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

Jay K. Joshi, Bichun Ouyang, Shyam Prabhakaran*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

41 Scopus citations

Abstract

Objective: For patients presenting with TIA, a previous study concluded that hospitalization is costeffective 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.

Original languageEnglish (US)
Pages (from-to)2082-2088
Number of pages7
JournalNeurology
Volume77
Issue number24
DOIs
StatePublished - Dec 13 2011

ASJC Scopus subject areas

  • Clinical Neurology

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