Thrombolysis in the Treatment of Acute Ischaemic Stroke
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Stroke kills 4.4 million individuals annually and is the most significant cause of somatic disability. Ultra-acute thrombolysis is the only proven specific medical therapy for stroke, but the pharmacoeconomic consequences of wide application of thrombolytic therapy have not been broadly reported. This review analyses available data on costs incurred by stroke morbidity and estimates how these might be influenced by thrombolytic therapy. These analyses are supported by: (i) estimated lifetime costs of stroke therapy (approximately $US60 000 per patient); (ii) a speculative example of thrombolytic therapy simulated in the setting of a comprehensive urban stroke centre; and (iii) recent data on the efficacy of thrombolysis in reducing disability. It is estimated that only 5% of acute stroke patients are eligible for thrombolysis, which prevents 1 case of long term disability among every 7 patients treated.
It can be argued that the reduction in costs during the first year of medical therapy (e.g. rehabilitation, co-morbidity, nursing) due to successful thrombolysis is cancelled out by increased costs due to the associated investments (increased acute hospitalisations and neuroimaging, drug costs and potential complications). However, successful thrombolysis cuts all lifetime indirect costs (e.g. disability pensions, reduced income and productivity) and direct nonmedical costs (e.g. disability aids, domestic help), and significantly reduces lifetime direct medical costs (e.g. rehabilitation, stroke co-morbidity, nursing). In such a case, these savings are estimated to account for 84% of the total lifetime costs (approximately $US52 200).
In our catchment area of 1 million individuals, the projected total savings in a simulated model of thrombolytic therapy would amount to 15 to 26% of the expenses budgeted for in-hospital therapy of the 800 patients with ischaemic stroke who are treated annually at our centre. Alternatively, the savings due to one successful thrombolysis cancel out the costs for the acute phase management of the number of patients needed to generate this nondisabled stroke survivor. Although these estimates are based on the use of thrombolysis in a well organised stroke care centre in an urban setting, where no substantial investments are necessary before full implementation of thrombolytic therapy can occur, it would seem advantageous to apply thrombolysis as widely as possible to reduce the economic burden of stroke. Since thrombolysis for ischaemic stroke is only well tolerated when administered by experienced clinicians in well established stroke centres, we encourage efforts to disseminate focused training programmes as well as investments in better organised stroke care worldwide3
KeywordsAcute Stroke Thrombolytic Therapy Alteplase Case Fatality Rate Stroke Centre
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