Assessing the clinical and cost-effective resource implications of mechanical thrombectomy for the treatment of acute ischaemic stroke within the NHS

Stroke is a major health issue associated with severe disability and high mortality, particularly in acute ischaemic stroke (AIS) due to large artery occlusion (LAO). Early and complete recanlisation can lead to improved functional outcomes and reduced mortality. Mechanical thrombectomy (MT) with intravenous thrombolysis (IVT) is the most effective treatment for acute ischaemic stroke due to LAO. Yet the true cost of delivering the treatment within the National Health Service (NHS) has not been previously fully established. This study aims to fill that information gap and provide better estimates of the costs and drivers of costs of providing MT within the NHS. The study begins with an evaluation of the evidence of the clinical benefit of MT with IVT by conducting a systematic review and meta-analysis of thrombectomy trials. Alternative treatment pathways are identified, and the resources used, for them, to determine the related unit costs along each identified treatment pathway using MT and IVT and various combinations. Through a comprehensive approach to measuring costs, the true cost of delivering MT and the main drivers of costs are also determined. The mean cost within 24 hours per patient treated with MT +/- IVT was £10,866 (standard deviation (SD) £2,801), with MT procedure accounting for 73% (£7,943/£10,866) of the 24-hour cost and devices, accounting for 65% (£5,176/ £7,943) of the procedure cost. The mean cost was £14,369 (SD £6,664) after 24 hours until discharge from MT centre (2018 prices). Next, the application of micro-costing data in an economic evaluation model provided health economic evidence and showed achievable cost-savings from health and social care; and societal perspectives. The research carried out for this thesis has contributed to the literature for the treatment of AIS by: confirming the clinical benefits of MT; identifying variations in treatment of MT and IVT in different centres in the UK and other countries; and by establishing the comprehensive costs of delivering MT. It has demonstrated clear evidence of the benefits of MT for the treatment of AIS for restoring patients’ functional independence to optimal levels and reducing avoidable morbidity. It concludes that MT with IVT is cost-effective when compared with standard care and associated cost-savings. This thesis provides clinicians, researchers, hospital managers and policy makers with more accurate and comprehensive information than previously available on the community-based costs of delivering MT within the clinical setting of the United Kingdom’s NHS.