1Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China.
2Deakin Health Economics, Institute of Health Transformation, School of Health and Social Development, Faculty of Health, Deakin University, Melbourne, Victoria, Australia; and.
J Neurosurg. 2023 Feb 10;139(3):678-686. doi: 10.3171/2022.12.JNS221791. Print 2023 Sep 1.
The use of thrombectomy alone (endovascular thrombectomy [EVT]) was found to be noninferior to combination therapy (EVT plus intravenous thrombolysis [IVT] with alteplase before thrombectomy [EVT+IVT]) in the DIRECT-MT (Direct Intra-Arterial Thrombectomy in Order to Revascularize AIS Patients With Large Vessel Occlusion Efficiently in Chinese Tertiary Hospitals: A Multicenter Randomized Clinical Trial), yet the economic value of omitting alteplase was unclear. Thus, in this paper the authors assessed the cost-effectiveness of EVT alone versus EVT+IVT in the DIRECT-MT.
In the context of the Chinese healthcare system, the authors conducted a post hoc economic analysis of the DIRECT-MT based on an intention-to-treat approach. Index stroke costs were collected at the individual level, while costs after discharge were complemented with published literature and government websites. Utility weights assessed at 90 days using the 5-Level EQ-5D questionnaire were prospectively collected. For long-term modeled cost-effectiveness analysis, a Markov model with 7 health states corresponding to the 7 modified Rankin Scale scores was used. Deterministic and probabilistic sensitivity analyses were performed. All costs are expressed in 2019 US dollars, discounted using the annual Consumer Price Index in China.
During the index hospitalization, the mean medication cost in the EVT-alone group was $487 lower than that in the EVT+IVT group ($2453 [95% CI $2205-$2701] vs $2940 [95% CI $2703-$3178], p = 0.01), but the mean overall costs were similar between the groups ($15,565 [95% CI $14,876-$16,254] vs $15,472 [95% CI $14,714-$16,230], p = 0.73). Within 90 days of the trial, there were no significant differences in total costs (difference -$222 [95% CI -$603 to $161], p = 0.06, bootstrapping) or utility values (median 0.84 [IQR 0.48-0.95] vs median 0.85 [IQR 0.26-1.00]; beta coefficient < 0.01 [95% CI -0.06 to 0.07]) between EVT alone and EVT+IVT. Over the lifetime horizon, EVT alone and EVT+IVT yielded comparable lifetime QALYs (2.02 QALYs [95% CI -0.07 to 4.55 QALYs] vs 1.90 QALYs [95% CI -0.09 to 4.55 QALYs]) and costs ($26,795 [95% CI $15,281-$54,463] vs $27,632 [95% CI $14,558-$52,251]).
In this economic analysis based on a trial conducted in China, the authors found that EVT alone was not associated with economic dominance over EVT+IVT in patients with anterior circulation large-vessel occlusion.
在 DIRECT-MT 研究中，单纯取栓（血管内血栓切除术[EVT]）与联合治疗（EVT 联合阿替普酶静脉溶栓[IVT]后行取栓[EVT+IVT]）相比并不劣效，但联合治疗中阿替普酶的经济性尚不明确。因此，本文作者评估了 DIRECT-MT 中单纯 EVT 与 EVT+IVT 的成本效果。
在符合中国医疗体系的情况下，作者基于意向治疗方法对 DIRECT-MT 进行了事后经济分析。个体水平采集了首发脑卒中的成本，而出院后的成本则通过发表文献和政府网站进行补充。90 天时使用 5 级 EQ-5D 问卷评估效用权重，采用前瞻性收集。对于长期的建模成本效果分析，使用对应 7 个改良 Rankin 量表评分的 7 个健康状态的 Markov 模型。进行确定性和概率敏感性分析。所有成本均以 2019 年美元表示，并使用中国年度消费者价格指数进行贴现。
在索引住院期间，单独 EVT 组的药物治疗费用比 EVT+IVT 组低 487 美元（EVT 组 2453 美元[95%CI 2205 美元至 2701 美元]与 EVT+IVT 组 2940 美元[95%CI 2703 美元至 3178 美元]，p = 0.01），但两组的总体成本相似（EVT 组 15565 美元[95%CI 14876 美元至 16254 美元]与 EVT+IVT 组 15472 美元[95%CI 14714 美元至 16230 美元]，p = 0.73）。在试验后 90 天内，两组总费用（差值-222 美元[95%CI -603 美元至 161 美元]，p = 0.06，bootstrap）或效用值（中位数 0.84 [IQR 0.48 至 0.95]与中位数 0.85 [IQR 0.26 至 1.00]；β系数＜0.01 [95%CI -0.06 至 0.07]）均无显著差异。在终生时间范围内，单独 EVT 和 EVT+IVT 具有相似的终生 QALYs（2.02 QALYs[95%CI -0.07 至 4.55 QALYs]与 1.90 QALYs[95%CI -0.09 至 4.55 QALYs]）和成本（EVT 组 26795 美元[95%CI 15281 美元至 54463 美元]与 EVT+IVT 组 27632 美元[95%CI 14558 美元至 52251 美元]）。
基于在中国开展的一项试验，本经济学分析发现，在前循环大血管闭塞患者中，单纯 EVT 与 EVT+IVT 相比并不具有经济性优势。
