Published Online
on April 22, 2004

A more recent version of this article appeared on June 1, 2004

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Submitted on May 15, 2003
Revised on January 7, 2004
Accepted on February 16, 2004

Cost-Effectiveness of Thrombolysis With Recombinant Tissue Plasminogen Activator for Acute Ischemic Stroke Assessed by a Model Based on UK NHS Costs

Peter Sandercock MA, DM, FRCPE, FMedSci^*; Eivind Berge MD; Martin Dennis MD, FRCPE; John Forbes BA, MSc, PhD; Peter Hand MB, BS(Hons), MD, FRACP; Joseph Kwan MPhil, MD, MRCP; Steff Lewis PhD, MSc, CStat; Richard Lindley MBBS, FRCPE, MD; Aileen Neilson BSc, MSc; and Joanna Wardlaw MD, FRCR, FRCPE

From the Division of Clinical Neurosciences (P.S., M.D., S.L., J.W.), University of Edinburgh, Western General Hospital, Edinburgh, UK; the Department of Internal Medicine (E.B.), Ulleval Hospital, Oslo, Norway; the Section of Public Health Sciences, Division of Community Health Sciences (J.F.), University of Edinburgh, Edinburgh, UK; the Department of Neurology (P.H.). Royal Melbourne Hospital, Melbourne, Australia; the University Department of Geriatric Medicine (J.K.). Southampton General Hospital, Southampton, UK; and HealthEcon (A.N.), Basel, Switzerland.

^* To whom correspondence should be addressed. E-mail: pags{at}skull.dcn.ed.ac.uk.

Background and Purpose--Thrombolytic therapy is licensed for use in highly selected patients with acute ischemic stroke. We aimed to model the health economic impact of limited use of thrombolytic therapy and to assess whether it was likely to be cost-effective when used more widely in the UK National Health Service (NHS).

Methods--The authors formed a discussion panel to develop the decision-analysis model of acute stroke care. It consisted of Markov state-transition processes, with probabilities of different health states determined by certain key variables. The range of estimates of efficacy of recombinant tissue plasminogen activator (rt-PA) was taken from an update to a Cochrane systematic review of randomized trials of thrombolysis. Data on outcome after stroke were taken from our hospital-based stroke register, supplemented by data derived from relevant literature sources.

Results--The model suggested that compared with standard care, if eligible patients were treated with rt-PA up to 6 hours, there was a 78% probability of a gain in quality-adjusted survival during the first year, at a cost of £13 581 per quality-adjusted life-year (QALY) gained. Over a lifetime, rt-PA was associated with cost-savings of £96 565 per QALY. However, the estimates were imprecise and highly susceptible to the assumptions used in the economic model; under several plausible assumptions, rt-PA was much less cost-effective than standard care, and under others, a great deal more cost-effective.

Conclusions--The estimates of effectiveness and cost-effectiveness were imprecise. Although the benefits appeared promising, the data did not support the widespread use of thrombolytic therapy outside the terms of the current restricted license in routine clinical practice in the NHS. There is a case for new large-scale randomized trials comparing thrombolytic therapy with control up to 6 hours to determine more precisely the effects of rt-PA on short-term and long-term survival and its cost-effectiveness when used in a wider range of patients.

Key words: thrombolytic therapy • tissue plasminogen activator • cerebral infarction • cost-benefit analysis

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