Cost-Effectiveness Study of Initial Imaging Selection in Acute Ischemic Stroke Care.
Cost-Effectiveness Study of Initial Imaging Selection in Acute Ischemic Stroke Care.
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DOI：
10.1016/j.jacr.2020.12.013
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发表时间：
2021-06
期刊：
影响因子：
--
通讯作者：
Sanelli PC
中科院分区：
文献类型：
--
作者：
Martinez G;Katz JM;Pandya A;Wang JJ;Boltyenkov A;Malhotra A;Mushlin AI;Sanelli PC
国家指南建议迅速确定急性缺血性中风(AIS)治疗的候选人，需要及时进行CT和/或MRI的神经成像。CT因其广泛的可获得性和快速的获得性而经常被人们所青睐。尽管MRI的诊断准确率更高，但它通常涉及复杂的工作流程，可能会导致治疗时间延误。这项研究的目的是分析在综合卒中中心(CSC)治疗决定之前，对于最后已知到达时间为0-24小时的前循环中出现疑似AIS的患者，影像利用率对预后的影响。根据美国心脏协会对AIS护理途径的建议，从医疗保健角度开发决策模拟模型，以比较初始成像策略：(A)STEPWISE-CT：呈现时的NCCT；仅在特定患者(初始成像不包括出血和广泛缺血)中的CTA±CTP用于机械血栓切除术(MT)评估；(B)STEPWISE-HEXED：呈现时的NCCT；MRA±MRP仅用于MT评估；(C)STEPWISE-Advanced：呈现时的NCCT+CTA；MR-DWI+MRP仅用于MT评估，(D)综合CT：表现时的NCCT+CTA+CTP，(E)综合-MR：表现时的MR-DWI+MRA+MRP。模型参数用循证数据定义。进行成本-效果和敏感性分析。成本-效果分析表明，综合CT和综合MR的寿命质量调整寿命年(QALY)最高(分别为4.81和4.82)。然而，与Complete-CT相比，Complete-MR的增量成本效益比为233,000美元/QALY。分步-CT、分步-混合和分步-高级策略占主导地位，与全面-CT相比，其QALY更低，成本更高。在演示时进行全面CT扫描是CSCS最具成本效益的初始成像策略。对于怀疑为前循环急性缺血性卒中的患者，在综合卒中中心最后已知到达时间为0-24小时时，在首次出现时进行全面CT(NCCT+CTA+CTP)比全面-MR和逐步方法更具成本效益。
National guidelines recommend prompt identification of candidates for acute ischemic stroke (AIS) treatment, requiring timely neuroimaging with CT and/or MRI. CT is often preferred because of its widespread availability and rapid acquisition. Despite higher diagnostic accuracy of MRI, it commonly involves complex workflows that could potentially cause treatment time-delays. The purpose of this study was to analyze the impact on outcomes of imaging utilization prior to treatment decisions, at comprehensive stroke centers (CSC) for patients presenting with suspected AIS in the anterior circulation with last-known-well-to-arrival time 0–24 hours. Decision-simulation model based on the American Heart Association’s recommendations for AIS-care pathways was developed from a healthcare perspective to compare initial imaging strategies: (a) Stepwise-CT: NCCT at time of presentation; CTA±CTP only in select patients (initial imaging exclude hemorrhage and extensive-ischemia) for mechanical thrombectomy (MT) evaluation, (b) Stepwise-Hybrid: NCCT at time of presentation; MRA±MRP only for MT evaluation, (c) Stepwise-Advanced: NCCT+CTA at presentation; MR-DWI+MRP only for MT evaluation, (d) Comprehensive-CT: NCCT+CTA+CTP at time of presentation, (e) Comprehensive-MR: MR-DWI+MRA+MRP at time of presentation. Model parameters were defined with evidence-based data. Cost-effectiveness and sensitivity analyses were performed. The cost-effectiveness analyses revealed that Comprehensive-CT and Comprehensive-MR yield highest lifetime quality-adjusted life-years (QALYs) (4.81 and 4.82, respectively). However, the incremental cost-effectiveness ratio of Comprehensive-MR is $233,000/QALY compared to Comprehensive-CT. Stepwise-CT, Stepwise-Hybrid, and Stepwise-Advanced strategies are dominated yielding lower QALYs and higher costs compared to Comprehensive-CT. Performing Comprehensive-CT at presentation is the most cost-effective initial imaging strategy at CSCs. Performing Comprehensive-CT (NCCT+CTA+CTP) at initial presentation in patients presenting with suspected acute ischemic stroke in the anterior circulation with last-known-well-to-arrival time 0–24 hours at comprehensive stroke centers is cost-effective compared to Comprehensive-MR and stepwise approaches.
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影响因子：
24
作者：
Anderson, Jeffrey L.;Heidenreich, Paul A.;Shaw, Leslee J.
通讯作者：
Shaw, Leslee J.
影响因子：
8.3
作者：
Chaisinanunkul N;Adeoye O;Lewis RJ;Grotta JC;Broderick J;Jovin TG;Nogueira RG;Elm JJ;Graves T;Berry S;Lees KR;Barreto AD;Saver JL;DAWN Trial and MOST Trial Steering Committees;Additional contributors from DAWN Trial Steering Committee
通讯作者：
Additional contributors from DAWN Trial Steering Committee
影响因子：
5.4
作者：
Apoil M;Turc G;Tisserand M;Calvet D;Naggara O;Domigo V;Baron JC;Oppenheim C;Touzé E
通讯作者：
Touzé E
影响因子：
8.3
作者：
Broderick JP;Adeoye O;Elm J
通讯作者：
Elm J
影响因子：
4.5
作者：
Earnshaw, Stephanie R.;Wilson, Michele;Joshi, Ashish V.
通讯作者：
Joshi, Ashish V.