Evaluaciones económicas
Medwave 2021;21(03):e8152 doi: 10.5867/medwave.2021.03.8152
Análisis de costo utilidad: trombectomía mecánica más trombólisis en accidente vascular cerebral isquémico debido a oclusión de grandes vasos en el sector público en Chile
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
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Palabras clave: 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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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.

Autores: Rony Lenz-Alcayaga[1,2], Daniela Paredes-Fernández[1], Karla Hernández-Sánchez[3], Juan E. Valencia-Zapata[4]

Filiación:
[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

Correspondencia a:
[1] Fernández Concha #700, Las Condes
Santiago, Chile

Citación: 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

Fecha de envío: 11/11/2020

Fecha de aceptación: 15/3/2021

Fecha de publicación: 13/4/2021

Origen: No solicitado

Tipo de revisión: Revisión por pares externa, por tres árbitros a doble ciego

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Sacco RL, Kasner SE, Broderick JP, Caplan LR, Connors JJ, Culebras A, et al. An updated definition of stroke for the 21st century: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013 Jul;44(7):2064-89. | CrossRef | PubMed |

Bogousslavsky J, Liu M, Moncayo J, Norrving B, Tsiskaridze A, Yamaguchi T et al. Neurological disorders, a public health approach. 3.9 Stroke. In Aarli J, Dua T, Janca A, Muscetta A, editors, Neurological Disorders. Public Health Challenges. World Health Organization. 2006. p. 151-163. | Link |

Bousser MG, Ferro JM. Cerebral venous thrombosis: an update. Lancet Neurol. 2007 Feb;6(2):162-70. | CrossRef | PubMed |

Organización Mundial de la Salud. Manual de la OMS para la vigilancia paso a paso de la OMS: estrategia paso a paso de la OMS para la vigilancia de accidentes cerebrovasculares. Ginebra: OMS 2005. [On line] | Link |

Institute for Health Metrics and Evaluation (IHME). 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 |

MINSAL. Encuesta Nacional de Salud 2016-2017 Primeros resultados. 2017.[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. N Engl J Med. 2015 Mar 12;372(11):1009-18. | CrossRef | PubMed |

Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015 Jan 1;372(1):11-20. | CrossRef | PubMed |

Raychev R, Saver JL. Mechanical thrombectomy devices for treatment of stroke. Neurol Clin Pract. 2012 Sep;2(3):231-235. | CrossRef | PubMed |

Lenz Alcayaga R, Paredes D, Hernández K, et al. PMD22 BUDGET IMPACT ANALYSIS OF THE INCORPORATION OF MECHANICAL THROMBECTOMY WITH STENT RETRIEVERS AFTER THROMBOLYSIS IN ISCHEMIC-STROKE WITH LARGE VESSEL OCCLUSION IN THE CHILEAN PUBLIC SECTOR. Value Heal 2020;23:S192. | CrossRef |

Saber H, Rajah GB, Kherallah RY, Jadhav AP, Narayanan S. Comparison of the efficacy and safety of thrombectomy devices in acute stroke : a network meta-analysis of randomized trials. J Neurointerv Surg. 2018 Aug;10(8):729-734. | CrossRef | PubMed |

The National Institute for Health and Care Excellence. Mechanical thrombectomy devices for acute ischaemic stroke. Reino Unido: 2018. | Link |

The Joanna Briggs Institute. Joanna Briggs Institute Reviewers’ Manual: 2015 edition. The Joanna Briggs Institute 2015. | Link |

Husereau D, Drummond M, Petrou S, Carswell C, Moher D, Greenberg D, et al. Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement. Value Health. 2013 Mar-Apr;16(2):e1-5. | CrossRef | PubMed |

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