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From the College of Pharmacy (Dr. Fagan), Wayne State University, Detroit, MI; the Departments of Pharmacy (Dr. Fagan and A. Petitta) and Neurology(Drs. Fagan and Levine), the Center for Clinical Effectiveness (Dr. Ward), and the Division of Biostatistics and Research Epidemiology (Dr. Tilley), Henry Ford Health System; the Department of Neurology (Dr. Morgenstern), University of Texas; the Division of Stroke and Trauma (Drs. Marler and Walker), NINDS, Bethesda, MD; the Department of Neurology (Drs. Broderick and Brott), University of Cincinnati, OH; the Department of Emergency Medicine(Dr. Kwiatkowski), Long Island Jewish Medical Center; and the Department of Neurology (Dr. Frankel), Emory University, Atlanta, GA.
Supported by the National Institute of Neurologic Disorders and Stroke(N01-NS-02382, N01-NS-02374, N01-NS-02377, N01-NS-02381, N0-NS-02379, N0-NS-02373, N0-NS-02376, N01-NS-02378, and N01-NS-02380).
Received June 2, 1997. Accepted in final form October 29, 1997.
Address correspondence and reprint requests to Dr. Susan C. Fagan, Department of Pharmacy Practice, Wayne State University, 1400 Chrysler, Detroit, MI 48202.
Tissue plasminogen activator (tPA) has been shown to improve 3-month outcome in stroke patients treated within 3 hours of symptom onset. The costs associated with this new treatment will be a factor in determining the extent of its utilization. Data from the NINDS rt-PA Stroke Trial and the medical literature were used to estimate the health and economic outcomes associated with using tPA in acute stroke patients. A Markov model was developed to estimate the costs per 1,000 patients eligible for treatment with tPA compared with the costs per 1,000 untreated patients. One-way and multiway sensitivity analyses (using Monte Carlo simulation) were performed to estimate the overall uncertainty of the model results. In the NINDS rt-PA Stroke Trial, the average length of stay was significantly shorter in tPA-treated patients than in placebo-treated patients (10.9 versus 12.4 days; p = 0.02) and more tPA patients were discharged to home than to inpatient rehabilitation or a nursing home (48% versus 36%;p = 0.002). The Markov model estimated an increase in hospitalization costs of $1.7 million and a decrease in rehabilitation costs of $1.4 million and nursing home cost of $4.8 million per 1,000 eligible treated patients for a health care system that includes acute through long-term care facilities. Multiway sensitivity analysis revealed a greater than 90% probability of cost savings. The estimated impact on long-term health outcomes was 564 (3 to 850) quality-adjusted life-years saved over 30 years of the model per 1,000 patients. Treating acute ischemic stroke patients with tPA within 3 hours of symptom onset improves functional outcome at 3 months and is likely to result in a net cost savings to the health care system.
*See the Appendix on page 889 for a list of participants and institutions of the NINDS rt-PA Study Group.
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