Cost-effectiveness analysis of tissue plasminogen activator in acute ischemic stroke in Iran

Figures & data

Figure 1. (A) Long-run model used to simulate lifetime patient outcomes. (B) Short-run decision analytic model used to model cost-effectiveness analysis of tissue-type plasminogen activator.

Table 1. Markov model parameters and range of values for sensitivity analysis, per one patient.

	Base case	Sensitivity range	Distribution	Reference
Transition probabilities
Movement from independent to:
Independent	0.875	0.77–0.89		[22,26,27]
Dependent	0.0938	0.07–0.11		[22,26,27]
Movement from dependent to:
Independent	0.1111	0.03–0.18		[22,26,27]
Dependent	0.7407	0.65–0.81		[22,26,27]
Initial distribution
Independent	0.26	0.07–0.45		[24]
Dependent	0.55	0.36–0.74		[24]
Utility
Independent	0.74			[22,29]
Dependent	0.38			[22,29]
QALY*
Independent tPA	0.30	0.1–0.50	Uniform	[21,22]
Dependent tPA	0.12	0–0.32	Uniform	[21,22]
Independent no tPA	0.24	0.04–0.44	Uniform	[21,22]
Dependent no tPA	0.14	0–0.34	Uniform	[21,22]
Costs ($)
Independent tPA	636.10	224.9–1078	Lognormal
Dependent tPA	1,857.90	0–9,565	Lognormal
Death tPA	2,506.30	391.30–5,820	Lognormal
Independent no tPA	1,108.20	267–35,26.14	Lognormal
Dependent no tPA	1,846.50	239–11,038.90	Lognormal
Death no tPA	1,759.40	232.60–6,913.20	Lognormal

* Quality adjusted life year.

Table 2. Demographic characteristics.

	tPA	No tPA
Number of patients, n	47	47
Women, n	17	17
Age (mean)	69.7	70.7
Cost of tPA ($)	18,938.5	–
Third party payer costs ($)
Inpatient costs	84,605.64	80,835.20
Rehabilitation costs	2,768.68	6,095.61
Drugs	11,635	7,909.90
Inpatient visits	8,523.80	9,605.90
Surgery	740.60	581.20
Diagnostic	13,514.30	5,723.30
Laboratory	4,836.60	1,813.60

Table 3. Base-case analysis per 1,000 patients: Costs, QALYs, and ICER of tPA within 4.5 h of symptom onset compared with no tPA in patients with acute ischemic stroke.

Time horizon	Strategy	QALY	Cost ($)	ICER	ACER
1 year	tPA*	0.42	3,730.53	3,087.60	8,843.69
	No tPA	0.39	3,817.54		9,697.77
Life time	tPA	1.64	8,796.96	9,201.14	5,335.68
	No tPA	1.43	10,718.45		7,444.03

* Tissue type plasminogen activator.

Figure 2. Tornado diagram for uncertain parameters. Initial QALYs of tPA, transition probability and initial distribution had the greatest impact. Abbreviations. QALY, Quality Adjusted Life-Year; tPA, tissue type Plasminogen Activator; mRS, modified Rankin Scale; Pr, probability; Incr, Incremental.

Figure 3. Cost-effectiveness acceptability curve, favors treatment with intravenous tPA in the 4.5-h time window over no tPA from the perspective of a third party payer in Iran.

Table 4. Summarize the ICER and ACER for various countries (cost per QALY).

Study	Country	Unit cost	Unit effect	ACER		ICER
				tPA	No tPA
Sinclair et al. 2001	Canada	CAN $	QALY	785	1,105	109
Stahl et al. 2003	US	US $	QALY	18,984	19,156	43,400
Sandercock 2002/4	UK	£	QALY	11,545	13,301	96,565
Moodie et al. 2004	Australia	AUS$	DALYs	4,109	4,107	3,841
Mar et al. 2004	Spain	€	QALY	2,437	2,276	4,528
Ehlers et al. 2006	Denmark	US $	QALY	31,896	42,551	33,523
Araujo et al.	Brazil	R $	QALY	–	–	36,836
Tung et al. 2011	US	US $	QALY	16,008	15,724	21,978
Tanny et al. 2013	Australia	US $	QALY	62,104	65,619	2,002
Boudreau et al. 2013	US	US $	QALY	16,720	17,111	6,255
Boudreau et al. 2014	US	US $	QALY	66,993	80,102	64,102
Pan et al. 2014	China	CNY	QALY	24,209	25,016	15,473
Present study	Iran	US $	QALY	5,335	7,444	9,201

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