Cost-Effectiveness of Thrombectomy in Patients With Acute Ischemic Stroke

Stroke is a major global health concern. The last estimation of the Global Burden of Disease Study (2013) showed that ≈6.5 million people worldwide died after a stroke and 25.7 million survived. However, the most devastating impact concerns the long-term effects of such accidents in terms of physical and psychological dependence. Hence, in France, stroke represents the leading cause of nontraumatic acquired disability and the second cause of dementia. About 130 000 hospitalizations because of ischemic stroke are recorded every year in France. Because of the burden of this morbidity in terms of long-term effects, dealing with the consequences constitutes a major challenge for both the healthcare system and the National Health Insurance System (NHIS) in France. In this regard, improving treatment efficacy with new techniques is of great importance to reduce the associated morbidity. Intravenous administration of tPA (tissue-type plasminogen activator) is the established standard treatment for stroke. Several studies have demonstrated a positive effect, especially when administered within 4.5 hours after stroke. However, with large proximal vessel occlusions, this treatment is associated with poor clinical outcomes. Combining standard treatment with endovascular treatment offers a significantly better outcome in this context. This approach combines the advantages of the 2 treatments in that intravenous thrombolysis (IVT) can be started within a short time, whereas endovascular treatment, which requires time to mobilize the interventional team, increases the rate of recanalization. As well as having clinical benefit, the economic advantage of the combined strategy was demonstrated in various studies. Background and Purpose—The benefit of mechanical thrombectomy added to intravenous thrombolysis (IVT) in patients with acute ischemic stroke has been largely demonstrated. However, evidence of the economic incentive of this strategy is still limited, especially in the context of a randomized controlled trial. We aimed to analyze whether mechanical thrombectomy combined with IVT (IVMT) is cost-effective when compared with IVT alone. Methods—Individual-level cost and outcome data were collected in the THRACE randomized controlled trial (Thrombectomie des Artères Cerébrales) including patients with acute ischemic stroke. Patients were assigned to receive IVT or IVMT. The primary outcomes were modified Rankin Scale score of functional independence at 90 days (score 0–2) and the EuroQol-5D quality-of-life score at 1 year. Results—Treating acute ischemic stroke with IVMT (n=200) versus IVT (n=202) increased the rate of functional independence by 10.9% (53.0% versus 42.1%; P=0.028), at an increased cost of $2116 (€1909), with no significant difference in mortality (12% versus 13%; P=0.70) or symptomatic intracranial hemorrhage (2% versus 2%; P=0.71). The cost per one averted case of disability was estimated at $19 379 (€17 480). The incremental cost per one quality-adjusted life year gained was $14 881 (€13 423). On sensitivity analysis, the probability of cost-effectiveness with IVMT was 84.1% in terms of cases of averted disability and 92.2% in terms of quality-adjusted life years. Conclusions—Based on randomized trial data, this study demonstrates that IVMT used to treat acute ischemic stroke is cost-effective when compared with IVT alone. Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT01062698. (Stroke. 2017;48:2843-2847. DOI: 10.1161/STROKEAHA.117.017856.)