1. In an acute stroke simulation, early carotid imaging and tissue plasminogen activator were associated with significant cost-effectiveness.
2. No significant quantifiable health effects were found for five quality measures endorsed by American Heart Association (AHA)/ American Stroke Association (ASA).
Evidence Rating Level: 1 (Excellent)
Study Rundown: Stroke is a leading cause of global mortality, with the AHA/ASA providing specific quality measures through guidelines for acute ischemic stroke care. These quality measures have not previously undergone a cost-effectiveness analysis. In this stroke simulation model, 15 AHA/ASA quality measures were estimated to improve life expectancy and quality-adjusted life years (QALY). The quality measures were found to be cost-effective based on the a previously published threshold by the AHA of $50,000 per QALY. However, there was significant inconsistency in the value across individual quality measures. Early carotid imaging provided the most significant increase in QALYs and saving of life-years. Furthermore, tissue plasminogen activator (tPA) produced the second most improvements, including being the only quality measure where quality-of-life adjustment increased incremental QALYs. When the cost-effective threshold was increased, the most costly quality measures accounted for more significant portions of the total value of improvement. A limitation of this study is that the modeling of the quality measures does not capture the potential confounders of their subsequent interaction with each other and its effect on cost.
In-Depth [outcome simulation model]: The present study evaluated the health impact and cost-effectiveness of acute ischemic stroke quality measures based on cost-effectiveness. A computer simulation model was created for patients with incident acute ischemic stroke to project lifetime health and outcomes. Model outputs include incremental life-years, incremental QALYs, incremental cost-effectiveness ratio (ICER), and incremental net health benefit (iNHB). Model inputs were from the previously published literature describing event rates, interventions’ effect size, utility weights, and costs. The model cohort had a mean age of 71.2 years with a standard deviation of 14.2 years at stroke onset. A total of 53% of the cohort was female and 47% was male. All quality measures were seen to improve life expectancy and QALYs. On average, the measures were cost-effective based on a threshold of $100,000 per QALY and $50,000 per QALY. This has previously been described by the American College of Cardiology/AHA Task Force on Performance Measures as high-value care. Early carotid imaging led to an increase of 10,814 QALYs and a saving of 34,688 life-years, whereas tPA provided the second-largest improvement in iNHB (6,970 QALYs). Early carotid imaging and tPA accounted for 72% of the total maximum value of quality improvement measured by iNHB. When the cost-effectiveness threshold increased, the costly quality measures accounted for more significant portions of the total augmentation. In summary, from a cost perspective, there may be a minimal benefit to some of the quality measures endorsed by the AHA/ASA.
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