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Cost-Effectiveness of Echocardiography to Identify Intracardiac Thrombus among Patients with First Stroke or Transient Ischemic Attack

Center for health Research,Portland, Richard.meenan{at}kpchr.org, Center for Health Research, Kaiser Permanente Northwest, Portland, OR, Section of General Internal Medicine, Portland VA Medical Center, Portland, OR

Somnath Saha, MD, MPH

Oregon Health & Science University, Portland, Center for Health Research, Kaiser Permanente Northwest, Portland, OR

Roger Chou, MD

Section of General Internal Medicine, Portland VA Medical Center, Portland, OR

Karleen Swarztrauber, MD, MPH

Department of Neurology, Oregon Health & Science University, Portland

Kathryn Pyle Krages, AMLS, MA

Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, Portland, OR

Maureen C. O'Keeffe-Rosetti, MS

Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, Portland, OR

Marian McDonagh, PharmD

Center for Health Research, Kaiser Permanente Northwest, Portland, OR

Benjamin K. S. Chan, MS

Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, Portland, OR

Mark C. Hornbrook, PhD

Center for Health Research, Kaiser Permanente Northwest, Portland, OR

Mark Helfand, MD, MPH

Section of General Internal Medicine, Portland VA Medical Center, Portland, OR

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. Key words: cost-effectiveness; decision analysis; stroke; transesophageal echocardiography; transthoracic echocardiography; diagnostic imaging. (Med Decis Making 2007;27:161—177)

Medical Decision Making, Vol. 27, No. 2, 161-177 (2007)
DOI: 10.1177/0272989X06297388


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