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Stroke: Effect of Implementing an Evaluation and Treatment Protocol Compliant with NINDS Recommendations¹

¹ From the Institute for Technology Assessment (J.E.S.) and Departments of Radiology (J.E.S., G.S.G.), Medicine (J.E.S.), and Neurology (K.L.F.), Massachusetts General Hospital, Harvard Medical School, Zero Emerson Bldg, Suite 2H, Boston, MA 02114; and Department of Economics, Trinity College, Hartford, Conn (S.G.). Received November 25, 2002; revision requested February 4, 2003; revision received March 31; accepted April 10. Supported in part by the U.S. Department of the Army with DAMD 17-99-2-9001. Address correspondence to J.E.S. (e-mail: james@mgh-ita.org).

PURPOSE: To evaluate—relative to routine clinical practice—the potential cost-effectiveness of implementing a strategy compliant with National Institute of Neurological Disorders and Stroke (NINDS) recommendations for care of patients presenting with signs and symptoms of acute ischemic stroke.

MATERIALS AND METHODS: A discrete-event simulation model of the process of stroke care from symptom onset through administration of tissue plasminogen activator (tPA) was constructed. A literature review was performed to determine process times, performance of computed tomography (CT), health outcomes, and cost estimates. The following were compared: (a) a "base-case" strategy determined on the basis of findings in the literature and (b) a NINDS-compliant strategy (ie, evaluation by emergency physician in less than 10 minutes, interpretation of CT scans within 45 minutes, and administration of tPA within 1 hour after presentation). Strategies were compared with regard to cost and effectiveness. Sensitivity analyses were performed for all relevant cost, timing, and resource parameters. Outcomes of concern were quality-adjusted life years and number of patients treated within a 3-hour therapeutic window.

RESULTS: The NINDS-compliant strategy resulted in an average quality-adjusted life years value of 3.64, versus 3.63 for the base case, at an approximate cost of $434 per patient. The NINDS-compliant strategy increased the proportion of treatable patients from 1.4% to 3.7% and remained cost-effective for expenditures of up to $450 per patient. Assuming base-case parameters are used, increasing the number of CT scanners from two to eight raised the proportion of treatable patients to 1.5%. Increasing the number of available neurologists from four to eight raised the proportion to 1.44%. Reducing the time from stroke onset to emergency department arrival by 30 minutes raised the proportion to up to 7.7%.

CONCLUSION: Applying NINDS recommendations is potentially cost-effective, although reducing the time from stroke onset to emergency department arrival may be even more so.

© RSNA, 2003

Index terms: Brain, infarction, 13.78 • Cost-effectiveness • Economics, medical • Radiology and radiologists, socioeconomic issues • Tissue plasminogen activator (TPA)

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