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OBJECTIVE Clinical outcomes following endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) treatment are highly time sensitive. Remote robotic (RR)–EVT systems may be capable of mitigating time delays in patient transfer from a primary stroke center (PSC) to a comprehensive/thrombectomy-capable stroke center. However, health economic evidence is needed to assess the costs and benefits of an RR-EVT system. Therefore, the authors of this study aimed to determine whether performing RR-EVT in suspected AIS patients at a PSC as opposed to standard of care might translate to cost-effectiveness over a lifetime. METHODS An economic evaluation study was performed from a US healthcare perspective, combining decision analysis and Markov modeling methods over a lifetime horizon to evaluate the cost-effectiveness of RR-EVT in suspected AIS patients at a PSC compared to the standard-of-care approach. Total expected costs and quality-adjusted life-years (QALYs) were estimated. RESULTS In the cost-effectiveness analysis, RR-EVT yielded greater effectiveness per patient (4.05 vs 3.88 QALYs) and lower costs (US$321,269 vs US$321,397) than the standard-of-care approach. Owing to these lower costs and greater health benefits, RR-EVT was the dominant cost-effective strategy. After initiation of an RR-EVT system, the average costs per year were similar (or slightly reduced), according to this simulation. Sensitivity analyses revealed that RR-EVT remains cost-effective in a wide variety of time delays and cost assumptions. In a one-way sensitivity analysis, RR-EVT remained the most cost-effective strategy when time delays were greater than 2.5 minutes, its complication rate did not exceed 37%, and costs were lower than $54,081. When the cost of the RR-EVT strategy ranged from $19,340 to $54,081 and its complication rate varied from 15% to 37%, the RR-EVT strategy remained the most cost-effective throughout the two ranges. RR-EVT was also the most cost-effective strategy even when its cost doubled (to approximately $40,000) and time delays exceeded 20 minutes. In a probabilistic sensitivity analysis, RR-EVT was the long-term cost-effective strategy in 89.8% of iterations at a willingness-to-pay threshold of $100,000/QALY. CONCLUSIONS This analysis suggests that RR-EVT as an innovative solution to expedite EVT is cost-effective. An RR-EVT system could potentially extend access to care in underserved communities and rural areas, as well as improve care for socioeconomically disadvantaged populations affected by health inequities.

BackgroundRapid time to reperfusion is essential to minimize morbidity and mortality in acute ischemic stroke due to large vessel occlusion (LVO). We aimed to evaluate the workflow times when utilizing a direct-to-angiography suite (DTAS) pathway for patients with suspected stroke presenting at a comprehensive stroke center compared with a conventional CT pathway.MethodsWe developed a discrete-event simulation (DES) model to evaluate DTAS workflow timelines compared with a conventional CT pathway, varying the admission NIHSS score treatment eligibility criteria. Model parameters were estimated based on 2 year observational data from our institution. Sensitivity analyses of simulation parameters were performed to assess the impact of patient volume and baseline utilization of angiography suites on workflow times utilizing DTAS.ResultsSimulation modeling of stroke patients (SimStroke) demonstrated door-to-reperfusion time savings of 0.2–3.5 min (p=0.05) for a range of DTAS eligibility criteria (ie, last known well to arrival ConclusionsThe results of the SimStroke model showed comparable time intervals for door-to-reperfusion for DTAS compared with a conventional stroke care pathway. However, the DTAS pathway was very sensitive to baseline angiography suite utilization, with even a 10% increase eliminating the advantages of DTAS compared with the conventional pathway. Given the minimal time savings modeled here, further investigation of implementing the DTAS pathway in clinical care is warranted.

