Cost-Effectiveness of Late Endovascular Thrombectomy vs. Best Medical Management in a Clinical Trial Setting and Real-World Setting.

Ospel, Johanna Maria; Zerna, Charlotte; Harrison, Emma; Kleinig, Timothy J.; Puetz, Volker; Kaiser, Daniel P. O.; Graham, Brett; Yu, Amy Y.X.; van Adel, Brian; Shankar, Jai J.; McTaggart, Ryan A.; Pereira, Vitor; Frei, Donald F.; Kunz, Wolfgang G.; Goyal, Mayank; Hill, Michael D.

Background and purpose: To assess cost-effectiveness of late time-window endovascular treatment (EVT) in a clinical trial setting and a "real-world" setting. Methods: Data are from the randomized ESCAPE trial and a prospective cohort study (ESCAPE-LATE). Anterior circulation large vessel occlusion patients presenting > 6 hours from last-known-well were included, whereby collateral status was an inclusion criterion for ESCAPE but not ESCAPE-LATE. A Markov state transition model was built to estimate lifetime costs and quality-adjusted life-years (QALYs) for EVT in addition to best medical care vs. best medical care only in a clinical trial setting (comparing ESCAPE-EVT to ESCAPE control arm patients) and a "real-world" setting (comparing ESCAPE-LATE to ESCAPE control arm patients). We performed an unadjusted analysis, using 90-day modified Rankin Scale(mRS) scores as model input and analysis adjusted for baseline factors. Acceptability of EVT was calculated using upper/lower willingness-to-pay thresholds of 100,000 USD/50,000 USD/QALY. Results: Two-hundred and forty-nine patients were included (ESCAPE-LATE: n = 200, ESCAPE EVT-arm: n = 29, ESCAPE control-arm: n = 20). Late EVT in addition to best medical care was cost effective in the unadjusted analysis both in the clinical trial and real-world setting, with acceptability 96.6%–99.0%. After adjusting for differences in baseline variables between the groups, late EVT was marginally cost effective in the clinical trial setting (acceptability:49.9%–61.6%), but not the "real-world" setting (acceptability:32.9%–42.6%). Conclusion: EVT for LVO-patients presenting beyond 6 hours was cost effective in the clinical trial setting and "real-world" setting, although this was largely related to baseline patient differences favoring the "real-world" EVT group. After adjusting for these, EVT benefit was reduced in the trial setting, and absent in the real-world setting.

MEDICAL care costs; ISCHEMIC stroke; ENDOVASCULAR surgery; MEDICAL economics; MEDICAL care

Canadian Journal of Neurological Sciences, 2024, Vol 51, Issue 6, p803

0317-1671

Academic Journal

10.1017/cjn.2024.19