From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN.
Neurology. 2020 Nov 3;95(18):e2465-e2475. doi: 10.1212/WNL.0000000000010867. Epub 2020 Sep 17.
To determine public health and cost consequences of time delays to endovascular thrombectomy (EVT) for patients, health care systems, and society, we estimated quality-adjusted life-years (QALYs) of EVT-treated patients and associated costs based on times to treatment.
The Markov model analysis was performed from US health care and societal perspectives over a lifetime horizon. Contemporary data from 7 trials within the Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials (HERMES) collaboration served as data source. Aside from cumulative lifetime costs, we calculated the net monetary benefit (NMB) to determine the economic value of care. We used a contemporary willingness-to-pay threshold of $100,000 per QALY for NMB calculations.
Every 10 minutes of earlier treatment resulted in an average gain of 39 days (95% prediction interval 23-53 days) of disability-free life. Overall, the cumulative lifetime costs for patients with earlier or later treatment were similar. Patients with later treatment had higher morbidity-related costs but over a shorter time span due to their shorter life expectancy, resulting in similar lifetime costs as in patients with early treatment. Regarding the economic value of care, every 10 minutes of earlier treatment increased the NMB by $10,593 (95% prediction interval $5,549-$14,847) and by $10,915 (95% prediction interval $5,928-$15,356) taking health care and societal perspectives, respectively.
Any time delay to EVT reduces QALYs and decreases the economic value of care provided by this intervention. Health care policies to implement efficient prehospital triage and to accelerate in-hospital workflow are urgently needed.
为了确定血管内血栓切除术（EVT）治疗患者的时间延迟对公共卫生和成本的影响，我们根据治疗时间来估计接受 EVT 治疗的患者的质量调整生命年（QALY）和相关成本。
这项从美国医疗保健和社会角度进行的终生马尔可夫模型分析，使用了高效再灌注评估的多项血管内卒中试验（HERMES）合作的 7 项试验中的当代数据作为数据源。除了累计终生成本外，我们还计算了净货币效益（NMB）以确定护理的经济价值。我们使用了 10 万美元/QALY 的当代意愿支付阈值来进行 NMB 计算。
每提前治疗 10 分钟，无残疾生活的平均获益为 39 天（95%预测区间为 23-53 天）。总体而言，早期或晚期治疗的患者的累积终生成本相似。晚期治疗的患者由于预期寿命较短，其与发病率相关的成本更高，但时间跨度较短，导致与早期治疗的患者的终生成本相似。关于护理的经济价值，每提前治疗 10 分钟，从医疗保健和社会角度来看，净货币效益分别增加了 10593 美元（95%预测区间为 5549 美元至 14847 美元）和 10915 美元（95%预测区间为 5928 美元至 15356 美元）。
任何 EVT 的时间延迟都会降低 QALY，并降低该干预措施的经济价值。迫切需要制定有效的院前分诊和加速院内工作流程的医疗保健政策。
