Rizwan Kalani, MD

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.