AUTHOR=Gao Lan , Bivard Andrew , Parsons Mark , Spratt Neil J. , Levi Christopher , Butcher Kenneth , Kleinig Timothy , Yan Bernard , Dong Qiang , Cheng Xin , Lou Min , Yin Congguo , Chen Chushuang , Wang Peng , Lin Longting , Choi Philip , Miteff Ferdinand , Moodie Marj 

TITLE=Real-World Cost-Effectiveness of Late Time Window Thrombectomy for Patients With Ischemic Stroke

JOURNAL=Frontiers in Neurology

VOLUME=Volume 12 - 2021

YEAR=2021

URL=https://www.frontiersin.org/journals/neurology/articles/10.3389/fneur.2021.780894

DOI=10.3389/fneur.2021.780894

ISSN=1664-2295

ABSTRACT=Background 
To compare the cost-effectiveness of providing endovascular thrombectomy (EVT) for ischemic stroke patients in the >4.5 hour time window between patient groups who do, and do not meet the perfusion imaging trial criteria.

Methods
A discrete event simulation (DES) model was developed to simulate the long-term outcome of patients post EVT in those meeting or not meeting the extended time window clinical trial perfusion imaging criteria at presentation, versus medical treatment alone (including intravenous thrombolysis). Effectiveness of thrombectomy in patients meeting the landmark trial criteria (DEFUSE 3 and DAWN) was derived from a prospective cohort study of Australian patients who received EVT for ischaemic stroke between 2015 and 2019 in the extended time window (>4.5 hours). 

Results
EVT was shown to be a cost-effective treatment for patients satisfying the clinical trial criteria in our prospective cohort (ICER of $11,608/QALY for DEFUSE 3-postive or $34,416/QALY for DAWN-positive). However, offering EVT to patients outside of clinical trial criteria was associated with reduced benefit (-1.02 QALY for DEFUSE 3; -1.43 QALY for DAWN) and higher long term patient costs ($8,955 for DEFUSE 3; $9,271 for DAWN), making it unlikely to be cost-effective in Australia. 

Conclusions
Treating patients not meeting the DAWN or DEFUSE 3 clinical trial criteria in the extended time window for EVT were associated with less QALYs gained and higher cost. Caution should be exercised when considering this procedure for patients not satisfying the trial perfusion imaging criteria for EVT.