Waimei Tai, MD

Simpson KN, Simpson AN, Mauldin PD, Hill MD, Yeatts SD, Spilker JA, et al. Drivers of Costs Associated With Reperfusion Therapy in Acute Stroke:The Interventional Management of Stroke III Trial. Stroke. 2014

Simpson et. al. did an elegant analysis of the costs associated with care in the IMS-3 patients. This study was designed to evaluate the difference in outcomes of patients who received iv tpa versus those who received iv tpa + endovascular therapy (thrombectomy and/or IA tpa). The study was ended early during a scheduled DSMB interim analysis which revealed that the outcomes crossed a futility boundary and that further enrollment of patients would be unlikely to demonstrate benefit from the endovascular approach.

This analysis looked specifically at the cost of care (measured by charges recorded and adjusted to CMS 2012 cost of medical services) for the initial hospitalization. About a $10,000 increase in cost was found in the endovascularly treated patients. Differences in procedural management (general anesthesia being a major upward driver in cost) as well as innate differences in the subjects (severity of stroke by NIHSS, age, diabetes as comorbidity) also affected cost of the initial hospitalization.  In addition, consistent with prior studies, earlier iv tpa delivery led to lower cost, due to decreased length of stay.

I take home a few points from this study:
-as clinicians-there are some things we cannot change:  stroke severity, age of the patient, comorbidities, possibly the time of arrival of the patient to treatment facility.
-but there are many things that are at the discretion of the clinician and/or the system of care:
1. How quickly can we deliver iv tpa to this patient (and by extension, how quickly can we recanalize a thrombosed large vessel by endovascular means?)
2. How can we make changes in the procedures (intubation vs. alternate sedation) do safely provide high quality care at lower cost?  They did not look at choice of devices in this study, but casual conversations with device company representatives suggest there is a large range of costs associated with device choice.

I think as we move forward in a value based healthcare world, more scrutiny will be placed on the way we deliver care to our patients. While IMS-3 did not meet their primary outcome to demonstrate long term efficacy and benefit for endovascular therapy, this analysis does answer some questions about how care is being delivered and how it can impact the cost of care delivery.