Costs and health effects of CT perfusion-based selection for endovascular thrombectomy within 6 hours of stroke onset: a model-based health economic evaluation

Henk van Voorst; Jan W Hoving; Miou S Koopman; Jasper D Daems; Daan Peerlings; Erik Buskens; Hester Lingsma; Henk A Marquering; Hugo W A M de Jong; Olvert A Berkhemer; Wim H van Zwam; Marianne A A van Walderveen; Ido R van den Wijngaard; Diederik W J Dippel; Albert J Yoo; Bruce Campbell; Wolfgang G Kunz; Charles B Majoie; Bart J Emmer; CLEOPATRA; MR CLEAN Registry; CONTRAST Consortium Investigators

doi:10.1136/jnnp-2023-331862

Costs and health effects of CT perfusion-based selection for endovascular thrombectomy within 6 hours of stroke onset: a model-based health economic evaluation

J Neurol Neurosurg Psychiatry. 2024 May 14;95(6):515-527. doi: 10.1136/jnnp-2023-331862.

Authors

Henk van Voorst^#^{1

2}, Jan W Hoving^#³, Miou S Koopman³, Jasper D Daems^{4

5}, Daan Peerlings⁶, Erik Buskens⁷, Hester Lingsma⁸, Henk A Marquering^{3

9}, Hugo W A M de Jong¹⁰, Olvert A Berkhemer^{11

11}, Wim H van Zwam¹², Marianne A A van Walderveen¹³, Ido R van den Wijngaard^{14

15}, Diederik W J Dippel¹⁶, Albert J Yoo¹⁷, Bruce Campbell¹⁸, Wolfgang G Kunz¹⁹, Charles B Majoie³, Bart J Emmer³; CLEOPATRA; MR CLEAN Registry; CONTRAST Consortium Investigators

