Thrombectomy is a highly effective way to treat ischaemic large vessel occlusion stroke. “Time is brain” remains crucial as the thrombectomy benefit is highly time-dependent. Speaking at the 15th annual meeting of the Society of NeuroInterventional Surgery (SNIS; 23–27 July, San Francisco, USA), Wolfgang G Kunz, (assistant professor of Radiology at LMU Munich, Germany) presented results from the HERMES collaboration on the lifetime health and cost consequences of treatment delays in thrombectomy for stroke. The data illustrate that not only is time brain, time also is money.
Thrombectomy is expected to reduce the financial impact that stroke has in many countries, including the USA, UK, Australia and Sweden, said Kunz. In a letter he co-wrote with Myriam G Hunink (Erasmus University Medical Center, Rotterdam, the Netherlands) and published in Stroke in 2017, he reinforced that the use of thrombectomy will lead to long-term cost-savings, not just in the US insurance-based system but also in the UK’s free at point of use system.
Knowing this means that it is imperative to implement thrombectomy and to reduce time to treatment—for the patients as well as to reduce the financial burden of stroke in ageing societies.
There are many delays in the stroke treatment workflow. Even before the patient gets to the hospital there can be delays in symptom recognition, contacting emergency services and getting the patient to a hospital that provides thrombectomy. Once a patient reaches the correct hospital, the workflow often is not optimised for stroke triage with serial instead of parallel task processing and imaging protocols that can add up to a 20-minute delay (Goyal et al. Radiology 2016).
Quality-adjusted life years (QALY) represent quality of life over time. The quality of life ranges from 1.0 representing a perfect quality of life, to 0.0 representing no quality of life. The stroke patients’ quality of life is closely related to their modified Rankin Scale (mRS): mRS of 0 typically leads to very high quality of life while patients with an mRS of 5 reported on average 0.0 quality of life, as evident from questionnaires across multiple large patient cohorts.
In a cost analysis of the SWIFT-PRIME trial, a thrombectomy procedure cost on average US$15,000 with the long-term care costs ranging from US$10,569 annually for patients with an mRS of 1, to US$64,327 annually for patients with an mRS of 5.
Mayank Goyal, senior author of the study, neurointerventionalist at the University of Calgary in Canada, and chair of the HERMES collaboration, co-designed the analysis with Kunz. They applied data from all seven participating trials of HERMES and used 90-day mRS outcome stratified by time to puncture as main input for the health economic model calculations.
They found that for every minute delay in treatment there was a loss of four days of disability-free life. Considering life with functional independence (mRS 0–2), a one-minute delay even resulted in a loss of 10 days on average. The net monetary benefit is an indicator of the economic value of care, and was highest when the time to puncture was shortest. The analysis showed that the median loss in net monetary benefit of thrombectomy per minute was US$1,059—expediting treatment with thrombectomy by 10 minutes in the USA on a national level would lead to a financial benefit of US$249 million annually.
By reducing time to treatment, streamlining workflow, and improving thrombectomy technique there is a vast potential, not only to save and improve patients’ lives, but also to reduce the economic burden of stroke.