You are here

  • Home
  • Archive
  • Volume 38, Issue 1
  • Secondary transfer of emergency stroke patients eligible for mechanical thrombectomy by air in rural England: economic evaluation and considerations

Article Text

Article menu
Original research
Secondary transfer of emergency stroke patients eligible for mechanical thrombectomy by air in rural England: economic evaluation and considerations
  1. Diarmuid Coughlan1,
  2. Peter McMeekin2,
  3. Darren Flynn3,
  4. Gary A Ford4,5,
  5. Hannah Lumley5,
  6. David Burgess6,
  7. Joyce Balami7,
  8. Andrew Mawson8,
  9. Dawn Craig1,
  10. Stephen Rice1,
  11. Phil White5
  1. 1 Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
  2. 2 Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
  3. 3 School of Health and Social Care, Teesside University, Middlesbrough, UK
  4. 4 Oxford University Hospitals NHS Trust, Oxford, UK
  5. 5 Institute of Neuroscience (Stroke Research Group), Newcastle University, Newcastle upon Tyne, UK
  6. 6 North East and North Cumbria Stroke Patient & Carer Panel, Newcastle upon Tyne, UK
  7. 7 Kellogg College, University of Oxford, Oxford, UK
  8. 8 Great North Air Ambulance, Northumberland Wing, The Imperial Centre, Darlington, UK
  1. Correspondence to Professor Phil White, Institute of Neuroscience (Stroke Research Group), Newcastle University, Newcastle upon Tyne, UK; phil.white{at}newcastle.ac.uk

Abstract

Background Mechanical thrombectomy (MT) is a time-sensitive emergency procedure for patients who had ischaemic stroke leading to improved health outcomes. Health systems need to ensure that MT is delivered to as many patients as quickly as possible. Using decision modelling, we aimed to evaluate the cost-effectiveness of secondary transfer by helicopter emergency medical services (HEMS) compared with ground emergency medical services (GEMS) of rural patients eligible for MT in England.

Methods The model consisted of (1) a short-run decision tree with two branches, representing secondary transfer transportation strategies and (2) a long-run Markov model for a theoretical population of rural patients with a confirmed ischaemic stroke. Strategies were compared by lifetime costs: quality-adjusted life years (QALYs), incremental cost per QALY gained and net monetary benefit. Sensitivity and scenario analyses explored uncertainty around parameter values.

Results We used the base case of early-presenting (<6 hours to arterial puncture) patient aged 75 years who had stroke to compare HEMS and GEMS. This produced an incremental cost-effectiveness ratio (ICER) of £28 027 when a 60 min reduction in travel time was assumed. Scenario analyses showed the importance of the reduction in travel time and futile transfers in lowering ICERs. For late presenting (>6 hours to arterial puncture), ground transportation is the dominant strategy.

Conclusion Our model indicates that using HEMS to transfer patients who had stroke eligible for MT from remote hospitals in England may be cost-effective when: travel time is reduced by at least 60 min compared with GEMS, and a £30 000/QALY threshold is used for decision-making. However, several other logistic considerations may impact on the use of air transportation.

  • stroke
  • thromboembolic diseasex
  • management
  • emergency ambulance systems
  • helicopter retrieval
  • emergency care systems
  • remote and rural medicine
https://creativecommons.org/licenses/by/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.

https://doi.org/10.1136/emermed-2019-209039

Statistics from Altmetric.com

    Request Permissions

    If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

    View Full Text

    Supplementary materials

    • Supplementary Data

      This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

    • Supplementary Data

      This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

    Footnotes

    • Handling editor Caroline Leech

    • Twitter @D6Coughlan

    • Correction notice This paper has been updated since first published to make revision in table headers.

    • Contributors PW, GAF, PM and DF conceived the presented idea. DC carried out the analysis with input from SR, DC, PM, DF and HL. DC, PM and PW drafted the manuscript and all coauthors contributed to the final version. DC is responsible for the overall content as guarantor.

    • Funding Department of Health and Social Care, National Institute for Health Research. Programme Grants for Applied Research. Grant/Award Number: RP-PG-1211–20012.

    • Disclaimer The views expressed are those of the author(s) and not necessarily those of the NHS, the National Institute for Health Research (NIHR) or the Department of Health.

    • Competing interests This paper summarises independent research funded by the NIHR under its Programme Grant for Applied Research Programme (RP-PG-1211-20012). PW is the co-principal investigator for two randomised thrombectomy trials (PISTE and STABILISE) in acute stroke. Start-up phase of PISTE was mainly funded by the Stroke Association but was also part-funded by unrestricted educational grants from Covidien (now Medtronic) and Codman who manufacture stroke thrombectomy devices. STABILISE is part-funded by Microvention grant to Newcastle University. PW has undertaken consultancy work for Stryker, Codman and Microvention who manufacture stroke thrombectomy devices. GAF’s previous institution has received research grants from Boehringer Ingelheim (manufacturer of alteplase), and honoraria from Lundbeck for stroke-related activities. GAF has also received personal remuneration for educational and advisory work from Boehringer Ingelheim and Lundbeck.

    • Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

    • Patient consent for publication Not required.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data availability statement Data are available on reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information.