Collaborators

Diederik Dippel, Charles Majoie, Rick van Nuland, Aad van der Lugt, Adriaan van Es, Pieter-Jan van Doormaal, René van den Berg, Ludo Beenen, Bart Emmer, Stefan Roosendaal, Wim van Zwam, Alida Annechien Postma, Lonneke Yo, Menno Krietemeijer, Geert Lycklama, Jasper Martens, Sebastiaan Hammer, Anton Meijer, Reinoud Bokkers, Anouk van der Hoorn, Ido van den Wijngaard, Albert Yoo, Dick Gerrits, Robert van Oostenbrugge, Jonathan M Coutinho, Martine Truijman, Julie Staals, Bart van der Worp, J Boogaarts, Sanne Zinkstok Ben Jansen, Yvo Roos, Peter Koudstaal, Koos Keizer, Sanne Manschot, Jelis Boiten, Henk Kerkhoff, Hester Lingsma, Vicky Chalos, Olvert Berkhemer, Adriaan Versteeg, Lennard Wolff, Matthijs van der Sluijs, Henk van Voorst, Manon Tolhuisen, Hugo Ten Cate, Moniek de Maat, Samantha Donse-Donkel, Heleen van Beusekom, Aladdin Taha, Aarazo Barakzie, Rob van de Graaf, Wouter van der Steen, Kilian Treurniet, Sophie van den Berg, Natalie LeCouffe, Manon Kappelhof, Rik Reinink, Leon Rinkel, Josje Brouwer, Agnetha Bruggeman, Robert-Jan Goldhoorn, Wouter Hinsenveld, Anne Pirson, Susan Olthuis, Simone Uniken Venema, Sjan Teeselink, Lotte Sondag, Sabine Collette, Martin Sterrenberg, Naziha El Ghannouti, Laurine van der Steen, Sabrina Verheesen, Jeannique Vranken, Ayla van Ahee, Hester Bongenaar, Maylee Smallegange, Lida Tilet, Joke de Meris, Michelle Simons, Wilma Pellikaan, Wilma van Wijngaarden, Kitty Blauwendraat, Yvonne Drabbe, Michelle Sandiman-Lefeber, Anke Katthöfer, Eva Ponjee, Rieke Eilander, Anja van Loon, Karin Kraus, Suze Kooij, Annemarie Slotboom, Marieke de Jong, Friedus van der Minne, Esther Santegoets, Rita Sprengers, Leontien Heiligers, Yvonne Martens, Diederik W J Dippel, Aad van der Lugt, Charles B L M Majoie, Yvo B W E M Roos, Robert J van Oostenbrugge, Wim H van Zwam, Jelis Boiten, Jan Albert Vos, Ivo G H Jansen, Maxim J H L Mulder, Robert-Jan B Goldhoorn, Kars C J Compagne, Manon Kappelhof, Josje Brouwer, Sanne J den Hartog, Wouter H Hinsenveld, Lotte van den Heuve, Bob Roozenbeek, Pieter Jan van Doormaal, Bart J Emmer, Jonathan M Coutinho, Wouter J Schonewille, Marieke J H Wermer, Marianne A A van Walderveen, C G M Adriaan, van Es, Julie Staals, Jeannette Hofmeijer, Jasper M Martens, Sebastiaan F de Bruijn, C Lukas, H van Dijk, Bart van der Worp, Rob H Lo, Ewoud J van Dijk, Hieronymus D Boogaarts, J de Vries, Paul L M de Kort, Julia van Tuijl, Issam Boukrab, Jo P Peluso, Puck Fransen, Jan S P van den Berg, Heleen M den Hertog, Boudewijn A A M van Hasselt, Leo A M Aerden, René J Dallinga, Maarten Uyttenboogaart, Omid Eschgi, Reinoud P H Bokkers, Tobien H C M L Schreuder, Roel J J Heijboer, Koos Keizer, Rob A R Gons, Lonneke S F Yo, Emiel J C Sturm, Tomas Bulut, Paul J A M Brouwers, Anouk D Rozeman, Otto Elgersma, Michel J M Remmers, Thijs E A M de Jong, Marieke E S Sprengers, Sjoerd F M Jenniskens, René van den Berg, Albert J Yoo, Ludo F M Beenen, Alida A Postma, Stefan D Roosendaal, Bas F W van der Kallen, Ido R van den Wijngaard, Joost Bot, Pieter-Jan van Doormaal, Anton Meijer, Elyas Ghariq, P Marc, G van Proosdij, Menno Krietemeijer, Rob Lo, Wouter Dinkelaar, Auke P A Appelman, Bas Hammer, Sjoert Pegge, Anouk van der Hoorn, Saman Vinke, Sandra Cornelissen, Christiaan van der Leij, Rutger Brans, Jeanette Bakker, Miou Koopman, Lucas Smagge, Olvert A Berkhemer, Jeroen Markenstein, Eef Hendriks, Patrick Brouwer, Dick Gerrits, Rob H Lo, H Zwenneke Flach, Hester F Lingsma, Naziha El Ghannouti, Martin Sterrenberg, Wilma