Any Delay in Stroke Thrombectomy Hurts Recovery, Ups Cost

Marlene Busko

October 25, 2018

MONTREAL — For patients with acute ischemic stroke who qualify for endovascular thrombectomy, every hour of delay in undergoing the procedure reduces quality of life and substantially decreases the economic value of healthcare, researchers report.

Within the first 6 hours of symptom onset, on average, every hour of delay in starting the thrombectomy procedure was associated with a loss of 0.64 quality-adjusted life years (QALYs), representing a loss of 7.7 months of disability-free life.

In addition, every hour of delay reduced the economic value of care (ie, the net monetary benefit) of the thrombectomy procedure by $63,558 (in 2017 US dollars).

These findings are based on an analysis of data from the HERMES collaboration of pooled patient-level data from seven trials (MR CLEAN, ESCAPE, REVASCAT, SWIFT PRIME, EXTEND IA, THRACE, and PISTE), which were published in 2015 and 2016. In those trials, eligible patients who had experienced acute ischemic stroke caused by occlusion of the proximal anterior circulation were randomly assigned to receive endovascular thrombectomy plus thrombolysis or thrombolysis alone.

Wolfgang G. Kunz, MD, an assistant professor of radiology at Ludwig Maximilian University in Munich, Germany, who conducted the study during a research fellowship at the University of Calgary, in Canada, presented these results here at the 11th World Stroke Congress (WSC) 2018.

"One thing that is striking," he told | Medscape Cardiology, "is that delays of even a minute can have a notable impact if you project this over a lifetime.

"We know that the treatment effect decreases over time, and we know this from outcomes that are typically measured at 90 days.

"But if you project the effects over many years, a minute delay in treatment — for example, you try to call someone, and the person is not responding — that deducts patient lifetime by 4 days, on average.

"It's almost a linear relationship, meaning that if you have a 10-minute delay, then it's 40 days."

The study showed not only that efforts to reduce delays in thrombectomy procedures improve quality life, he said, but also that, by reducing delays, "investments in improved prehospital triage and in-hospital workflow are likely to be highly cost-effective."

Impact of Delayed Thrombectomy on Outcomes, Costs

"The benefit that endovascular therapy offers to stroke patients with large-vessel occlusion is highly time dependent," Kunz said.

Previous studies in the United States, the United Kingdom, Australia, and Sweden have reported that thrombectomy is expected to save costs.

The researchers aimed to investigate the impact of delays in thrombectomy on long-term quality of life and healthcare costs, using data from the HERMES collaboration of trials conducted in Canada, the United States, the United Kingdom, the Netherlands, and Australia.

They restricted the analysis to data from patients who had been randomly assigned to receive thrombectomy. These patients represent a contemporary thrombectomy population, said Kunz.

For their model, the investigators assumed that a thrombectomy procedure costs about US$15,000. Costs were determined on the basis of the most recent data from the SWIFT PRIME trial.

They determined that healthcare costs (such as nursing-home care, physician visits, and medication) increased almost exponentially from $10,500/year for a patient with a 90-day modified Rankin scale (mRS) score of 0 (excellent quality of life) to $64,000/year for a patient with a 90-day mRS score of 5 (very low quality of life).

Very significant delays of on average 2 hours are typically associated with "drip 'n ship" care, as opposed to "mothership" care, said Kunz.

A "drip 'n ship" case is one in which a patient with a stroke is given intravenous thrombolysis, is put in an ambulance, and is taken to a larger center. In the "mothership" scenario, the patient is taken directly to a large stroke center and receives thrombectomy a lot sooner.

"Faster treatment results in better outcomes and better quality of life," said Michael Hill, MD, Department of Clinical Neurosciences, the University of Calgary, in a statement. Dr Hill is one of the study authors.

"The speed of treatment is one of the modifiable factors that will improve outcomes and reduce cost at both the system and the hospital level," Hill said.

The HERMES collaboration is supported by an unrestricted grant to the University of Calgary. Dr Kunz has disclosed no relevant financial relationships.

11th World Stroke Congress (WSC) 2018. Presented October 18, 2018.

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