Cost-Effectiveness Study of Initial Imaging Selection in Acute Ischemic Stroke Care |
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| Affiliation: | 1. Siemens Healthineers, Malvern, Pennsylvania;2. Department of Radiology, Northwell Health, Manhasset, New York;3. Feinstein Institutes for Medical Research, Manhasset, New York;4. Chief, Neurovascular Services and Director Comprehensive Stroke Center at North Shore University Hospital, Department of Neurology, North Shore University Hospital, Manhasset, New York;5. Director of Neuroendovascular surgery, Neurology Service Line, Northwell Health, Manhasset, New York;6. Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York;7. T. H. Trustee (unpaid), Society for Medical Decision Making, T.H Chan School of Public Health, Harvard University, Boston, Massachusetts;8. Radiology & Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut;9. Healthcare Policy and Research, Weill Cornell Medical College, New York, New York;10. Vice Chair of Research, Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York;1. Professor of Emergency Medicine; Chief, Section of Emergency Ultrasound;2. Director of Pediatric Neuroradiology, Department of Radiology, Children''s Healthcare of Atlanta, Director for Quality, Department of Radiology, Children''s Healthcare of Atlanta, Associate Professor, Emory University School of Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia;3. Medical Director Sutter Physicians Network, Medical Director Quality and Safety, Neuroradiologist, Sutter Medical Group—Sutter Medical Network, Sacramento, California;4. Hackensack Radiology Group; Board member, Hackensack Meridian Health Partners Clinically Integrated Network; Finance Chair, Hackensack Meridian Health Partners Clinically Integrated Network; Hackensack Radiology Group, Hackensack, New Jersey;5. American College of Radiology, Reston, Virginia;6. Chief, Section of Administration and Associate Professor, Department of Emergency Medicine at Yale University School of Medicine and Scientist at the Yale New Haven Hospital Center for Outcomes Research and Evaluation, New Haven, Connecticut;1. Liberty Hospital Women''s Imaging, Department of Radiology, Liberty Hospital/Alliance Radiology, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri;2. Department of Radiology, AdventHealth Medical Group, Orlando, Florida;3. Quantum Radiology, Atlanta, Georgia;4. Divisional Wellness Lead, Division of Diagnostic Imaging, Department of Radiology, University of Texas MD Anderson Cancer Center, Houston, Texas;1. Envision Imaging Medical Director and Recruitment Chair, Radiology Associates of North Texas, Fort Worth, Texas; Assistant Professor, Clinical Sciences, Texas Christian University and University of North Texas Health Science Center School of Medicine, Fort Worth, Texas;2. Division of Radiology and Biomedical Imaging, College of Human Medicine, Michigan State University, Grand Rapids, Michigan;3. Vice President of Clinical Operations and Quality Chair, Advanced Radiology Services, Grand Rapids, Michigan;1. Professor and Vice Chair-Faculty Affairs, Department of Radiology, University of Pittsburgh and UPMC International. Chief Medical Officer, The Radiology Leadership Institute and Chair of the Commission on Leadership and Practice Development of the American College of Radiology, Reston, Virginia;2. Chair of the Executive Committee, and Chair of Clinical Operations, Triad Radiology Associates, Winston-Salem, North Carolina |
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| Abstract: | PurposeNational 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 before treatment decisions at comprehensive stroke centers for patients presenting with suspected AIS in the anterior circulation with last-known-well-to-arrival time 0 to 24 hours.MethodsA decision simulation model based on the American Heart Association’s recommendations for AIS care pathways was developed from a health care perspective to compare initial imaging strategies: (1) stepwise-CT: noncontrast CT (NCCT) at the time of presentation, with CT angiography (CTA) ± CT perfusion (CTP) only in select patients (initial imaging to exclude hemorrhage and extensive ischemia) for mechanical thrombectomy (MT) evaluation; (2) stepwise-hybrid: NCCT at the time of presentation, with MR angiography (MRA) ± MR perfusion (MRP) only for MT evaluation; (3) stepwise-advanced: NCCT + CTA at presentation, with MR diffusion-weighted imaging (MR DWI) + MRP only for MT evaluation; (4) comprehensive-CT: NCCT + CTA + CTP at the time of presentation; and (5) comprehensive-MR: MR DWI + MRA + MRP at the time of presentation. Model parameters were defined using evidence-based data. Cost-effectiveness and sensitivity analyses were performed.ResultsThe cost-effectiveness analyses revealed that comprehensive-CT and comprehensive-MR yield the 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 with comprehensive-CT. Stepwise-CT, stepwise-hybrid, and stepwise-advanced strategies are dominated, yielding lower QALYs and higher costs compared with comprehensive-CT.ConclusionsPerforming comprehensive-CT at presentation is the most cost-effective initial imaging strategy at comprehensive stroke centers. |
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| Keywords: | Cost-effectiveness advanced neuroimaging acute ischemic stroke imaging |
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