Boudreau DM, Guzauskas GF, Chen E, Lalla D, Darren Tayama D, Fagan SC, and Veenstra DL. Cost-Effectiveness of Recombinant Tissue-Type Plasminogen Activator Within 3 Hours of Acute Ischemic Stroke: Current Evidence. Stroke. 2014
Many years ago, Bill Foege, brought up the idea that potential solutions to many of the existing health system problems can come from repeatedly asking ourselves how to optimally balance costs, quality, and outcomes. It is clear that not all diagnostic tests and treatments we offer and order on patients affects clinical outcomes. Few interventions have as profound of a benefit as intravenous tissue plasminogen activator (TPA) given in the first three hours of symptom onset of suspected acute ischemic stroke. In 2010, an estimated $74 billion was spent on stroke-related medical costs and disability; this is likely going to increase given the rising cerebrovascular disease burden. Analysis from the NINDS TPA Stroke Study supported TPA administration within the first three hours of symptom onset resulting in net cost savings to the health care system; only a single US study evaluated this and it was published in 1998.
Boudreau et al re-evaluated cost-effectiveness of TPA given within three hours of symptom onset using most recent data on its efficacy, safety, and cost. A decision analysis comparing use of TPA vs no TPA from the perspective of a US third party payer (insurance company, Medicare/Medicaid) was completed. This was done by review of recent literature (meta-analyses, secondary stroke prevention trials, health economic evaluations) taking into account post-stroke disability at 3 months (modified rankin score), symptomatic intracerebral hemorrhage rates, long-term outcomes (annual stroke recurrence and mortality rates), as well as acute care and long-term healthcare costs. Subsequently, quality-adjusted life years (QALYs) and lifetime direct health costs were calculated between the TPA and no-TPA groups in the model.
The primary analysis demonstrated that lifetime medical costs and QALYs were: $287,400 & 4.29 for the TPA group and $312,400 & 3.90 in the no-TPA group, respectively. Thus, TPA treatment increased QALYs by 0.39 and decreased cost by $25,000. The results of the model held true with sensitivity analyses.
This report demonstrates TPA given within 3 hours of symptom onset is cost-effective from the viewpoint of a US payer, taking into consideration more recent data on outcomes and medical costs. From this analysis, for every 100 patients treated, 39 years of QALYs are gained and $2.5 million are saved. It reiterates the importance of efforts targeting improvement in TPA delivery, such as telestroke and Get With the Guidelines Stroke program.
A Stitch in Time? Onset to Imaging Time Does Not Correlate with DWI Volume in Large Anterior Circulation Occlusions
Hakimelahi R, Vachha B, Copen W, Papini G, He J, Higzai M, et al. Time and Diffusion Lesion Size in Major Anterior Circulation Ischemic Strokes. Stroke. 2014
Gould B, McCourt R, Gioia RC, Kate M, Hill MD, Asdaghi N, et al. Acute Blood Pressure Reduction in Patients With Intracerebral Hemorrhage Does Not Result in Borderzone Region Hypoperfusion. Stroke. 2014
The authors appropriately list the limitations of this study, namely that they only see a very early point in time and that there was substantial heterogeneity in patients and scanners, but this is still an important contribution. This is one more piece of evidence to suggest that the supposed controversy of blood pressure reduction (Scylla) vs hypoperfusion (Charybdis) is perhaps overstated and that Circe’s advice still stands: hug the Scylla side.
Opeolu et al evaluate how accessible acute stroke care treatment is to the US population. In order to tackle this task, they evaluated the MEDPAR database from 2011 using ICD-9 codes seeking out patients who recieved IV-tPA and or intra-arterial therapy (IA-therapy). Time duration from the field to ED arrival was calculated by employing the ArcMap 10.1, a proven EMS ground model used to estimate call to ED arrival time. For helicopters, the Atlas and Database of Air Medical Services (ADAMS) model was used. 370,351 patients were diagnosed with a primary diagnosis of acute ischemic strokes (AIS). 4% of patients received IV-tPA and 0.5% received IA therapy. Of the 4,583 acute care hospitals in the MEDPAR database, 2,895 (63%) did not give any doses of IV-tPA while 4,252 (93%) did not perform any thrombectomy procedures for stroke. 327 (7%) of hospitals gave at least one dose of IV-tPA and performed at least one thrombectomy for stroke. 455 hospitals (9.9%) gave IV-tPA more than ten times during the year.
Results showed that 81% of the US population had 60 minute access to IV-tPA capable hospitals; 66% had access to primary stroke centers and 56% had access to endovascular capable hospitals. By air, 97% had 60-minute access to IV capable hospitals, 91% had access to primary stroke centers and 85% had access to endovascular capable hospitals.
Between 2008, the same group reported that 55% of the US population had ground access and 79% had air access to primary stroke centers within 60 minutes. Those numbers have increased as noted in the results above. This is likely owing to the increased number of primary stroke centers. No data remains available yet regarding comprehensive stroke center certification.
While it is a practical way to evaluate the data, use of the Medicare database may not be truly reflective of the US population as a whole. Patients omitted include carriers of private insurance, those younger than 65 years of age and those without insurance. Additionally, much of the time to hospital is inferred through models and calculations; and not actual monitored times. However, due to practicality, these methods were employed; and this data does provide us with a national perspective on acute stroke care and show us that there has been an improvement with regards to increasing access since 2008. The increase in access can be loosely tied to an increase in number of primary stroke centers. However, a question that remains at large is whether or not comprehensive stroke center certification will have an effect on patient care outcomes and improving access to acute stroke interventions.
Sharma M, Pearce LA, Benavente OR, Anderson DC, Connolly SJ, Palacio S, et al. Predictors of Mortality in Patients With Lacunar Stroke in the Secondary Prevention of Small Subcortical Strokes Trial. Stroke. 2014
One short of a Baker’s dozen: A Twelve-SNP Genetic Risk Score Identifies Individuals at Increased Risk for Future Atrial Fibrillation and Stroke
Tada H, Shiffman D, Smith JG, Sjögren M, Lubitz SA, Ellinor PT, et al. Twelve–Single Nucleotide Polymorphism Genetic Risk Score Identifies Individuals at Increased Risk for Future Atrial Fibrillation and Stroke. Stroke. 2014
1) a AF genetic risk score (AF-GRS) combining 12 single nucleotide polymorphisms (SNPs) would associate with risk for AF beyond the established risk factors (hypertension, smoking, obesity, diabetes, age, male sex and heart disease)
2) AF-GRS composed of the same 12 SNPs would also be associated with risk of ischemic stroke.
Nagayoshi M, Everson-Rose SA, Iso H, Mosley, Jr TH, Rose KM, and Lutsey PL. Social Network, Social Support, and Risk of Incident Stroke:Atherosclerosis Risk in Communities Study. Stroke. 2014
Man is a social animal. In the age of social networks, when dynamics of social interactions are morphing, we know very little about how social variables affect stroke risk. Association between social stress and coronary artery disease has been previously reported. But prospective data on social support and incident stroke has been scant, as most studies have focused on social support post stroke and recovery outcomes. The Atherosclerosis Risk in Communities (ARIC) is a bi-racial prospective epidemiologic study which was started in 1989 to investigate the etiology and sequelae of atherosclerosis and its variation in cardiovascular risk factors, medical care, and disease by race, sex, place, and time in four US communities–Forsyth County, North Carolina, Jackson, Mississippi, suburbs of Minneapolis, Minnesota, and Washington County, Maryland. Data from the cohort has led to several important papers in stroke risk factor epidemiology over the years.