If you recall, last year was a bumper crop of prospective, randomized, controlled trials testing the efficacy of endovascular devices versus tPA alone for acute ischemic stroke. These trials – SYNTHESIS, MR-RESCUE, and IMS-III – were unified by demonstrating no additive benefit. Of course, these trials proved nothing to proponents of endovascular therapy, owing to the “outdated” devices used.
Interestingly, IMS-III also prospectively gathered costs associated with both treatment modalities. Presumably, the authors expected to show a treatment advantage despite increased costs, and would follow-up with a cost-effectiveness analysis. Now, since there was no advantage with endovascular treatment, this is simply a fascinating observational report.
So, how much did everything cost? The answer, like everything in medicine: depends on who’s paying. Hospital charges for patients receiving tPA were a mean of $86,880, with a median of $58,247, and ranged from $13,701 to $830,652. Hospital charges for endovascular treatment would have been a mean of $113,185, with a median cost of $86,481, and ranged from $23,350 to $552,279. Thankfully, this is the funny money that few patients are realistically expected to pay. Costs, on the other hand, are based off the negotiated Medicare reimbursements, and were estimated at a mean cost of $25,630 for IV tPA and $35,130 for endovascular therapy. So, a fair bit of extra cost to the system for a therapy that isn’t providing any proven benefit.
Given the lack of efficacy and increased costs, you’d think it should be obvious we ought not be deploying endovascular therapy widely – but, clearly, this is unfortunately not the case. Medicare and Medicaid still reimburse for endovascular interventions – and its use is bolstered by its sponsors and other such propaganda in the NEJM. Until proven otherwise, this is all simply money down the drain.
“Drivers of Costs Associated With Reperfusion Therapy in Acute Stroke: The Interventional Management of Stroke III Trial”
http://stroke.ahajournals.org/content/early/2014/05/13/STROKEAHA.113.003874.abstract