This cost-effective strategy benefits both patients and the bottom line, according to a Canadian study.
Use endovascular therapy for acute ischemic stroke substantially reduces patients’ need for healthcare services for up to 12 months, according a Canadian analysis published online June 3, 2019, ahead of print in Stroke.
The study’s impetus arose from the need to demonstrate the impact of endovascular therapy to policy makers in Canada, which has a single-payer system, lead author Noreen Kamal, PhD (Dalhousie University, Halifax, Canada), told Neurovascular Exchange. The challenge, she said, was finding an appropriate control group.
“In order to have a control, you have to select the patients who should have received the therapy but did not, and in our current situation in Alberta, everyone is now receiving the therapy who should be receiving it. So, we went back to the ESCAPE trial, which was led out of Calgary in Alberta,” Kamal explained. “We used the controls who were enrolled to ESCAPE in Alberta as our control and then compared [their outcomes] to how endovascular therapy is doing in the real world outside of a trial.”
She emphasized that real-world data are needed because clinical trials, due to their carefully controlled, artificial circumstances, frequently have better outcomes than what can be achieved in regular practice.
Kamal et al analyzed data on 99 patients from Alberta, Canada, who were enrolled in the ESCAPE trial (52 in the treatment arm and 47 in the control arm) as well as 187 patients who received endovascular therapy as part of usual care and were included in the Quality Improvement and Clinical Research registry during the 2016-2017 fiscal year. Through linkages to several administrative data sets, the daily location of each patient was assessed in various healthcare settings, such as acute care hospitals, rehabilitation hospitals, long-term care facilities, supportive living facilities, and subacute facilities.
Use of healthcare services was the primary outcome, because “no one wants to be in hospital, and hospitalization costs a lot of money,” Kamal stressed. “So if you can lower the utilization of healthcare, it’s good for the patient and it’s good for the bottom line in terms of the health system.” Dollar amounts were not included in the analysis because they are difficult to calculate in a single-payer setting.
The likelihood of a patient being out of a healthcare setting over 1 year after the stroke was significantly higher when they received endovascular therapy, both in ESCAPE trial patients (OR 3.46; 95% CI 1.68-7.30) and in the Quality Improvement and Clinical Research patients (OR 2.00; 95% CI 1.08-3.75).
A Pleasant Surprise
“It was such an alarming difference,” sad Kamal. “People didn’t think that in the real world we would see as much of an impact as we saw. . . . What was a bit unexpected was that the control group, yes, they had [poorer] outcomes at 3 months, but they continued to use health services beyond the 3 months.” The differences past 3 months were apparent for both acute services and rehab, she noted, and continued up to 1 year.
These were very encouraging finding, though, given how endovascular therapy is actually used in the real world. “You want to make the treatment available to patients who may already use a cane or a walker [in the real world],” said Kamal. Such patients would be excluded from trials. Many stroke neurologists in Alberta had not anticipated the benefit seen here, given how many older and sicker patients they treat with endovascular therapy. Mortality rates were higher in the real-world setting compared with in ESCAPE, but this was to be expected what with the differences in patient selection.
Endovascular therapy “is an expensive treatment, but it certainly is cost-effective when you go out to 1 year and you can see that patients are spending less time in rehab,” concluded Kamal. “They are spending much more time at home and outside of health services. So, I think all of this really bodes well for endovascular therapy in the sense that not only is it good for the patients in a clinical trial setting at 3 months [based on] mRS, but overall it is really good in terms of the bottom line.
Kamal N, Rogers E, Stang J et al. Stroke. 2019;Epub ahead of print.
Kamal reports no relevant conflicts of interest.