Cost-Effectiveness of Smoking Cessation Interventions in Patients With Ischemic Stroke and Transient Ischemic Attack

Abstract

BACKGROUND: Smoking cessation rates after stroke and transient ischemic attack are suboptimal, and smoking cessation interventions are underutilized. We performed a cost-effectiveness analysis of smoking cessation interventions in this population. METHODS: We constructed a decision tree and used Markov models that aimed to assess the cost-effectiveness of varenicline, any pharmacotherapy with intensive counseling, and monetary incentives, compared with brief counseling alone in the secondary stroke prevention setting. Payer and societal costs of interventions and outcomes were modeled. The outcomes were recurrent stroke, myocardial infarction, and death using a lifetime horizon. Estimates and variance for the base case (35% cessation), costs and effectiveness of interventions, and outcome rates were imputed from the stroke literature. We calculated incremental cost-effectiveness ratios and incremental net monetary benefits. An intervention was considered cost-effective if the incremental cost-effectiveness ratio was less than the willingness-to-pay threshold of $100 000 per quality-adjusted life-year (QALY) or when the incremental net monetary benefit was positive. Probabilistic Monte Carlo simulations modeled the impact of parameter uncertainty. RESULTS: From the payer perspective, varenicline and pharmacotherapy with intensive counseling were associated with more QALYs (0.67 and 1.00, respectively) at less total lifetime costs compared with brief counseling alone. Monetary incentives were associated with 0.71 more QALYs at an additional cost of $120 compared with brief counseling alone, yielding an incremental cost-effectiveness ratio of $168/QALY. From the societal perspective, all 3 interventions provided more QALYs at less total costs compared with brief counseling alone. In 10 000 Monte Carlo simulations, all 3 smoking cessation interventions were cost-effective in >89% of runs. CONCLUSIONS: For secondary stroke prevention, it is cost-effective and potentially cost-saving to deliver smoking cessation therapy beyond brief counseling alone.

Smoking cessation interventions are cost-effective in people affected by stroke

“…From the societal perspective, the three interventions were more cost-effective than brief counselling alone. Furthermore, the Monte Carlo method of multiple probability simulation to predict a long-term model found that the interventions were cost-effective in >89% of the runs 4…”

“…Decision tree models combined with Markov models are employed. Payer and societal costs of interventions and outcomes are also modelled 4. The Markov state transition model was constructed using a cycle length of 5 years, after which patients entered the Markov model through different health states: they could remain in the same health state, experience another stroke, suffer a myocardial infarction or die, and they progressed through it until death.…”

“…The cost of interventions and events was calculated in dollars, and the effectiveness of interventions in quality-adjusted life-years (QALYs). The incremental cost-effectiveness ratio and the incremental net monetary benefit were used to evaluate cost-effectiveness 4…”

“…Clinical practice often fails to go beyond brief counselling to encourage people to stop smoking despite numerous studies proposing more effective measures. Wechsler et al 4 contribute to the wealth of evidence that more needs to be done undertaking a study to determine the cost effectiveness of three smoking cessation interventions (varenicline, any pharmacotherapy with intensive counselling and monetary incentives) in smokers who have suffered a stroke.…”

Effect of smoking cessation medications on intracranial aneurysm risk: A Mendelian randomization study

“…The effectiveness of these medications for smoking cessation is well established 11 , 12 . In the secondary prevention of stroke, pharmacotherapy with counseling was associated with more cost-effectiveness than brief counseling alone 13 . Moreover, the number of incidentally discovered IAs is increasing due to imaging detection technologies’ increasing availability and quality 5 .…”