Table 2. Expected Values of Cost-effectiveness of Mechanical Thrombectomy With Standard Medical Care vs Standard Medical Care Alone per Patient with Acute Ischemic Stroke Stratified by Subgroup in the Base Case.
| Subgroups according to criteria | DAWN | DEFUSE 3 | ||||||
|---|---|---|---|---|---|---|---|---|
| Incremental costs (95% CI), $ | Incremental QALY (95% CI) | ICER ($/QALY) | Incremental NMB (95% CI), $a | Incremental costs (95% CI), $ | Incremental QALY (95% CI) | ICER ($/QALY) | NMB (95% CI), $a | |
| Time from stroke onset, hb | ||||||||
| 6 to ≤24, ie, full DAWN group | 1380 (−62 510 to 52 675) | 2.085 (1.283 to 3.239) | 662 | 207 125 (121 419 to 328 519) | NA | NA | NA | NA |
| 6 to ≤12 | −24 340 (−109 596 to 51 786) | 1.968 (0.793 to 3.403) | −12 369 (dominant) | 221 130 (87 319 to 389 968) | NA | NA | NA | NA |
| >12 | 23 446 (−46 225 to 85 923) | 2.244 (1.259 to 3.468) | 10 063 | 200 996 (88 012 to 340 344) | NA | NA | NA | NA |
| 6 to ≤16, ie, full DEFUSE 3 group | NA | NA | NA | NA | 25 098 (−35 502 to 76 710) | 1.809 (0.972 to 2.847) | 13 877 | 155 767 (63 411 to 277 583) |
| 6 to ≤11 | NA | NA | NA | NA | 8511 (−62 240 to 71 472) | 1.086 (−0.036 to 2.387) | 7838 | 100 076 (−26 195 to 247 802) |
| >11 | NA | NA | NA | NA | 49 256 (−32 490 to 128 731) | 2.599 (1.453 to 4.016) | 18 951 | 210 654 (85 444 to 366 389) |
| Age, y | ||||||||
| ≥80 | 14 451 (−38 704 to 58 813) | 0.677 (−0.110 to 1.666) | 19 994 | 57 825 (−23 371 to 153 740) | 10 957 (−45 627 to 59 194) | 0.504 (−0.256 to 1.376) | 21 733 | 39 461 (−48 722 to 198 257) |
| <80 | −28 675 (−106 405 to 36 384) | 2.062 (1.043 to 3.344) | −13 908 (dominant) | 234 857 (114 005 to 388 901) | 29 235 (−40 244 to 89 664) | 1.930 (0.906 to 3.214) | 15 151 | 163 727 (45 800 to 314 595) |
| NIHSS score | ||||||||
| 10 to <17 | −14 030 (−91 236 to 47 696) | 2.4972 (1.331 to 3.932) | −5675 (dominant) | 261 266 (129 596 to 424 608) | NA | NA | NA | NA |
| ≥17 | 18 125 (−62 348 to 81 368) | 1.427 (0.472 to 2.581) | 12 698 | 124 620 (24 100 to 258 074) | NA | NA | NA | NA |
| <16 | NA | NA | NA | NA | 5473 (−62 186 to 61 355) | 1.540 (0.363 to 2.871) | 3555 | 148 488 (10 890 to 304 083) |
| ≥16 | NA | NA | NA | NA | 56 866 (−21 042 to 132 049) | 1.334 (0.256 to 2.443) | 42 635 | 76 514 (−42 001 to 196 691) |
| Mode of presentation | ||||||||
| Wake up | −9275 (−88 519 to 58 881) | 2.241 (1.172 to 3.549) | −4139 (dominant) | 233 341 (119 290 to 386 019) | 10 318 (−81 241 to 82 859) | 1.949 (0.891 to 3.355) | 5294 | 184 593 (73 893 to 338 877) |
| Witnessed | 13 005 (−117 373 to 130 783) | 2.921 (0.786 to 5.218) | 4453 | 279 067 (36 291 to 537 288) | 21 061 (−57 981 to 93 981) | 2.143 (0.721 to 3.738) | 9828 | 193 230 (24 396 to 377 276) |
| Unwitnessed | 9522 (−86 403 to 95 731) | 1.507 (0.094 to 3.044) | 6319 | 141 170 (−12 913 to 312 454) | NA | NA | NA | NA |
| Clinical infarct mismatchc | ||||||||
