Integrating CT angiography (CTA) into the routine clinical evaluation of patients with an acute minor stroke has the potential to lower costs and improve patient outcomes compared with standard medical management, according to a study published online January 14 in Radiology.
The researchers, led by Dr. Ajay Malhotra from Yale School of Medicine, used computational modeling to assess the cost-effectiveness and potential clinical benefits of using CTA in the initial evaluation of patients with an acute minor stroke.
Current stroke management guidelines recommend surgical intervention only for stroke patients determined to have a score greater than 6 on the U.S. National Institutes of Health Stroke Scale (NIHSS). Most of these patients undergo a vascular imaging exam such as CTA to confirm the presence of a large-vessel occlusion and their need for thrombectomy.
Conversely, clinicians do not routinely acquire vascular imaging for patients with milder symptoms (NIHSS score of 6 or less) in favor of medical management -- occasionally overlooking these patients' need for surgery, the authors noted. Recent studies have reported, however, that as many as 8.7% to 30% of patients with a minor stroke were found to have a large-vessel occlusion requiring thrombectomy.
Malhotra and colleagues thus set out to determine whether minor stroke patients might benefit from undergoing CTA despite presenting with milder symptoms, and whether the integration of CTA into minor stroke management might be cost-effective.
They performed this analysis by using a Markov decision model to simulate three different management approaches for patients with a minor stroke:
- Medical management (i.e., clot-busting drugs) without vascular imaging
- Medical management with CTA, plus rescue thrombectomy for those with neurological deterioration
- CTA immediately followed by thrombectomy for eligible patients
The decision model assumed a baseline age of 65 years for the patients and an average cost of $596 for a CTA exam and $16,783 for immediate thrombectomy.
After analyzing the simulations, the decision model projected that CTA plus immediate thrombectomy would be the most cost-effective strategy and lead to the best patient outcomes. The model estimated that this approach would cost less and lead to 0.39 more quality-adjusted life years (QALYs), or 142 days of good health, per patient, compared with medical management without vascular imaging.
| Comparison of management strategies for acute minor stroke | |||
| No imaging + medical management | CT angiography + medical management | CT angiography + thrombectomy | |
| QALYs gained | 8.87 | 9.09 | 9.26 |
| Total cost per patient | $358,295 | $346,500 | $346,007 |
Furthermore, the net monetary benefit of performing CTA was greater for younger patients than older patients, the researchers found. For example, the net monetary benefit was $68,950 when using the CTA plus thrombectomy approach for 55-year-old patients, compared with only $20,931 for 85-year-old patients.
"Our study findings emphasize the utility of early CT angiographic detection of large-vessel occlusion to improve health outcomes and reduce overall costs," the authors concluded. "The costs incurred in faster and better selection of patients for mechanical thrombectomy must be seen in the overall context of cost savings from better outcomes."
