Cost-effectiveness of CT perfusion for the detection of large vessel occlusion acute ischemic stroke followed by endovascular treatment: a model-based health economic evaluation study
Authors: van Voorst Henk , Hoving Jan W. , Koopman Miou S. , Daems Jasper D. , Peerlings Daan , Buskens Erik , Lingsma Hester F. , Beenen Ludo F. M. , de Jong Hugo W. A. M. , Berkhemer Olvert A. , van Zwam Wim H. , Roos Yvo B. W. E. M. , van Walderveen Marianne A. A. , van den Wijngaard Ido , Dippel Diederik W. J. , Yoo Albert J. , Campbell Bruce C. V. , Kunz Wolfgang G. , Emmer Bart J. , Majoie Charles B. L. M. ,   for the CLEOPATRA investigators,   for the CONTRAST consortium, van Nuland Rick , van der Lugt Aad , van Es Adriaan , van Doormaal Pieter-Jan , van den Berg René , Beenen Ludo F. M. , Roosendaal Stefan D. , Postma Alida Annechien , Yo Lonneke S. F. , Krietemeijer G. Menno , Nijeholt Geert J. Lycklama à , Martens Jasper M. , Hammer Sebastiaan , Meijer Anton , Bokkers Reinoud P. H. , van der Hoorn Anouk , Gerrits Dick , van Oostenbrugge Robert , Coutinho Jonathan M. , Truijman Martine , Staals Julie , van der Worp H. Bart , Boogaarts J. , Jansen Ben , Zinkstok Sanne , Truijman Martine , Staals Julie , Koudstaal Peter , Keizer Koos , Manschot Sanne , Boiten Jelis , Kerkhoff Henk , Chalos Vicky , Versteeg Adriaan , Wolff Lennard , van der Sluijs Matthijs , Tolhuisen Manon L. , Cate Hugo ten , de Maat Moniek , Donse-Donkel Samantha , van Beusekom Heleen , Taha Aladdin , Barakzie Aarazo , van de Graaf Rob , van der Steen Wouter , Treurniet Kilian M. , van den Berg Sophie , LeCouffe Natalie , Kappelhof Manon , Reinink Rik , Rinkel Leon , Brouwer Josje , Bruggeman Agnetha , Goldhoorn Robert-Jan , Hinsenveld Wouter , Pirson Anne , Olthuis Susan , Venema Simone Uniken , Teeselink Sjan , Sondag Lotte , Collette Sabine , Sterrenberg Martin , Ghannouti Naziha el , van der Steen Laurine , Verheesen Sabrina , Vranken Jeannique , van Ahee Ayla , Bongenaar Hester , Smallegange Maylee , Tilet Lida , de Meris Joke , Simons Michelle , Pellikaan Wilma , van Wijngaarden Wilma , Blauwendraat Kitty , Drabbe Yvonne , Sandiman-Lefeber Michelle , Katthöfer Anke , Ponjee Eva , Eilander Rieke , van Loon Anja , Kraus Karin , Kooij Suze , Slotboom Annemarie , van der Minne Friedus , Santegoets Esther , Heiligers Leontien , Martens Yvonne ,   for the MR CLEAN Registry Investigators, Vos Jan Albert , Jansen Ivo G. H. , Mulder Maxim J. H. L. , Compagne Kars C. J. , den Hartog Sanne J. , Roozenbeek Bob , Schonewille Wouter J. , Wermer Marieke J. H. , Hofmeijer Jeannette , Nijeholt Geert J. Lycklama à , de Bruijn Sebastiaan F. , van Dijk Lukas C. , Lo Rob H. , van Dijk Ewoud J. , Boogaarts Hieronymus D. , de Vries J. , de Kort Paul L. M. , van Tuijl Julia , Peluso Jo P. , Fransen Puck , van den Berg Jan S. P. , van Hasselt Boudewijn A. A. M. , Aerden Leo A. M. , Dallinga René J. , Uyttenboogaart Maarten , Eschgi Omid , Schreuder Tobien H. C. M. L. , Heijboer Roel J. J. , Keizer Koos , den Hertog Heleen M. , Sturm Emiel J. C. , Sprengers Marieke E. S. , Jenniskens Sjoerd F. M. , van der Kallen Bas F. W. , Bot Joost , Ghariq Elyas , van Proosdij Marc P. , Dinkelaar Wouter , Appelman Auke P. A. , Hammer Bas , Pegge Sjoert , Vinke Saman , Flach H. Zwenneke , Sprengers Rita , Elfrink Marjan , Vossers Marjolein , de Meris Joke , Vermeulen Tamara , Geerlings Annet , van Vemde Gina , Simons Tiny , Messchendorp Gert , Nicolaij Nynke , Bodde Karin , Kleijn Sandra , Lodico Jasmijn , Droste Hanneke , Wollaert Maureen , Jeurrissen D. , Bos Erna , Sandiman Michelle , Aaldering Nicoline , Zweedijk Berber , Vervoort Jocova , Romviel Sharon , Kanselaar Karin , Barning Denn , Venema Esmee , Geuskens Ralph R. , van Straaten Tim , Ergezen Saliha , Harmsma Roger R. M. , Muijres Daan , de Jong Anouk , Boers Anna M. M. , Groot P. F. C. , Mens Marieke A. , van Kranendonk Katinka R. , Alves Heitor , Weterings Annick J. , Kirkels Eleonora L. F. , Voogd Eva J. H. F. , Schupp Lieve M. , Groot Adrien E. D. , Konduri Praneeta R. , Prasetya Haryadi , Arrarte-Terreros Nerea , Ramos Lucas A. 
Published: September 2023

