Xiao WuFollow

Date of Award

January 2020

Document Type


Degree Name

Medical Doctor (MD)



First Advisor

Ajay Malhotra


The purpose of this study was to examine the practice of recent cost-effectiveness analyses (CEA) on endovascular treatment (EVT) in ischemic stroke patients, with a particularly focus on methodological conduct of accounting for costs and utilities.

We performed a literature search in Ovid Embase, Ovid MEDLINE, and Web of Science for CEAs published in the last 10 years on EVT. Cost or comparative effectiveness analyses were excluded.

Twenty-two studies were included in the final analysis, from the United States, Canada, Europe, Asia, and Australia. They all concluded EVT to be cost-effective, but with significant variations in methodology. Fifteen studies employed a long-term horizon (>20 years), while only 11 incorporated risk of recurrent strokes. The willingness-to-pay (WTP) threshold varied from $10,000/quality-adjusted life year (QALY to $120,000/QALY, with $50,000/QALY and $100,000/QALY being the most commonly used ones. Five studies undertook a societal perspective, but only one accounted for indirect costs. Gamma distribution was most commonly assigned to cost-parameters (7 studies). Eighteen studies based outcomes on 90-day modified Rankin Scale (mRS) scores, and 9 of these 18 studies grouped outcomes by mRS 0-2 and 3-5. Eight studies included 7 terminal states, one for each mRS score.

In conclusion, our study reveals significant heterogeneity in previously published stroke thrombectomy CEAs. There is significant gap between the current practice and the latest recommendations from the Second Panel on Cost-Effectiveness Analysis in Health and Medicine. Our study highlights the need for more practical guidelines to allow for better definition and standardization in future CEAs.


This thesis is restricted to Yale network users only. It will be made publicly available on 09/10/2022