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1 November 1997 | Volume 127 Issue 9 | Pages 775-787
Background: No consensus exists about the use of imaging strategies to identify potential cardiovascular sources of emboli in patients who have had strokes.
Objective: To determine the cost-effectiveness of various cardiac imaging strategies after stroke.
Design: A Markov model decision analysis was used to evaluate the benefits and costs of nine diagnostic strategies, including transthoracic echocardiography, transesophageal echocardiography, sequential approaches, selective imaging, and no imaging.
Setting: Simulated clinical practice in the United States.
Patients: Hypothetical patients with a first stroke who were in normal sinus rhythm.
Measurements: Echocardiographic detection rates of potential sources of emboli were ascertained by doing a systematic review of the literature. Values for event rates, anticoagulation effects, utilities, and costs were obtained from the literature and Medicare data.
Results: When visualized left atrial thrombus was used as the only indication for anticoagulation, transesophageal echocardiography performed only in patients with a history of cardiac problems cost $9000 per quality-adjusted life-year; transesophageal echocardiography in all patients cost $13 000 per quality-adjusted life-year. Cost savings and decreased morbidity and mortality rates associated with reduction in preventable recurrent strokes substantially offset examination costs and risks of anticoagulation. These results were moderately sensitive to efficacy of anticoagulation and incidence of intracranial bleeding during anticoagulation and were mildly sensitive to prevalence of left atrial thrombus, rate of recurrent stroke in patients with thrombus, quality of life after stroke, cost of transesophageal echocardiography, and specificity of transesophageal echocardiography. Transthoracic echocardiography, alone or in sequence with transesophageal echocardiography, was not cost-effective compared with transesophageal echocardiography.
Conclusion: Physicians should consider doing transesophageal echocardiography in all patients with new-onset stroke.
Author and Article Information
For author affiliations and current author addresses, see end of text.
ARTICLE
Echocardiographic Identification of Cardiovascular Sources of Emboli To Guide Clinical Management of Stroke: A Cost-Effectiveness Analysis
For definitions of terms used, see Glossary at end of text.
Grant Support: In part by training grant T32 HL07024-21 from the National Heart, Lung, and Blood Institute, Bethesda, Maryland (Dr. McNamara); grant KO1 AG00561 from the National Institute on Aging, Bethesda, Maryland (Dr. Powe); and General Clinical Research Grant 5M01RR00722 from the National Center for Research Resources, National Institutes of Health.
Requests for Reprints: Neil R. Powe, MD, MPH, MBA, Welch Center for Prevention, Epidemiology, and Clinical Research, The Johns Hopkins Medical Institutions, 2024 East Monument Street, Suite 2-645, Baltimore, MD 21250-2223.
Current Author Addresses: Dr. McNamara, MD, MHS, School of Hygiene and Public Health, Room 6009, 615 North Wolfe Street, Baltimore, MD 21117.
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