Stroke: Effect of implementing an evaluation and treatment protocol compliant with NINDS recommendations

Purpose: To evaluate-relative to routine clinical practice-the potential cost-effectiveness of implementing a strategy compliant with National Institute of Neurological Disorders and Stroke (NINDS) recommendations for care of patients presenting with signs and symptoms of acute ischemic stroke. Materials and Methods: A discrete-event simulation model of the process of stroke care from symptom onset through administration of tissue plasminogen activator (tPA) was constructed. A literature review was performed to determine process times, performance of computed tomography (CT), health outcomes, and cost estimates. The following were compared: (a) a "base-case" strategy determined on the basis of findings in the literature and (b) a NINDS-compliant strategy (ie, evaluation by emergency physician in less than 10 minutes, interpretation of CT scans within 45 minutes, and administration of tPA within I hour after presentation). Strategies were compared with regard to cost and effectiveness. Sensitivity analyses were performed for all relevant cost, timing, and resource parameters. Outcomes of concern were quality-adjusted life years and number of patients treated within a 3-hour therapeutic window. Results: The NINDS-compliant strategy resulted in an average quality-adjusted life years value of 3.64, versus 3.63 for the base case, at an approximate cost of $434 per patient. The NINDS-compliant strategy increased the proportion of treatable patients from 1.4% to 3.7% and remained cost-effective for expenditures of up to $450 per patient. Assuming base-case parameters are used, increasing the number of CT scanners from two to eight raised the proportion of treatable patients to 1.5%. Increasing the number of available neurologists from four to eight raised the proportion to 1.44%. Reducing the time from stroke onset to emergency department arrival by 30 minutes raised the proportion to up to 7.7%. Conclusion: Applying NINDS recommendations is potentially cost-effective, although reducing the time from stroke onset to emergency department arrival may be even more so.