Echocardiographic identification of cardiovascular sources of emboli to guide clinical management of stroke: A cost-effectiveness analysis

Robert L. McNamara, Joao Lima, Paul K. Whelton, Neil R. Powe

Research output: Contribution to journalArticle

Abstract

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.

Original languageEnglish (US)
Pages (from-to)775-787
Number of pages13
JournalAnnals of Internal Medicine
Volume127
Issue number9
StatePublished - Nov 1 1997

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Transesophageal Echocardiography
Embolism
Cost-Benefit Analysis
Stroke
Costs and Cost Analysis
Thrombosis
Quality-Adjusted Life Years
Echocardiography
Decision Support Techniques
Cost Savings
Medicare
Quality of Life
Hemorrhage
Morbidity
Physicians
Mortality
Incidence

ASJC Scopus subject areas

  • Medicine(all)

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Echocardiographic identification of cardiovascular sources of emboli to guide clinical management of stroke : A cost-effectiveness analysis. / McNamara, Robert L.; Lima, Joao; Whelton, Paul K.; Powe, Neil R.

In: Annals of Internal Medicine, Vol. 127, No. 9, 01.11.1997, p. 775-787.

Research output: Contribution to journalArticle

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