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Best Test and Treatment for Stroke Patients Determined
Researchers have determined which combination of diagnostic and treatment techniques is most cost-effective in preventing a repeated stroke in persons having their first stroke. Those stroke patients who receive a relatively new imaging procedure called transesophageal echocardiography (TEE) and have their treatment based on the tests results likely will have significantly fewer strokes later on, with improved quality of life and decreased medical costs. In contrast, another older imaging method widely used in stroke patients, transthoracic echocardiography (TTE), often does not see clots in a particular region of the heart where many clots form, thus leaving patients vulnerable to recurrent strokes and higher medical costs. The study appeared in the November 1 issue of the Annals of Internal Medicine.
By reviewing evidence on case histories of first-time stroke patients in the medical literature, the researchers were able to compare the benefits, risks, and cost effectiveness of various imaging strategies. Neil R. Powe, MD, MPH, Director of the Evidence-Based Practice Center at the Johns Hopkins School of Public Health and senior author said, "Although a variety of cardiovascular imaging techniques are now used to locate emboli in patients after stroke, until now the most cost-effective technique for preventing future strokes and improving quality of life had not been determined. Physicians often perform tests sequentially, ordering the least costly and invasive test first followed by the more expensive. For first time stroke patients this is not cost-effective and may not be in the patient's best interest."
Because strokes that are caused by clots traveling in the blood (emboli) carry the greatest risk of subsequent emboli-induced strokes, identifying potential sources of cardiovascular emboli and then dissolving any new clots with anticoagulation therapy (ACT) is crucial in reducing the incidence of later strokes. Anticoagulation therapy, however, cannot be given indiscriminately to all stroke patients because it can sometimes rupture weak blood vessels in the brain and trigger a hemorrhagic stroke.
The case histories studied revealed that when the decision to give anticoagulation therapy was based on diagnostic images from TEE alone, the number of recurrent strokes was reduced, and that the better patient outcomes made TEE more cost-effective than redundant, sequential testing strategies or less aggressive management options.
The least aggressive treatment option--not giving anticoagulation therapy to any first-stroke patient--was the least expensive initially but, because this group suffered more emboli-induced strokes later on, the no-ACT option was ultimately more expensive than giving ACT when indicated by TEE. Similarly, those patients in the most aggressively treated group, in which all first-time stroke patients received ACT without an imaging test, had a higher-than-average incidence of intracranial hemorrhage and thus higher costs.
No diagnostic or treatment method based on the older and widely used transthoracic echocardiology was cost-effective, due its inability to spot some emboli. Even when TTE was combined with TEE, medical costs increased and outcomes did not improve compared to when TEE was used by itself.
Robert L. McNamara, MD, MHS, the principal investigator of the study, attributes TEE's greater cost effectiveness to two things. "First, it is a very sensitive imaging technique that can accurately identify left atrial thrombi; second, improved outcomes in the group studied by TEE more than compensate for the test's initial expense."
In the United States, stroke occurs in half a million people each year, is leading cause of long-term illness and death, and costs $15 billion to $30 billion annually.
The study was funded in part by grants from the National Heart, Lung, and Blood Institute, the National Institute on Aging, and the National Center for Research Resources, National Institute of Health.
In addition to Drs. McNamara and Powe, other authors of the study include Joao A.C. Lima, MD and Paul Whelton, MD, MSc.
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