Cost-Effectiveness Study of Initial Imaging Selection in Acute Ischemic Stroke Care

Martinez, Gabriela; Katz, Jeffrey M.; Pandya, Ankur; Wang, Jason; Boltyenkov, Artem; Malhotra, Ajay; Mushlin, Alvin I.; Sanelli, Pina C.

doi:10.1016/j.jacr.2020.12.013

Cited by 33 publications

(47 citation statements)

References 62 publications

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“…Advanced CTAP imaging in acute ischemic stroke patients was shown to be cost-effective in prior work (17). In that study, the cost-effectiveness analysis was performed from a health care perspective.…”

Section: Introductionmentioning

confidence: 99%

Cost-Consequence Analysis of Advanced Imaging in Acute Ischemic Stroke Care

et al. 2021

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Introduction: The purpose of this study was to illustrate the potential costs and health consequences of implementing advanced CT angiography and perfusion (CTAP) as the initial imaging in patients presenting with acute ischemic stroke (AIS) symptoms at a comprehensive stroke center (CSC).Methods: A decision-simulation model based on the American Heart Association's recommendations for AIS care pathways was developed to assess imaging strategies for a 5-year period from the institutional perspective. The following strategies were compared: (1) advanced CTAP imaging: NCCT + CTA + CT perfusion at the time of presentation; (2) standard-of-care: non-contrast CT (NCCT) at the time of presentation, with CT angiography (CTA) ± CT perfusion only in select patients (initial imaging to exclude hemorrhage and extensive ischemia) for mechanical thrombectomy (MT) evaluation. Model parameters were defined with evidence-based data. Cost-consequence and sensitivity analyses were performed. The modified Rankin Scale (mRS) at 90 days was used as the outcome measure.Results: The decision-simulation modeling revealed that adoption of the advanced CTAP imaging increased per-patient imaging costs by 1.19% ($9.28/$779.72), increased per-patient treatment costs by 33.25% ($729.96/$2,195.24), and decreased other per-patient acute care costs by 0.7% (–$114.12/$16,285.85). The large increase in treatment costs was caused by higher proportion of patients being treated. However, improved outcomes lowered the other per-patient acute care costs. Over the five-year period, advanced CTAP imaging led to 1.63% (66/4,040) more patients with good outcomes (90-day mRS 0-2), 2.23% (66/2,960) fewer patients with poor outcomes (90-day mRS 3-5), and no change in mortality (90-day mRS 6). Our CT equipment utilization analysis showed that the demand for CT equipment in terms of scanner time (minutes) was 24% lower in the advanced CTAP imaging strategy compared to the standard-of-care strategy. The number of EVT procedures performed at the CSC may increase by 50%.Conclusions: Our study reveals that adoption of advanced CTAP imaging at presentation increases the demand for treatment of acute ischemic stroke patients as more patients are diagnosed within the treatment time window compared to standard-of-care imaging. Advanced imaging also leads to more patients with good functional outcomes and fewer patients with dependent functional status.

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Section: Introductionmentioning

confidence: 99%

Cost-Consequence Analysis of Advanced Imaging in Acute Ischemic Stroke Care

et al. 2021

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“…Both intravenous thrombolytic administration and delayed onset-to-arrival times were independently associated with rescanning imaging time delays, while implementing protocols to obtain NCCT and CTAP simultaneously was associated with avoiding the observed time delays associated with rescanning. Considering that this imaging paradigm has been shown to be the most cost-effective imaging strategy for patients with acute ischemic stroke, 38 the current study provides further support for simultaneous NCCT and CTA 6 CTP imaging to minimize time delays to treatment.…”

Section: Discussionmentioning

confidence: 66%

Rescan Time Delays in Ischemic Stroke Imaging: A Retrospective Observation and Analysis of Causes and Clinical Impact

