Departments of Neurology, University of California, San Francisco, 94143-0114, USA.
AJNR Am J Neuroradiol. 2011 Feb;32(2):244-9. doi: 10.3174/ajnr.A2329. Epub 2011 Jan 27.
It is unclear whether the costs and risks of mechanical therapies make them cost-effective. We examined whether interventions such as mechanical clot removal or disruption with angioplasty are cost-effective for acute ischemic stroke compared with best medical therapy.
We performed a cost-utility analysis of patients with acute stroke due to large intracranial artery occlusion presenting beyond the 3-hour window for IV tPA. Model inputs for the mechanical arm were derived from Multi MERCI trial data and a recent meta-analysis. For best medical therapy, we used rates of spontaneous recanalization, ICH, and functional outcomes based on a systematic literature review. Discounted QALYs were determined by using the Markov modeling for 65-year-old patients with acute ischemic stroke.
On the basis of a systematic literature review, we modeled an 84% rate of recanalization with mechanical intervention and a 6.3% rate of symptomatic ICH. For best medical therapy, we modeled a spontaneous recanalization rate of 24% with a 2% rate of symptomatic ICH. Mechanical therapies were associated with a $7718 net cost and a gain of a 0.82 QALYs for each use, thus yielding a net of $9386/QALY gained. In sensitivity analyses, results were dependent on the rates of recanalization, symptomatic ICH rates, and costs of treatment.
On the basis of available data, mechanical therapies in qualified patients with acute stroke beyond the window for IV tPA appear to be cost-effective. However, the inputs are not derived from randomized trials, and results are sensitive to several assumptions.
机械治疗的成本和风险是否使其具有成本效益尚不清楚。我们研究了机械血栓切除术或血管成形术等干预措施与最佳药物治疗相比，是否对急性缺血性脑卒中具有成本效益。
我们对发病 3 小时后接受 IV tPA 治疗时间窗内的大血管颅内闭塞导致的急性脑卒中患者进行了成本效用分析。机械臂的模型输入数据来源于 Multi MERCI 试验和最近的荟萃分析。对于最佳药物治疗，我们使用了基于系统文献回顾的自发性再通率、ICH 和功能结局的发生率。使用 Markov 模型计算 65 岁急性缺血性脑卒中患者的贴现 QALY。
根据系统文献回顾，我们对机械干预的再通率建模为 84%，症状性 ICH 率为 6.3%。对于最佳药物治疗，我们建模自发性再通率为 24%，症状性 ICH 率为 2%。机械治疗的净费用为 7718 美元，每次使用可获得 0.82 个 QALY，因此，每获得一个 QALY 的净收益为 9386 美元。在敏感性分析中，结果取决于再通率、症状性 ICH 率和治疗成本。
根据现有数据，在符合条件的发病 3 小时后接受 IV tPA 治疗时间窗内的急性脑卒中患者中，机械治疗似乎具有成本效益。然而，这些输入数据并非来自随机试验，并且结果对几个假设敏感。
