For patients with a transient ischemic attack (TIA), hospitalization does not appear to be cost-effective compared with urgent, same-day evaluation in a specialized clinic, according to a new study.

Researchers at Rush University Medical Center (Chicago, IL, USA) created a decision tree model to compare hospitalizing TIA patients or referring them to an urgent-access specialty clinic. To do so, the researchers estimated probabilities, utilities, and direct costs from the available literature, and calculated the incremental cost-effectiveness ratio (ICER). Equal access to standard medical treatments between the two approaches was assumed, but the researchers estimated higher tissue plasminogen activator (tPA) utilization among hospitalized patients. Sensitivity analyses were done to assess all assumptions in the model.

The resulting statistical model showed that hospitalization resulted in a slight increase in quality-adjusted life years (QALYs), which was offset by a much higher price tag. The cost of a hospital stay was estimated to be USD 3,052 per day, while the total cost of an evaluation in an urgent-access clinic was estimated to be only USD 528, including the cost of the visit, computerized tomography (CT) scans of the head, and carotid ultrasound. The cost savings for each tPA treatment--considering both acute care and long-term care through 30 years--was estimated at USD 6,762.

At one year, the ICER would be USD 21.4 million per QALY, well over the traditional threshold of USD 50,000 per QALY used to assess cost-effectiveness. In the long-term analysis, the researchers concluded that hospitalization would be cost-effective if the 48-hour stroke risk were greater than about 20%, and only when using a cost-effectiveness threshold of USD 100,000 per QALY. The study was published in the December 13, 2011, issue of Neurology.

“TIA clinics probably will not work for all patients; [some] patients may have high-risk conditions, such as intracranial or extracranial stenosis, crescendo TIA, or cardioembolic sources,” concluded lead author Shyam Prabhakaran, MD, of, and colleagues. “Through the use of risk stratification tools, a more rational approach could emerge that selectively triages very high-risk patients for hospitalization based on risk factors, clinical features, imaging results, and presumed mechanism.”

TIA, often referred to as “mini stroke,” is a transient episode of neurologic dysfunction caused by ischemia without acute infarction. TIAs share the same underlying etiology and the same symptoms as stroke, and may cause sudden dimming or loss of vision, aphasia, slurred speech, and mental confusion. However, unlike a stroke, the symptoms of a TIA can resolve within a few minutes or 24 hours. Having a TIA is a risk factor for eventually having a stroke or a silent cerebral infarct (SCI), which may cause long lasting neurological dysfunction affecting such areas as mood, personality, and cognition.
 

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