Should TIA patients be hospitalized or referred to a same-day clinic?: a decision analysis

Neurology. 2011 Dec 13;77(24):2082-8. doi: 10.1212/WNL.0b013e31823d763f. Epub 2011 Nov 16.

Abstract

Objective: For patients presenting with TIA, a previous study concluded that hospitalization is cost-effective compared to discharge without treatment from the emergency department. We performed a cost-effectiveness analysis of hospitalization vs urgent clinic evaluation following TIA.

Methods: Among a cohort of TIA patients, we created a decision tree model to compare the decision to hospitalize or refer to urgent-access specialty clinic. We estimated probabilities, utilities, and direct costs from the available literature and calculated incremental cost-effectiveness ratio (ICER). We assumed equal access to standard medical treatments between the 2 approaches; however, we estimated higher tissue plasminogen activator (tPA) utilization among hospitalized patients. We performed sensitivity analyses to assess all assumptions in our model.

Results: In patients with TIA aged 65-74 years, hospitalization yielded additional 0.00026 quality-adjusted life-years (QALYs) at 1 year, but at an additional cost of $5,573 per patient compared to urgent clinic evaluation (ICER = $21,434,615/QALY). Over 30 years, the ICER was $3,473,125/QALY. These results were not sensitive to varying 48-hour stroke risk, length of stay, tPA utilization rate, QALYs saved per tPA treatment, and hospitalization and clinic costs, and cost saved per tPA treatment.

Conclusion: Despite increased access to tPA in the hospital, we found that hospitalization is not cost-effective compared to same-day clinic evaluation following TIA. A very small fraction of patients benefits from hospitalization if urgent-access TIA clinics are available. The widespread development of urgent-access TIA clinics is warranted.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Cost-Benefit Analysis
  • Decision Support Techniques
  • Decision Trees
  • Female
  • Fibrinolytic Agents / economics
  • Hospitalization / economics*
  • Humans
  • Ischemic Attack, Transient / economics*
  • Ischemic Attack, Transient / therapy
  • Male
  • Models, Economic
  • Quality-Adjusted Life Years
  • Referral and Consultation / economics*
  • Tissue Plasminogen Activator / economics

Substances

  • Fibrinolytic Agents
  • Tissue Plasminogen Activator