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Rev Neurol (Paris). 2019 Jan 11. pii: S0035-3787(18)30411-9. doi: 10.1016/j.neurol.2018.06.007. [Epub ahead of print]

Cost-effectiveness analysis of mechanical thrombectomy plus tissue-type plasminogen activator compared with tissue-type plasminogen activator alone for acute ischemic stroke in France.

Author information

1
Pôle de santé publique, service d'information médicale, USMR & CIC-EC 14-01, CHU de Bordeaux, 33000 Bordeaux, France; Inserm, Bordeaux Population Health Research Center, team EMOS, UMR 1219, université Bordeaux, 33000 Bordeaux, France.
2
Pôle imagerie médicale, service de radiologie et de neuro-imagerie diagnostique et thérapeutique, CHU de Bordeaux, 33000 Bordeaux, France.
3
Pôle neurosciences cliniques, unité neurovasculaire, CHU de Bordeaux, 33000 Bordeaux, France.
4
Inserm, Bordeaux Population Health Research Center, team EMOS, UMR 1219, université Bordeaux, 33000 Bordeaux, France.
5
Pôle produits de santé, pharmacie clinique dispositifs médicaux, CHU de Bordeaux, 33000 Bordeaux, France.
6
Pôle neurosciences cliniques, unité neurovasculaire, CHU de Bordeaux, 33000 Bordeaux, France; INCIA, CNRS UMR 5287, université de Bordeaux, 33000 Bordeaux, France.
7
Pôle de santé publique, service d'information médicale, USMR & CIC-EC 14-01, CHU de Bordeaux, 33000 Bordeaux, France; Inserm, Bordeaux Population Health Research Center, team EMOS, UMR 1219, université Bordeaux, 33000 Bordeaux, France. Electronic address: antoine.benard@u-bordeaux.fr.

Abstract

BACKGROUND AND PURPOSE:

Recent studies demonstrated the benefit of mechanical thrombectomy (MT) plus intravenous tissue-type plasminogen activator (IV-tPA) (MT-IV-tPA) in acute ischemic stroke. This study aimed to estimate the cost-utility of MT-IV-tPA compared with IV-tPA alone from the perspective of the French National Health Insurance.

METHODS:

We developed a decision tree for the first 3 months after stroke onset and a Markov model until 10 years post-stroke. The health states of the Markov model were according to the modified Rankin Scale (mRS): independent (mRS=0-2), dependent (mRS=3-5), dead (mRS=6). Recurrent stroke was the fourth health stage of our model. We conducted systematic literature reviews and meta-analyses to estimate the cost and utility of each health state, and the transition probabilities between health states. A microcosting study was conducted to estimate the cost of MT. We estimated the incremental cost-effectiveness ratio of MT-IV-tPA and conducted a probabilistic analysis in order to estimate the probability that MT-IV-tPA is cost-effective compared to IV-tPA, the expected value of perfect information (EVPI), and the expected value of partial perfect information (EVPPI), given the uncertainty surrounding the value of our model's parameters.

RESULTS:

The total mean (standard deviation (SD) cost of MT was €6708.9 (2357.0). The incremental cost-effectiveness ratio (ICER) of the strategy using IV-tPA combined to MT costs was €14,715 per QALY gained as compared to a strategy using IV-tPA alone. The probabilistic analysis showed that the probability of MT-IV-TPA being cost-effective was 85.4% at threshold willingness-to-pay of €30,000 per QALY gained, reaching 98% at €50,000 per QALY gained.

CONCLUSION:

Although there is no universally accepted willingness-to-pay threshold in France, our analysis suggest that MT combined to IV-tPA can be considered a cost-effective treatment compared with IV-tPA alone.

KEYWORDS:

Acute ischemic stroke; Cost-effectiveness; Cost-utility; Expected value of partial perfect information; Expected value of perfect information; Mechanical thrombectomy

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