BackgroundEvidence has shown that endovascular thrombectomy (EVT) treatment improves clinical outcomes. Yet, its benefit remains uncertain in patients with large established infarcts as defined by ASPECTS (Alberta Stroke Program Early CT Score) MethodsAn economic evaluation study was performed combining a decision tree and Markov model to estimate lifetime costs (2021 US$) and quality-adjusted life years (QALYs) of AIS patients with ASPECTS 3–5. Incremental cost-effectiveness ratios (ICERs), net monetary benefits (NMBs), and deterministic one-way and two-way sensitivity analyses were performed. Probabilistic sensitivity analyses were also performed to evaluate the robustness of our model.ResultsCompared with SC, the cost-effectiveness analyses revealed that EVT yields higher lifetime benefits (2.20 QALYs vs 1.41 QALYs) with higher lifetime healthcare cost per patient ($285 861 vs $272 954). The difference in health benefits between EVT and SC was 0.79 QALYs, equivalent to 288 additional days of healthy life per patient. Even though EVT is more costly than SC alone, it is still cost-effective given better outcomes with ICER of $16 239/QALY. The probabilistic sensitivity analyses indicated that EVT was the most cost-effective strategy in 98.8% (9882 of 10 000) of iterations at the willingness-to-pay threshold of $100 000 per QALY.ConclusionsThe results of this study suggest that EVT is cost-effective in AIS patients with a large ischemic core (ASPECTS 3–5), compared with SC alone over the patient’s lifetime.

We measure the benefit to society created by preventing COVID-19 deaths through a marginal increase in early social distancing. We exploit county-level rainfall on the last weekend before statewide lockdown in the early phase of the pandemic. After controlling for historical rainfall, temperature, and state fixed-effects, current rainfall is a plausibly exogenous instrument for social distancing. A one percent decrease in the population leaving home on the weekend before lockdown creates an average of 132 dollars of benefit per county resident within 2 weeks. The impacts of earlier distancing compound over time and mainly arise from lowering the risk of a major outbreak, yielding large but unevenly distributed social benefit.

Study ObjectiveDementia related psychosis (DRP), characterized by debilitating symptoms such as hallucinations and delusions, is estimated to affect 2.4M people with dementia in the US. Patients with DRP may have twice the rate of dementia progression compared to patients with no DRP. Given that dementia disproportionally impacts the elderly, a comprehensive cost of-illness analysis may add to the current understanding of the overall economic burden of DRP prevalence. The objective of this study was to estimate the cost of DRP from a Centers for Medicare and Medicaid Services (CMS) perspective.MethodsA five state-transition Markov analysis, adapted from Green et al, was conducted to assess the annual direct DRP cost burden to CMS. Patients entering the model were allowed to transition between three at-home health-states (mild dementia plus psychosis, moderate dementia plus psychosis, severe dementia plus psychosis), one long-term care/nursing home (LTC/NH) stay, or death (absorbent health state) at any given time. Since the model accommodates tunnel health-states based on dementia, psychosis and functioning severity levels, patients stayed in the same health-state or transitioned to a more severe health-state or progressed to death (i.e., absorbent health-state) between each 30-day cycle. Prevalence, disease-severity, and state-transition probability estimates were derived from literature while direct costs of DRP were derived from a Medicare claims analysis. Costs were discounted at 3%. Model robustness was tested to check if results were sensitive to changes in inputs and assumptions.ResultsOf the estimated 61.5M Medicare beneficiaries, about 6.87M may suffer from dementia. In the base-case scenario, an estimated total of 2.2M prevalent DRP patients enter the model based on dementia severity into one of the 4 non-absorbent health-states: three at-home (10% mild, 60% moderate, and 10% severe) and one LTC-NH (10%). Total Medicare annual direct DRP costs are estimated to be approximately $119.98B ($113.96B-$125.96B) and about $54K PPPY (Per-Patient-Per-Year) costs (2019 USD). NH costs and patient volume at higher severity levels are significant cost drivers. Sensitivity analysis results show that the model is sensitive to disease severity and disease progression.ConclusionsThese results suggest that DRP imposes a significant direct cost burden despite its low prevalence. In this analysis, per-patient per year (PPPY) cost of DRP prevalence was estimated to be slightly higher than incident PPPY DRP costs. These differences may be attributed to the number of patients at higher severity levels and the time spent in a severe health state as well as cost of LTC/NH stays. Especially given the ageing population in the US, DRP could become an increasing public health concern. There is a significant need for education and awareness about DRP cost burden.FundingAcadia Pharmaceuticals Inc.

Policy and investment decisions regarding new health technologies are often complex. They require a careful balancing of multiple perspectives and differing objectives. On some occasions, policymakers or analysts approaching these decisions have access to cost-effectiveness or cost-benefit analyses to help guide their decisions, but almost invariably such analyses are inadequate.