Pellikaan, Rita Sprengers, Marjan Elfrink, Michelle Simons, Marjolein Vossers, Joke de Meris, Tamara Vermeulen, Annet Geerlings, Gina van Vemde, Tiny Simons, Gert Messchendorp, Nynke Nicolaij, Hester Bongenaar, Karin Bodde, Sandra Kleijn, Jasmijn Lodico, Hanneke Droste, Maureen Wollaert, Sabrina Verheesen, D Jeurrissen, Erna Bos, Yvonne Drabbe, Michelle Sandiman, Nicoline Aaldering, Berber Zweedijk, Jocova Vervoort, Eva Ponjee, Sharon Romviel, Karin Kanselaar, Denn Barning, Laurine van der Steen, Esmee Venema, Vicky Chalos, Ralph R Geuskens, Tim van Straaten, Saliha Ergezen, Roger R M Harmsma, Daan Muijres, Anouk de Jong, Anna M M Boers, J Huguet, P F C Groot, Marieke A Mens, Katinka R van Kranendonk, Kilian M Treurniet, Manon L Tolhuisen, Heitor Alves, Annick J Weterings, Eleonora L F Kirkels, Eva J H F Voogd, Lieve M Schupp, Sabine L Collette, Adrien E D Groot, Natalie E LeCouffe, Praneeta R Konduri, Haryadi Prasetya, Nerea Arrarte-Terreros, Lucas A Ramos, Nikki Boodt, Anne F A V Pirson, Agnetha A E Bruggeman, Nadinda A M van der Ende, Rabia Deniz, Susanne G H Olthuis, Floor Pinckaers, Geert J Lycklama À Nijeholt, Bart Emmer, Charles Majoie, Henk Marquering, Hugo de Jong, Hester Lingsma, Diederik Dippel, Arnolt-Jan Hoving, Henk van Voorst, Daan Peerlings, Jasper Daems, Miou Koopman, Jonathan Coutinho, Bart van der Worp, Rob Lo, Jan Willem Dankbaar, Bob Roozenbeek, Adriaan van Es, Pieter-Jan van Doormaal, Jasper Martens, Jeanette Hofmeijer, Maarten Uyttenboogaart, Reinoud Bokkers, Marianne van Walderveen, Marieke Wermer, Lonneke Yo, Koos Keizer, Rob Gons, Aad van der Lugt, Julie Staals, Wim van Zwam, Inger de Ridder, Karlijn de Laat, Lukas van Dijk, Jelis Boiten, Sebastiaan de Bruijn, Ido van den Wijngaard, Paul de Kort, Michel Remmers, Anouk van Norden, Issam Boukrab, Julia van Tuijl, Hans Kortman, Anton Meijer, Floris Schreuder, Ewoud van Dijk, Hieronymus Boogaarts, Heleen den Hertog, Zwenneke Flach, Jan van den Berg, Boudewijn van Hasselt, Farshad Imani, Otto Elgersma, Anouk Rozeman, Paul Brouwers, Dick Gerrits, Thomas Bulut, Jan Albert Vos, Wouter Schonewille, Albert Yoo, Wolfgang Kunz, Bruce Campbell, Nienke Pannekoek, Erik Buskens, Olvert Berkhemer, Yvo Roos, Robert van Oostenbrugge, Linda Jacobi, René van den Berg, Ludo Beenen, Bas Hammer, Stefan Roosendaal, Menno Krietemeijer, Anouk van der Hoorn, Marieke Sprengers, Sjoer Jenniskens, Alida Postma, Bas van der Kallen, Bart Emmer, Joost Bot, Elyas Ghariq, Wouter Dinkelaar, Auke Appelman, Sjoert Pegge, Saman Vinke, Sandra Cornelissen, Christiaan van der Leij, Rutger Brans, Jeanette Bakker, Lucas Smagge, Olvert A Berkhemer, Jeroen Markenstein, Eef Hendriks, Patrick Brouwer, Adriaan Versteeg, Lennard Wolff, Jiahang Su, Manon Tolhuisen, Esmee Venema, Vicky Chalos, Ralph Geuskens, Tim van Straaten, Saliha Ergezen, Roger Harmsma, Daan Muijres, Anouk de Jong, Merel Boers, J Huguet, Paul Groot, Marieke Mens, Katinka van Kranendonk, Kilian Treurniet, Heitor Alves, Annick Weterings, Eleonora Kirkels, Eva Voogd, Lieve Schupp, Sabine L Collette, Adrien Groot, Natalie LeCouffe, Praneeta Konduri, Haryadi Prasetya, Nerea Arrarte Terreros, Lucas Ramos, Nikki Boodt, Anne Pirson, Agnetha Bruggeman, Nadinda van der Ende, Rabia Deniz, Susan Olthuis, Floor Pinckaers, Anke Wouters, Josje Brouwer, Manon Kappelhof, Sophie van den Berg, Rob van de Graaf, Robert-Jan Goldhoorn, Aladdin Taha, Samantha Donse-Donkel, Wouter Hinsenveld, Lotte Sondag, Rik Reinink, Sabine Collette, Wouter van der Steen, Geert Lycklama À Nijeholt