| Group A | 14 451 (−35 197 to 56 392) | 0.723 (−0.022 to 1.623) | 19 994 | 57 825 (−20 168 to 153 024) | NA | NA | NA | NA |
| Group B | −28 621 (−106 109 to 37 741) | 1.988 (0.95 to 3.348) | −14 397 (dominant) | 227 428 (106 248 to 387 532) | NA | NA | NA | NA |
| Group C | −22 379 (−214 699 to 145 798) | 1.380 (−1.639 to 4.234) | −16 211 (dominant) | 160 340 (−153 172 to 480 987) | NA | NA | NA | NA |
| Occlusion location | ||||||||
| ICA | 22 813 (−80 872 to 118 427) | 1.930 (0.149 to 4.018) | 11 819 | 170 202 (−19 862 to 383 228) | NA | NA | NA | NA |
| MCA M1 | 804 (−66 161 to 56 198) | 1.982 (1.097 to 3.162) | 406 | 197 363 (91 793– 330 057) | NA | NA | NA | NA |
| MCA M2 | −49 769 (−283 278 to 189 815) | 1.782 (−3.319 to 6.476) | −27 934 (dominant) | 227 933 (−303 565 to 711 711) | ||||
| Time from symptom first observed, hd | ||||||||
| ≤6 | 9340 (−61 634 to 67 879) | 2.006 (1.083 to 3.245) | 4657 | 191 216 (81 783 to 334 672) | NA | NA | NA | NA |
| >6 | −18 671 (−115 297 to 60 878) | 2.367 (1.01 to 3.96) | −7888 (dominant) | 255 379 (104 956 to 429 484) | NA | NA | NA | NA |
| Trial eligibility criteria | ||||||||
| Not DAWN eligible | NA | NA | NA | NA | 46 853 (−34 763 to 119 181) | 1.972 (0.577 to 3.602) | 23 763 | 150 317 (−4487 to 326 266) |
| DAWN eligible | NA | NA | NA | NA | 11 420 (−59 575 to 68 490) | 1.589 (0.622 to 2.778) | 7186 | 147 497 (36 712 to 282 645) |
Abbreviations: ICA, internal carotid artery; ICER, incremental cost-effectiveness ratio; MCA, middle cerebral artery; NA, not applicable; NIHSS, National Institutes of Health Stroke Scale; NMB, net monetary benefit; QALY, quality-adjusted life-year.
NMB set at a willingness-to-pay threshold of $100 000/QALY.
Time from stroke onset to randomization. Data from the DAWN trial were used to estimate the cost-effectiveness of mechanical thrombectomy with standard medical care vs standard medical care alone. These results are presented for patients treated between 6 and 24 hours, between 6 and 12 hours, and between 12 and 24 hours from stroke onset. Data from the DEFUSE 3 trial were used to estimate the cost-effectiveness of mechanical thrombectomy with standard medical care vs standard medical care alone for patients treated between 6 and 16 hours, between 6 and 11 hours, and between 11 and 16 hours from stroke onset. The same logic applies to the other subgroups per trial defined according to the different criteria presented in the first column.
Clinical infarct mismatch indicates a mismatch between the severity of the clinical deficit and the infarct volume defined according to the following groups: A, aged 80 years and older, NIHSS score of at least 10, and infarct volume of less than 21 mL; B, younger than 80 years, NIHSS score of at least 10, and infarct volume of less than 31 mL; C, younger than 80 years, NIHSS score of at least 20, and infarct volume between 31 and 51 mL.
Time of symptom first observed to randomization.