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Cost-Effectiveness of Echocardiography after Stroke
- Robert L. McNamara, MD, MHS;
- Joao A.C. Lima, MD; and
- Neil R. Powe, MD, MPH, MBA
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IN RESPONSE:
Tam and colleagues disagree with our recommendations and present the clinical algorithm used at their institution. The main difference between their proposed algorithm and our formal analysis lies in their recommendation for using TTE to select patients for TEE, a strategy that they admit has not been formally validated. We believe that clinical history plays a larger role in selecting patients who may benefit from TEE. In our analysis, the cost-effectiveness ratio for the strategy that includes TEE only for patients with a “cardiac history” was indeed lowest compared with no imaging and no treatment. Because the conditions constituting a cardiac history can range from restrictive (myocardial infarction) to broad (hypertension), the value of clinical history is difficult to quantify by using the evidence currently in the literature. Nonetheless, in the studies that reported on cardiac history, findings on TTE rarely changed management, confirming the results of Sansoy and colleagues [1].
More than half of the 1.8% incidence of complications for TEE in the study that Tam and colleagues cite [2] involved “minor adverse events” or “superficial thrombophlebitis”; only one patient died. This retrospective study did not have a control group, making attribution of clinical events difficult.
Dr. Korb postulates that the average length of stay for strokes would be increased if all patients with new-onset stroke were to have TEE. This may be true in some patients. However, there is no stipulation that TEE must be performed on an inpatient basis. In addition, bypassing the use of TTE before TEE may actually decrease length of stay. We also believe that cost-effectiveness analysis is a more comprehensive approach than the simpler analysis of the number needed to test. Decision analysis quantifies the tradeoffs by using explicitly stated values of probabilities, costs, and utilities of various outcomes. The threshold that society, a clinician, or a patient is willing to “pay” for better outcomes is left open to debate. Our analysis suggests that the strokes prevented may be “worth” the cost of TEE. In addition, we made the conservative assumption in our analysis that the only reason to perform echocardiography was to identify a thrombus. It remains to be seen whether treating other potential sources of intrathoracic emboli will reduce recurrent strokes.
Robert L. McNamara, MD, MHS
Joao A.C. Lima, MD
Neil R. Powe, MD, MPH, MBA
Johns Hopkins University; Baltimore, MD 21205
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
- Copyright ©2004 by the American College of Physicians
