Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (P.M.W., A.L.L., D.R., B.B.N., H.K., N.S.P.), Weill Cornell Medicine, New York, NY.
Department of Pediatrics (E.L.A.), Weill Cornell Medicine, New York, NY.
Stroke. 2023 Apr;54(4):992-1000. doi: 10.1161/STROKEAHA.122.040356. Epub 2023 Mar 3.
Smoking cessation rates after stroke and transient ischemic attack are suboptimal, and smoking cessation interventions are underutilized. We performed a cost-effectiveness analysis of smoking cessation interventions in this population.
We constructed a decision tree and used Markov models that aimed to assess the cost-effectiveness of varenicline, any pharmacotherapy with intensive counseling, and monetary incentives, compared with brief counseling alone in the secondary stroke prevention setting. Payer and societal costs of interventions and outcomes were modeled. The outcomes were recurrent stroke, myocardial infarction, and death using a lifetime horizon. Estimates and variance for the base case (35% cessation), costs and effectiveness of interventions, and outcome rates were imputed from the stroke literature. We calculated incremental cost-effectiveness ratios and incremental net monetary benefits. An intervention was considered cost-effective if the incremental cost-effectiveness ratio was less than the willingness-to-pay threshold of $100 000 per quality-adjusted life-year (QALY) or when the incremental net monetary benefit was positive. Probabilistic Monte Carlo simulations modeled the impact of parameter uncertainty.
From the payer perspective, varenicline and pharmacotherapy with intensive counseling were associated with more QALYs (0.67 and 1.00, respectively) at less total lifetime costs compared with brief counseling alone. Monetary incentives were associated with 0.71 more QALYs at an additional cost of $120 compared with brief counseling alone, yielding an incremental cost-effectiveness ratio of $168/QALY. From the societal perspective, all 3 interventions provided more QALYs at less total costs compared with brief counseling alone. In 10 000 Monte Carlo simulations, all 3 smoking cessation interventions were cost-effective in >89% of runs.
For secondary stroke prevention, it is cost-effective and potentially cost-saving to deliver smoking cessation therapy beyond brief counseling alone.
中风和短暂性脑缺血发作后的戒烟率不理想，且戒烟干预措施的利用率不足。我们针对该人群进行了戒烟干预的成本效益分析。
我们构建了一个决策树，并使用马尔可夫模型，旨在评估在二级卒中预防环境下，与单独简短咨询相比，用伐伦克林、任何强化咨询药物治疗和经济激励进行戒烟的成本效益。干预措施和结果的支付者和社会成本建模。使用终生时间范围评估了复发性卒中、心肌梗死和死亡的结果。根据中风文献估算了基础案例（35%戒烟）的干预措施和结果的估计值和方差、成本和效果，以及结果发生率。我们计算了增量成本效益比和增量净货币收益。如果增量成本效益比低于每质量调整生命年（QALY） 10 万美元的支付意愿阈值，或者增量净货币收益为正，则认为干预措施具有成本效益。概率蒙特卡罗模拟对参数不确定性的影响进行建模。
从支付者的角度来看，与单独简短咨询相比，伐伦克林和强化咨询药物治疗分别与更多的 QALY（分别为 0.67 和 1.00）相关，且总成本更低。与单独简短咨询相比，经济激励在额外成本为 120 美元的情况下，与更多的 QALY 相关，增量成本效益比为 168 美元/QALY。从社会角度来看，与单独简短咨询相比，所有 3 种戒烟干预措施都以更低的总成本提供了更多的 QALY。在 10000 次蒙特卡罗模拟中，所有 3 种戒烟干预措施在超过 89%的模拟中均具有成本效益。
对于二级卒中预防，提供戒烟治疗超越单独简短咨询是具有成本效益的，并且在潜在上可能具有成本节约效果。
