Cost-effectiveness of mechanical thrombectomy for acute ischemic stroke: generalizability across implementation settings

BACKGROUND AND PURPOSE: Mechanical thrombectomy (MT) is a cost–effective treatment for large–vessel occlusion stroke. However, existing economic evaluations rely on restrictive assumptions regarding care pathways and resource use, limiting their applicability to real–world implementation. We evaluated the cost and cost–effectiveness implications of implementing MT across alternative, empirically observed clinical pathways in England to address this source of decision uncertainty. METHODS: A state–transition Markov model was populated with detailed United Kingdom clinical, outcome, and micro–costing data from five thrombectomy centres in England to compare MT with standard care. Alternative implementation scenarios reflected real–world variation in treatment pathways, including intervention–centre type, anaesthesia use, intensive care unit setting, and models of care. Scenarios were characterised using detailed pathway and cost data. Costs and quality–adjusted life–years were evaluated over a 5–year time horizon from National Health Service and societal perspectives. RESULTS: Mean procedural costs for MT were £6,135 (95% CI, £5,961–£6,318) per patient in the primary analysis, compared with £7,283 in the earlier protocol–based model. Over 5 years, MT was a dominant intervention, associated with both lower costs and improved health outcomes compared with standard care. Mean cost savings were £2,297 per patient, corresponding to an estimated annual saving of £52.6 million if all 22,908 potentially eligible patients were treated. Across all five centres and implementation scenarios, incremental cost–effectiveness ratios consistently remained below currently accepted willingness–to–pay thresholds per quality–adjusted life–year gained. CONCLUSIONS: Across a range of real–world clinical pathways, MT is highly likely to be a cost–saving alternative to current practice and cost–effective at current health opportunity–cost thresholds. These findings suggest that cost–effectiveness is robust to local variation in service delivery and support broader implementation of MT within the English stroke–care system.