Abstract
Objectives
CT perfusion (CTP) has been suggested to increase the rate of large vessel occlusion (LVO) detection in patients suspected of acute ischemic stroke (AIS) if used in addition to a standard diagnostic imaging regime of CT angiography (CTA) and non-contrast CT (NCCT). The aim of this study was to estimate the costs and health effects of additional CTP for endovascular treatment (EVT)–eligible occlusion detection using model-based analyses.

Methods
In this Dutch, nationwide retrospective cohort study with model-based health economic evaluation, data from 701 EVT-treated patients with available CTP results were included (January 2018–March 2022; trialregister.nl:NL7974). We compared a cohort undergoing NCCT, CTA, and CTP (NCCT + CTA + CTP) with a generated counterfactual where NCCT and CTA (NCCT + CTA) was used for LVO detection. The NCCT + CTA strategy was simulated using diagnostic accuracy values and EVT effects from the literature. A Markov model was used to simulate 10-year follow-up. We adopted a healthcare payer perspective for costs in euros and health gains in quality-adjusted life years (QALYs). The primary outcome was the net monetary benefit (NMB) at a willingness to pay of €80,000; secondary outcomes were the difference between LVO detection strategies in QALYs (ΔQALY) and costs (ΔCosts) per LVO patient.

Results
We included 701 patients (median age: 72, IQR: [62–81]) years). Per LVO patient, CTP-based occlusion detection resulted in cost savings (ΔCosts median: € − 2671, IQR: [€ − 4721; € − 731]), a health gain (ΔQALY median: 0.073, IQR: [0.044; 0.104]), and a positive NMB (median: €8436, IQR: [5565; 11,876]) per LVO patient.

Conclusion
CTP-based screening of suspected stroke patients for an endovascular treatment eligible large vessel occlusion was cost-effective.

Clinical relevance statement.
Although CTP-based patient selection for endovascular treatment has been recently suggested to result in worse patient outcomes after ischemic stroke, an alternative CTP-based screening for endovascular treatable occlusions is cost-effective.

Key Points
• Using CT perfusion to detect an endovascular treatment-eligible occlusions resulted in a health gain and cost savings during 10 years of follow-up.
• Depending on the screening costs related to the number of patients needed to image with CT perfusion, cost savings could be considerable (median: € − 3857, IQR: [€ − 5907; € − 1916] per patient).
• As the gain in quality adjusted life years was most affected by the sensitivity of CT perfusion-based occlusion detection, additional studies for the diagnostic accuracy of CT perfusion for occlusion detection are required.