Comment by Dr Nicolas Martinez-Majander, Department of Neurology, Helsinki University Hospital, Finland
According to the World Health Organization, noncommunicable diseases (NCD), such as cardiovascular diseases, cancer, and chronic obstructive pulmonary disease account for 80% of deaths in the European Region. Particularly, diseases of the circulatory system (e.g. stroke) are the most important cause of premature death in Europe, accounting for nearly 50% of the total. Stroke is also the leading cause of disability and a major cause of dementia in Europe.1,2
In 2018, European Stroke Organisation (ESO) prepared a European Stroke Action Plan for the next decade, in cooperation with the Stroke Alliance for Europe.3 As described in this plan, four ambitious targets for the next decade were identified: (1) to reduce the absolute number of strokes in Europe by 10%, (2) to treat 90% or more of all patients with stroke in Europe in a dedicated stroke unit as the first level of care, (3) to have national plans for stroke encompassing the entire chain of care, (4) to fully implement national strategies for multisector public health interventions.
In this paper, published in the European Journal of Neurology, Vanhooren and colleagues present their study and results. A Markov model was used to determine cost-effectiveness of comprehensive stroke services. Outcomes included total costs, QALYs, incremental costs, incremental QALYs, as well as the incremental cost-effectiveness ratio (ICER). Several interventions, such as IVT with alteplase, early aspirin use, and rhythm monitoring for atrial fibrillation, were explored. The model was adapted to the UK setting due to availability of data.
The main findings were as follows:
- Key unmet needs in stroke patient pathway and significant gaps in implementation of effective interventions included low implementation of comprehensive stroke services, inadequate treatment of atrial fibrillation, and limited access to rehabilitation.
- Full implementation of comprehensive stroke services could led to an absolute risk reduction in death or dependency of 9.8% and the average cost of this intervention was £9,566 vs £6,640 in the standard of care group. Furthermore, long-term care costs were £35,169 per 5.1251 QALYs vs £32,347.40 per 4.5853 QALYs, yielding an ICER of £5,227.89.
- With a literature search, the authors showed that these results were also comparable to previous estimates of the cost-effectiveness of establishing comprehensive stroke services.
In conclusion, the authors recommend most importantly that primary and secondary prevention of stroke should be improved (especially identification and treatment of individuals with asymptomatic atrial fibrillation), implementation of comprehensive stroke services should be fostered, and access to timely and effective rehabilitation should be improved. Filling these gaps was shown to be cost-effective and could reduce the prolonged impairment, dependency and loss of productivity caused by stroke. Other recommendations for development of comprehensive stroke services referring to the Stroke Action Plan 2018-2030 (ESO) can be found in the paper itself below.
Webb, A.J.S., Fonseca, A.C., Berge, E., Randall, G., Fazekas, F., Norrving, B., Nivelle, E., Thijs, V., Vanhooren, G. and (2020), Value of treatment by comprehensive stroke services for the reduction of critical gaps in acute stroke care in Europe. Eur J Neurol. https://doi.org/10.1111/ene.14583
- Feigin VL, Forouzanfar MH, Krishnamurthi R, Mensah GA, Connor M, Bennett DA, et al. Global and regional burden of stroke during 1990-2010: Findings from the global burden of disease study 2010. Lancet. 2014;383:245-254
- Pendlebury ST, Rothwell PM. Prevalence, incidence, and factors associated with pre-stroke and post-stroke dementia: A systematic review and meta-analysis. Lancet Neurol. 2009;8:1006-1018.
- Norrving B, Barrick J, Davalos A, et al. Action Plan for Stroke in Europe 2018-2030. Eur Stroke J. 2018;3:309-336.