
Clinical, psychological, social, and family characterization of suicidal behavior in Chilean adolescents: a multiple correspondence analysis
Systematization of initiatives in sexual and reproductive health about good practices criteria in response to the COVID-19 pandemic in primary health care in Chile
Clinical, psychological, social, and family characterization of suicidal behavior in Chilean adolescents: a multiple correspondence analysis