Affiliations

¹ Department of Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, North Holland, The Netherlands [email protected].
² Department of Biomedical Engineering and Physics, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands.
³ Department of Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, North Holland, The Netherlands.
⁴ Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands.
⁵ Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands.
⁶ Department of Radiology, University Medical Center Utrecht, Utrecht, Utrecht, The Netherlands.
⁷ Epidemiology, University Medical Centre Groningen, Groningen, Groningen, The Netherlands.
⁸ Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands.
⁹ Biomedical Engineering and Physics, Amsterdam UMC Location AMC, Amsterdam, North Holland, The Netherlands.
¹⁰ UMC Utrecht, Utrecht, Utrecht, The Netherlands.
¹¹ Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
¹² Radiology, Maastricht University Medical Center, Maastricht, The Netherlands.
¹³ Leids Universitair Medisch Centrum, Leiden, Zuid-Holland, The Netherlands.
¹⁴ Neurology, HMC Westeinde, The Hague, Zuid-Holland, The Netherlands.
¹⁵ Neurology, Leiden University, Leiden, The Netherlands.
¹⁶ Neurology, Erasmus Mc University Medical Center, Rotterdam, The Netherlands.
¹⁷ Neurointervention, Texas Stroke Institute, Plano, Texas, USA.
¹⁸ The Royal Melbourne Hospital, Parkville, Melbourne, Australia.
¹⁹ Ludwig Maximilians University Munich, Munich, Germany.

^# Contributed equally.

PMID: 38124162
DOI: 10.1136/jnnp-2023-331862

Abstract

Background: Although CT perfusion (CTP) is often incorporated in acute stroke workflows, it remains largely unclear what the associated costs and health implications are in the long run of CTP-based patient selection for endovascular treatment (EVT) in patients presenting within 6 hours after symptom onset with a large vessel occlusion.

Methods: Patients with a large vessel occlusion were included from a Dutch nationwide cohort (n=703) if CTP imaging was performed before EVT within 6 hours after stroke onset. Simulated cost and health effects during 5 and 10 years follow-up were compared between CTP based patient selection for EVT and providing EVT to all patients. Outcome measures were the net monetary benefit at a willingness-to-pay of €80 000 per quality-adjusted life year, incremental cost-effectiveness ratio), difference in costs from a healthcare payer perspective (ΔCosts) and quality-adjusted life years (ΔQALY) per 1000 patients for 1000 model iterations as outcomes.

Results: Compared with treating all patients, CTP-based selection for EVT at the optimised ischaemic core volume (ICV≥110 mL) or core-penumbra mismatch ratio (MMR≤1.4) thresholds resulted in losses of health (median ΔQALYs for ICV≥110 mL: -3.3 (IQR: -5.9 to -1.1), for MMR≤1.4: 0.0 (IQR: -1.3 to 0.0)) with median ΔCosts for ICV≥110 mL of -€348 966 (IQR: -€712 406 to -€51 158) and for MMR≤1.4 of €266 513 (IQR: €229 403 to €380 110)) per 1000 patients. Sensitivity analyses did not yield any scenarios for CTP-based selection of patients for EVT that were cost-effective for improving health, including patients aged ≥80 years CONCLUSION: In EVT-eligible patients presenting within 6 hours after symptom onset, excluding patients based on CTP parameters was not cost-effective and could potentially harm patients.

Keywords: HEALTH ECONOMICS; IMAGE ANALYSIS; NEURORADIOLOGY; STROKE.

MeSH terms

Aged
Aged, 80 and over
Cost-Benefit Analysis*
Endovascular Procedures* / economics
Endovascular Procedures* / methods
Female
Humans
Ischemic Stroke / diagnostic imaging
Ischemic Stroke / economics
Ischemic Stroke / surgery
Male
Middle Aged
Models, Economic
Netherlands
Patient Selection
Perfusion Imaging
Quality-Adjusted Life Years*
Stroke* / diagnostic imaging
Stroke* / economics
Stroke* / surgery
Thrombectomy* / economics
Thrombectomy* / methods
Tomography, X-Ray Computed / economics