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Cost Utility Analysis of Routine Hypercoagulable State Testing in Young Patients with Ischemic Stroke

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Cost-Utility Analysis of Routine Hypercoagulable State Testing in Young Patients with Ischemic Stroke

Michael S. Freedman1, Natalie T. Cheng2, Anthony S. Kim3

1UCSF School of Medicine, 2New York-Presbyterian Brooklyn Methodist Hospital Department of Neurology, 3UCSF Department of Neurology

 

Introduction

• Causes of stroke in the young (18-45) are diverse and testing for rare hypercoagulable disorders is routine1,2

• Unclear whether routine hypercoagulable state testing with targeted anticoagulation based on this testing or empiric antiplatelet therapy is preferred, given:

• Uncertain benefits, high costs of testing

• Bleeding risks associated with long-term anticoagulation3

 

Objectives

1. To evaluate the cost-utility of hypercoagulable testing in first-time ischemic stroke/TIA in young adults

2. To determine the variables with the largest impact on the cost-utility of hypercoagulable testing in this setting

 

Methods

Model Overview

• Decision-analytic and Markov state-transition models were created with TreeAge 2015

• Baseline scenario is an 18-26 year old adult with first-time ischemic stroke

• Two treatment strategies were compared:

• Test strategy: Hypercoagulable state testing

• If positive: anticoagulation therapy

• If negative: antiplatelet therapy

• No Test strategy: empiric antiplatelet therapy

• Markov model includes 6 mutually exclusive annual transition states (recurrent stroke, major hemorrhage, minor hemorrhage, mRS 0-2, mRS 3-5, death) (Fig. 1)

• Model includes costs and utilities of the resulting disease states in a given year which are aggregated over 20 years

• All model inputs varied across plausible ranges to reflect input uncertainty

• First order Monte-Carlo simulation was performed to generate probabilistic sensitivity analyses

 

Model Design

• Disease States

• Recurrent Stroke: includes ischemic stroke and TIA

• Major Hemorrhage: intracranial hemorrhage, or bleeding requiring hospitalization or transfusion.

• Minor Hemorrhage: bleeding that did not meet criteria for major hemorrhage

• Modified Rankin Scale (mRS) 0-2: no to mild disability

• mRS 3-5: moderate to severe disability

• mRS 6: death

• Cost-utility Parameters

• Cost: cost for care, as well as costs to society, measured in 2015 USD.

• Utility: ranges from 0 (death) to 1 (one year of perfect health), measured in quality-adjusted life years(QALYs)

• Assumptions

• Death is irreversible

• Sensitivity and specificity of hypercoagulable testing assumed to be 100% as simplifying assumption

• No back-to-back major events

• Inputs

• Point estimates and sensitivity ranges and distributions derived from the medical literature (Table 1)

 

Results

• Test strategy resulted in an increase of $2,669 and a loss of 0.04 QALYs compared to No

Test strategy (Table 2)

• Test strategy is not cost-effective in 98% of outcomes (Fig. 2)

• Preferred strategy is not affected by willingness-to-pay (Fig. 3)

• Three variables have potential to change the directionality of incremental cost or

incremental benefit (Fig. 4)

 

Conclusion

• Test strategy may not be cost-effective

• Routine hypercoagulable testing in young patients with ischemic stroke may result in increased cost without any increase in benefit

• In the absence of increased clinical suspicion of underlying hypercoagulable state, hypercoagulable testing may not be warranted

 

Acknowledgements

I would like to acknowledge Naomi Bardach for her thoughtful comments in the revision process. Support provided by NIH StrokeNet (NIH/NINDS Award Number U01NS086872).

 

References

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2Carolei et al. Stroke 1993;24(3):362–7.

3Kernan et al. Stroke 2014;45(7):2160-236.

4Goeggel et al. Stroke 2015;84:1941-7.

5Mohr et al. NEJM 2001;345(20):1444-51.

6Synhaeve et al. Stroke 2014;45(4):1157–60.

7Saloheimo et al. Stroke 2006;37(1):129-33.

8Hart et al. Stroke 1995;26(8):1471-7.

9Kochanek et al. National Vital Statistics Reports, CDC 2012;61(6):1-51.

10Kim et al. Stroke 2011;42(7):2013-8.

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