Cost-effectiveness of improvement strategies for reperfusion treatments in acute ischemic stroke: a systematic review

(2023) 23:315 Nguyen et al. BMC Health Services Research https://doi.org/10.1186/s12913-023-09310-0 BMC Health Services Research Open Access RESEARCH Cost‑effectiveness of improvement strategies for reperfusion treatments in acute ischemic stroke: a systematic review Chi Phuong Nguyen1,2,3*†, Willemijn J. Maas2,4†, Durk‑Jouke van der Zee1,2, Maarten Uyttenboogaart4,5, Erik Buskens1,2, Maarten M. H. Lahr2 and on behalf of the CONTRAST consortium Abstract Background Reducing delays along the acute stroke pathway significantly improves clinical outcomes for acute ischemic stroke patients eligible for reperfusion treatments. The economic impact of different strategies reducing onset to treatment (OTT) is crucial information for stakeholders in acute stroke management. This systematic review aimed to provide an overview on the cost-effectiveness of several strategies to reduce OTT. Methods A comprehensive literature search was conducted in EMBASE, PubMed, and Web of Science until Janu‑ ary 2022. Studies were included if they reported 1/ stroke patients treated with intravenous thrombolysis and/or endovascular thrombectomy, 2/ full economic evaluation, and 3/ strategies to reduce OTT. The Consolidated Health Economic Evaluation Reporting Standards statement was applied to assess the reporting quality. Results Twenty studies met the inclusion criteria, of which thirteen were based on cost-utility analysis with the incre‑ mental cost-effectiveness ratio per quality-adjusted life year gained as the primary outcome. Studies were performed in twelve countries focusing on four main strategies: educational interventions, organizational models, healthcare delivery infrastructure, and workflow improvements. Sixteen studies showed that the strategies concerning educa‑ tional interventions, telemedicine between hospitals, mobile stroke units, and workflow improvements, were costeffective in different settings. The healthcare perspective was predominantly used, and the most common types of models were decision trees, Markov models and simulation models. Overall, fourteen studies were rated as having high reporting quality (79%-94%). Conclusions A wide range of strategies aimed at reducing OTT is cost-effective in acute stroke care treatment. Exist‑ ing pathways and local characteristics need to be taken along in assessing proposed improvements. Keywords Stroke, Time delay, Cost-effectiveness, Systematic review † Chi Phuong Nguyen, and Willemijn J. Maas contributed equally to this work. *Correspondence: Chi Phuong Nguyen Full list of author information is available at the end of the article © The Author(s) 2023. 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The Creative Commons Public Domain Dedication waiver (http://creativeco mmons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Nguyen et al. BMC Health Services Research (2023) 23:315 Background Worldwide, stroke is the second leading cause of death and the most common cause of permanent disability, resulting in huge societal and economic burdens related to long-term care, rehabilitation, and productivity loss [1, 2]. Acute ischemic stroke (AIS) represents the majority of stroke patients, and reperfusion treatments like intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT) have shown to be effective in improving functional outcomes. Both treatments are highly timedependent, with IVT effective up to 4.5 h after symptom onset and EVT within 6 h [3, 4]. For selected patients suspected of a large vessel occlusion (LVO), EVT has shown to be effective even up to 24 h [5]. Importantly, shorter time from onset to treatment (OTT) with IVT or EVT is associated with better functional outcomes [6–8]. Due to the time dependency of reperfusion treatments, multiple strategies or interventions have been proposed to reduce time delays along the acute stroke pathway. Examples include educational interventions to create awareness among citizens to contact emergency services immediately following symptom onset [9], a mobile stroke unit that brings IVT to the patient instead of transporting the patients to the nearest IVT capable facility [9], telemedicine solutions for expert opinion at a distance [10], and workflow improvements including inter-hospital patients transfer, teamwork and feedback on performance [9, 11]. In addition, direct transport of acute stroke patients suspected of LVO from the onset scene to a comprehensive stroke center based on prehospital triage instruments [12] is a promising alternative organizational model, which could decrease the OTT time for patients eligible for EVT [13]. While several strategies have been developed to reduce time to reperfusion treatments, less is known about their cost-effectiveness. As stroke incidence and its burden on society are expected to increase [14], evidence generated by economic evaluations of these strategies will support policymakers, clinicians, and other stakeholders in deciding how to allocate scarce resources whilst optimizing clinical outcomes for patients. Therefore, the aim of this study is to systematically review the cost-effectiveness of strategies directed at reducing time to reperfusion treatments for AIS patients. Methods Search strategy and study selection This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [15]. The search strategy was constructed by the first two authors (C.P.N. and W.J.M). Three electronic databases (EMBASE, Page 2 of 16 MEDLINE/ Pubmed, and Web of Science) were searched to identify relevant articles published between January 2010 to January 2022. The search strategy was based on the PICOS format: The population (P) were ‘stroke’ patients, the intervention (I) ‘EVT or IVT’ and ‘reducing time-to-treatment’, and the outcome (O) was ‘incremental cost-effectiveness ratio’ (ICER). Comparators (C) and study design (S) were not included to maximize records retrieved. Our eligibility criteria were: (1) stroke patients treated with IVT and/or EVT, (2) full economic evaluation was (...truncated)