Thrombolysis in the treatment of acute ischaemic stroke - What are the likely pharmacoeconomic consequences?

Stroke kills 4.4 million individuals annually and is the most significant c ause of somatic disability. Ultra-acute thrombolysis is the only proven spe cific medical therapy for stroke, but the pharmacoeconomic consequences of wide application of thrombolytic therapy have not been broadly reported. Th is review analyses available data on costs incurred by stroke morbidity and estimates how these might be influenced by thrombolytic therapy. These ana lyses are supported by: (i) estimated lifetime costs of stroke therapy (app roximately $US60 000 per patient); (ii) a speculative example of thrombolyt ic therapy simulated in the setting of a comprehensive urban stroke centre; and (iii) recent data on the efficacy of thrombolysis in reducing disabili ty. It is estimated that only 5% of acute stroke patients are eligible for thrombolysis, which prevents 1 case of long term disability among every 7 p atients treated. It can be argued that the reduction in costs during the first year of medic al therapy (e.g. rehabilitation, co-morbidity, nursing) due to successful t hrombolysis is cancelled out by increased costs due to the associated inves tments (increased acute hospitalisations and neuroimaging, drug costs and p otential complications). However, successful thrombolysis cuts all lifetime indirect costs (e.g, disability pensions, reduced income and productivity) and direct nonmedical costs (e.g. disability aids, domestic help), and sig nificantly reduces lifetime dir ect medical costs (e.g. rehabilitation, str oke co-morbidity, nursing). In such a case, these savings are estimated to account for 84% of the total lifetime costs (approximately $US52 200). In our catchment area of 1 million individuals, the projected total savings in a simulated model of thrombolytic therapy would amount to 15 to 26% of the expenses budgeted for in-hospital therapy of the 800 patients with isch aemic stroke who are treated annually at our centre. Alternatively, the sav ings due to one successful thrombolysis cancel out the costs for the acute phase management of the number of patients needed to generate this nondisab led stroke survivor. Although those estimates are based on the use of throm bolysis in a well organised stroke care centre in an urban setting, where n o substantial investments are necessary before full implementation of throm bolytic therapy can occur, it would seem advantageous to apply thrombolysis as widely as possible to reduce the economic burden of stroke. Since throm bolysis for ischaemic stroke is only well tolerated when administered by ex perienced clinicians in well established stroke centres, we encourage effor ts to disseminate focused training programmes as well as investments in bet ter organised stroke care worldwide. Globally, stroke is one of the leading medical causes of morbidity and mort ality, and is a tremendous burden for healthcare systems around the world. Mortality due to stroke is second only to ischaemic heart disease, with 4.4 million individuals dying annually as the result of stroke (9% of all deat hs).([1]) Stroke is the most significant cause of somatic disability. In the UK, even though the proportion of patients with stroke who are admit ted to hospitals is among the lowest in Western countries,([2]) stroke stil l accounts for almost 5% of all health service costs, 7% of all hospital-be d days and 6% of all hospital costs.([3]) Novel acute-phase therapeutic options for stroke are becoming available. On e such therapy is thrombolytic treatment using intravenous alteplase (recom binant tissue plasminogen activator). This has been investigated in 3 large international randomised controlled trials (RCTs).([4-6]) These studies de monstrated the efficacy of alteplase. For example, in the European study [E uropean Cooperative Acute Stroke Study II (ECASS II)1,([5]) alteplase impro ved the likelihood of nondependent outcome by 8.3% at the expense of depend ent outcomes, while mortality was not increased. One disadvantage of altepl ase is that it can only be used in hospitals equipped with the medical tech nology associated with acute stroke care. To return the necessary investments in such equipment with a dividend, adop tion of thrombolysis for stroke must be planned wisely. Therefore, attentio n is being focused on how the acute management of stroke should be organise d, how large short term investments should be, and what the likely overall health economic implications stemming from these management modifications w ill be. These issues must be weighed against the decrease in stroke morbidi ty rates as well as changes in incidence of stroke as the population grows older. Furthermore, improved acute care is necessary to improve the functio nal outcome of the increasing number of stroke survivors. In the past, Western societies have allocated funds to investigate and inst itute the medically most effective therapies without rigorous consideration of their economic effectiveness (cost effectiveness), but this situation i s rapidly changing. Cost-effectiveness analyses are becoming necessary for the treatments used for many disorders, and stroke is no exception. The use of data from these analyses is particularly important for developing count ries, where healthcare funds and advanced medical technology are at a premi um. The aim of this review is to gather information published on the economic i mpact and implications of thrombolytic therapy in stroke, and to project th e actual cost effectiveness of this therapy by simulation in our own health care organisation as a model.