Katz

Wang

Boltyenkov

et al. 2021

AJNR Am J Neuroradiol

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BACKGROUND AND PURPOSE: Delays to reperfusion negatively impact outcomes of patients with ischemic stroke, yet current guidelines recommend selective sequential imaging for thrombectomy candidates. We aimed to quantify and analyze time delays associated with rescanning in sequential acute stroke imaging. MATERIALS AND METHODS:This was a retrospective cohort study of consecutive patients with acute ischemic stroke who underwent imaging for treatment decision-making from January 1, 2017, to June 30, 2020. Rescan time delay was defined as $10-minute difference between initial NCCT and CTA 6 CTP. Mean rescan time delays in comprehensive and primary stroke centers were compared. Bivariate and multivariable regression analyses assessed clinical and imaging factors associated with rescanning time delays and early outcomes.RESULTS: A total of 588 patients with acute ischemic were included in statistical analyses. Rescanning occurred in 27.9% (164/588 patients), with a mean time delay of 53.7 (SD, 43.4) minutes. For patients presenting at primary compared with comprehensive stroke centers, rescan time delays were more common (59.6% versus 11.8%, P , .001), with longer delays (65.4 [SD, 45.4] minutes versus 23.6 [SD, 14.0] minutes, P , .001). Independent predictors of rescan time delays included primary stroke center presentation, intravenous thrombolysis administration, black race, admission NIHSS $10, baseline independent ambulation, and onset-tocomprehensive stroke center arrival in $6 hours. Protocols for early simultaneous comprehensive CT (NCCT 1 CTA 1 CTP) were associated with lower odds of time delays (OR = 0.34; 95% CI, 0.21-0.55). Rescanning was associated with lower odds of home discharge (OR ¼ 0.53; 95% CI, 0.30-0.95). CONCLUSIONS:A sequential approach to CT-based imaging may be significantly associated with prolonged acute stroke evaluations. Adoption of early simultaneous comprehensive CT could minimize treatment delays and improve outcomes.

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“…Hopyan et al found that multimodal CT, including NCCT, CTA, and CTP, was about 12% more sensitive than NCCT and CTA and about 18% more sensitive than NCCT alone in stroke determination [ 17 ]. Regarding cost-effectiveness, Martinez et al found that comprehensive CT (NCCT, CTA, and CTP at time of presentation) and comprehensive MR (MRI-DWI, MRA, and MRP) had the greatest lifetime quality-adjusted life-years (QALYs) at 4.81 and 4.82, respectively [ 18 ]. When compared with comprehensive CT, the incremental cost-effectiveness ratio of comprehensive MR was $233,000/QALY.…”

Section: Discussionmentioning

confidence: 99%

“…Regarding costeffectiveness,Martinez et al found that comprehensive CT (NCCT, CTA, and CTP at time of presentation) and comprehensive MR (MRI-DWI, MRA, and MRP) had the greatest lifetime quality-adjusted life-years (QALYs) at 4.81 and 4.82, respectively[18]. When compared with comprehensive CT, the incremental costeffectiveness ratio of comprehensive MR was $233,000/QALY.…”

mentioning

confidence: 99%

Utilization of Cerebral Blood Flow Study With Computed Tomography for Subdural Hematoma Management

Amidon¹,

Ordookhanian²,

Vartanian³

et al. 2021

Cureus

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Stroke is among the leading causes of death in the United States, and with our aging population, it will remain a pertinent obstacle in the acute setting. While the field of neuroradiology has advanced tremendously over the years, particularly in improving what we can visualize and quantify, the phrase "time is brain" yet dominates acute stroke management. Optimizing diagnostic protocols for suspected stroke requires a careful balance of data acquisition and speed, as well as taking into account available resources. We present a case of a middle-aged patient with notable risk factors for stroke presenting to the emergency department with altered mental status and suspected stroke. Radiography revealed a large subacute subdural hematoma (SDH) with a mild mass effect on the surface of the brain. The evaluation was supplemented by a computed tomography (CT) and perfusion cerebral blood flow (CBF) study indicating cortical ischemia with penumbra from the SDH compression. SDH evacuation was successfully performed, and patient recovery was achieved within the intensive care unit (ICU). Rapid data acquisition via CBF with CT imaging is crucial for guiding treatment decisions for SDHs. While protocols for ischemic stroke are well-established, SDH protocols are not studied. Thus, we discuss the value of a multimodal CT imaging approach, including CBF studies, in SDH evaluation.

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Cost-Effectiveness Study of Initial Imaging Selection in Acute Ischemic Stroke Care

Cited by 33 publications

References 62 publications

Cost-Consequence Analysis of Advanced Imaging in Acute Ischemic Stroke Care

Cost-Consequence Analysis of Advanced Imaging in Acute Ischemic Stroke Care

Rescan Time Delays in Ischemic Stroke Imaging: A Retrospective Observation and Analysis of Causes and Clinical Impact

Utilization of Cerebral Blood Flow Study With Computed Tomography for Subdural Hematoma Management

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