Majda Thomas, Mearns Elizabeth S, Kowal Stacey
Genentech, Inc., South San Francisco, CA, USA.
Appl Health Econ Health Policy. 2025 Jul 1. doi: 10.1007/s40258-025-00985-6.
A distributional cost-effectiveness analysis (DCEA) was conducted to evaluate how alteplase for acute ischemic stroke affected overall health and disparities in the USA.
Using an existing, published, cost-effectiveness analysis, a DCEA was developed from a US payer perspective. The population was divided into 25 equity-relevant subgroups based on race and ethnicity (5 census-based groups), and county-level social vulnerability index (quintiles). Inputs for stroke outcomes, incidence and alteplase utilization varied across subgroups. Opportunity costs were estimated by converting total spend on alteplase into quality-adjusted life-years (QALYs) using an equal distribution across subgroups. Various scenarios explored the impact of health system changes to improve stroke care access.
Alteplase treatment resulted in larger relative QALY gains in more vulnerable versus less vulnerable subgroups owing to increased acute ischemic stroke incidence and lower receipt of thrombolysis. Using an opportunity cost threshold of US$150,000/QALY, alteplase was estimated to improve social welfare by increasing population health (45,606 QALYs gained) and reducing existing overall US inequities by 0.0001% annually. Results were robust across all levels of population inequality aversion and alternate opportunity cost thresholds. Health system scenarios that reduced care gaps promoted additional reductions in existing inequalities, because more patients with lower baseline health were eligible for treatment.
Under current treatment patterns, this DCEA demonstrated that alteplase for acute ischemic stroke increased population health and improved health equity. It is critical to address existing care gaps to enable equitable access to alteplase across race, ethnicity and geography.
进行分布性成本效益分析（DCEA），以评估急性缺血性中风使用阿替普酶对美国整体健康和健康差异的影响。
基于一项已发表的现有成本效益分析，从美国医保支付方的角度开展了DCEA。根据种族和族裔（5个基于人口普查的群体）以及县级社会脆弱性指数（五分位数），将人群分为25个与公平性相关的亚组。各亚组的中风结局、发病率和阿替普酶使用情况的输入数据有所不同。通过将阿替普酶的总支出按照各亚组平均分配的方式转化为质量调整生命年（QALY）来估算机会成本。各种情景探讨了卫生系统变革对改善中风治疗可及性的影响。
由于急性缺血性中风发病率增加以及溶栓治疗接受率较低，在较脆弱亚组中，与较不脆弱亚组相比，阿替普酶治疗带来的相对QALY增益更大。使用150,000美元/QALY的机会成本阈值，估计阿替普酶通过提高人群健康水平（获得45,606个QALY）和每年将美国现有的总体不公平性降低0.0001%来改善社会福利。在所有人口不平等厌恶水平和替代机会成本阈值下，结果都是稳健的。减少治疗差距的卫生系统情景促进了现有不平等的进一步减少，因为更多基线健康状况较差的患者有资格接受治疗。
在当前治疗模式下，这项DCEA表明急性缺血性中风使用阿替普酶可提高人群健康水平并改善健康公平性。解决现有的治疗差距对于实现不同种族、族裔和地域人群公平获得阿替普酶治疗至关重要。
