Reduceren tijd tussen CVA en aankomst SEH belangrijkste kosten-effectieve maatregel

Stahl JE, Furie KL, Gleason S, Gazelle GS. Stroke: Effect of implementing an evaluation and treatment protocol compliant with NINDS recommendations. Radiology 2003 Sep;228(3):659-68

Doel: Te beoordelen - ten opzichte van de routine klinische praktijk - de potentiële kosten-effectiviteit van de uitvoering van een strategie die voldoet aan de aanbevelingen van het National Institute of Neurological Disorders en Stroke (NINDS) voor de zorg van patiënten met tekenen en symptomen van een acute ischemische beroerte

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 1 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 US dollars 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 US dollars 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

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