Cost-utility analysis of tissue plasminogen activator therapy for acute ischaemic stroke - A Canadian healthcare perspective

Background: There are over 40 000 ischaemic strokes annually in Canada, whi ch result in significant morbidity, mortality and burden to the healthcare system. A recent, large clinical trial has evaluated tissue plasminogen act ivator (t-PA) intravenously for the treatment of acute ischaemic stroke wit h promising outcomes but with an increased risk of symptomatic intracranial haemorrhage. Objective: To compare clinical and economic outcomes of intravenous t-PA th erapy (0.9 mg/kg, to a maximum of 90mg, initiated within 3 hours of stroke onset) versus no t-PA for acute ischaemic stroke based on the outcomes achi eved in the National Institute of Neurological Disorders and Stroke (NINDS) trial. Design: A Markov model depicting the natural lifetime course after an initi al acute ischaemic stroke. On the basis of this model, a simulated trial co mpared no t-PA with t-PA. Patients: A hypothetical cohort of 1000 patients with acute ischaemic strok e. Study perspective: Canadian healthcare system. Outcome measures: Total acute stroke and post-stroke treatment costs and cu mulative quality-adjusted life-years (QALYs). Results: For a hypothetical cohort of 1000 patients, the estimated lifetime stroke costs were 103 100 000 Canadian dollars ($Can) [1999 values) in the t-PA arm ($Can103 100 per patient) compared with $Can106 900 000 in the no t-PA arm ($Can106 900 per patient), yielding a lifetime cost difference of $Can3 800 000 in favour of t-PA versus no t-PA ($Can3800 per patient). In the hypothetical cohort, t-PA treatment resulted in 13 130 QALYs versus 967 0 QALYs with no t-PA treatment. This translated into a net benefit of 3460 additional QALYs per 1000 patients (3.46 QALYs per patient). No treatment, outcome or economic variables influenced the model outcome.