Transesophageal echocardiography generated a cost per QALY of $137,000 relative to standard treatment at 5% thrombus prevalence, dropping to $50,000 at ≥15% prevalence.
Is echocardiography cost-effective for identifying intracardiac thrombus in patients with new stroke or TIA?
Current evidence is insufficient to justify widespread use of echocardiography for identifying intracardiac thrombus in stroke patients due to uncertain cost-effectiveness.
BACKGROUND AND PURPOSE: Echocardiography to select stroke patients for targeted treatments, such as anticoagulation (AC), to reduce recurrent stroke risk is controversial. The authors' objective was to evaluate the cost-effectiveness of imaging strategies that use transthoracic (TTE) and transesophageal (TEE) echocardiography for identifying intracardiac thrombus in new stroke patients. METHODS: Model-based cost-effectiveness analysis of 7 echocardiographic imaging strategies and 2 nontesting strategies with model parameters based on systematic evidence review related to effectiveness of echocardiography in newly diagnosed ischemic stroke patients (white males aged 65 years in base case). Primary outcome was cost per quality-adjusted life year (QALY). RESULTS: All strategies containing TTE were dominated by others and were eliminated from the analysis. Assuming that AC reduces recurrent stroke risk from intracardiac thrombus by 43% over 1 year, TEE generated a cost per QALY of 137, 000 (relative to standard treatment) among patients with 5% thrombus prevalence. Cost per QALY dropped to 50, 000 in patients with at least 15% intracardiac thrombus prevalence, or, if an 86% relative risk reduction with AC is assumed, in patients with thrombus prevalence of at least 6%. Probabilistic analyses indicate considerable uncertainty around the cost-effectiveness of echocardiography across a wide range of intracardiac thrombus prevalence (pretest probability). CONCLUSIONS: Current evidence on cost-effectiveness is insufficient to justify widespread use of echocardiography in stroke patients. Additional research on recurrent stroke risk in patients with intracardiac thrombus and on the efficacy of AC in reducing that risk may contribute to a better understanding of the circumstances under which echocardiography will be cost-effective.
Meenan et al. (2007) studied First stroke or transient ischemic attack. Echocardiography (TTE and TEE) vs. Nontesting strategies (standard treatment) was evaluated on Cost per quality-adjusted life year (QALY). Transesophageal echocardiography generated a cost per QALY of $137,000 relative to standard treatment at 5% thrombus prevalence, dropping to $50,000 at ≥15% prevalence.
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