Endovascular Therapy for Acute Ischemic Stroke
Health Technology Assessment Committee Recommendations¹
- Endovascular Therapy (EVT) for acute ischemic stroke is clinically and cost-effective and should be publicly funded in B.C.’s health authorities.
- Equitable access to treatment is an issue, particularly for B.C. residents in rural and northern areas of the province, and further work to ensure that capacity within the health system is in place to serve all British Columbians is necessary over the longer term.
- Long term planning for a coordinated provincial approach to EVT at major centres continue to be undertaken by Stroke Services BC, in partnership with health authorities.
Health Technology Assessment Committee Findings
- The evidence of the clinical effectiveness of Endovascular Therapy (EVT) for acute ischemic stroke is substantial and compelling. This includes evidence from a meta-analysis of five recent good quality randomized controlled trials based on the current technology and protocols:
- Pooled evidence shows that the number of patients who were functionally independent following EVT treatment was more than double those treated with intravenous tissue plasminogen activator alone.
- There was no increase in adverse events reported with EVT and a possible trend toward decreased mortality (although this finding was not statistically significant).
- EVT is appropriate for patients with large, proximal vessel occlusions; without intervention these patients generally have high morbidity and mortality, imposing significant burden on the individual, their family, and the health system as a whole:
- Increased functional independence with EVT enables more survivors of stroke to return home and resume normal lives while decreasing the impact on rehabilitation and long-term care services.
- Five cost-effectiveness studies were identified that focused on the current technology; these studies showed that EVT was cost-effective using a willingness to pay threshold of $50,000 per quality-adjusted life-year; two studies concluded the technology was cost saving.
- In the short term (1 year), there are increased health care costs associated with the delivery of EVT:
- BC is already providing EVT at three major stroke care centres. 214 cases were reported in 2016 (as of July 22) at an estimated cost of $4.6 million. Assuming all three centres treat the expected number of patients eligible for EVT in their respective catchment areas (311 cases), annual expenditures would be approximately $6.7 million.
- Further investment of approximately $5.5 million (including up to $2.7 M for air transport expenditures alone) annually would be required in order to serve the entire population of British Columbia.
- Current budget impact analysis was limited to one year due to data limitations in the literature. A longer term assessment of cost savings and budget impact for BC, including further analysis of the lifetime health and societal costs associated with disability from a major stroke, would likely strengthen the case for public provision. Cost-effectiveness studies estimated additional cost savings (costs avoided) over longer time horizons (3 – 15 years).
- There are moderate implementation considerations for B.C. when considering increasing EVT capacity at major stroke care centres and access for rural and northern communities. These include:
- the need for enhanced use of air transportation,
- planning and coordination among local hospitals and major centres performing EVT, including the potential need to increase diagnostic capacity at local hospitals, and
- the potential need for additional training and credentialing in EVT and hospital infrastructure for new or existing sites, depending on the approach taken.
- Stakeholders interviewed support improving access to the technology and stroke care clinical pathway, and agreed that a well-coordinated, appropriately resourced program that has functional relationships among health regions and with neighbouring jurisdictions is required to optimize service provision in British Columbia. Doing all of this within the first six hours of stroke will require significant coordination and support.
- EVT is now considered the standard of care in national and international guidelines. Other provinces provide EVT and are actively developing new transportation protocols to enable provincial service.
Health Technology Assessment Committee recommendations on Endovascular Treatment for Acute Ischemic Stroke were accepted by a committee of senior health authority and ministry executives in October 2016. Please note health authorities determine how health technologies are implemented within their programs and services. Other relevant scientific findings may have been reported since the completion of the reference documents used to form the basis of the committee's recommendations.
¹ The findings and recommendations of the Health Technology Assessment Committee do not necessarily reflect the views or policy of the Ministry of Health. Estimated budget impacts are taken from the health technology assessment produced by the Health Technology Assessment unit based at the University of Calgary.