Analyzing Cost-Effectiveness of Allocating Neurointerventionist for Drive and Retrieve System for Patients with Acute Ischemic Stroke


      • DRS was considered in terms of both cost-effectiveness and accessibility.
      • Cost-effectiveness of allocating a neurointerventionist by policy was evaluated.
      • Our analyze clarified in which area DRS would be cost-effective.
      • 100 repetitions conducted to consider the effect of uncertainty in patient locations.
      • Costs for DRS paid by the government was comprehensively included for the analysis.



      There are regional disparities in implementation rates of endovascular thrombectomy due to time and resource constraints such as endovascular thrombectomy specialists. In Hokkaido, Japan, Drive and Retrieve System (DRS), where endovascular thrombectomy specialists perform early endovascular thrombectomies by traveling from the facilities where they normally work to facilities closer to the patient. This study analyzed the cost-effectiveness of allocating a endovascular thrombectomy specialist for DRS to treat stroke patients.

      Materials and methods

      he number of ischemic stroke patients expected to receive endovascular thrombectomy in Hokkaido in 2015 was estimated. It was assumed that an additional neutointerventionist was allocated for DRS. The analysis was performed from the government's perspective, which includes medical and nursing-care costs, and the personnel cost for endovascular thrombectomy specialist. The analysis was conducted comparing the current scenario, where patients received endovascular thrombectomy in facilities where endovascular thrombectomy specialists normally work, with the scenario with DRS within 60 min drive distance. Patient transport time was analyzed using geographic information system, and patient severity was estimated from the transport time. The primary outcome was incremental cost-effectiveness ratio (ICER) in each medical area which was calculated from the incremental costs and the incremental quality-adjusted life years (QALYs), estimated from patient severity using published literature. The entire process was repeated 100 times.


      DRS was most cost-effective in Kamikawachubu area, where the ICER was $14,173±16,802/QALY, significantly lower than the threshold that the Japanese guideline suggested.


      Since DRS was cost-effective in Kamikawachubu area, the area should be prioritized when a endovascular thrombectomy specialist for DRS is allocated as a policy.

      Key Words

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      1. The Ministry of Health Labour and Welfare. Survey on the Trend of Medical Care Expenditures FY2017.
        2019 (Available at) (Accessed on November 18) (In Japanese)
      2. The ministry of health labour and welfare.
        Comprehensive Survey of Living Conditions. 27. 2013 (nursing care. Avaiable at) (accessd on September2018) (In Japanese)
        • Kobayashi H.
        • The Japanese Stroke Databank
        Total Medical Fees. Nakayama Shoten.
      3. The Ministry of Health Labour and Welfare. Stroke and cardiovascular disease control act.
        May 24, 2020 (available at) (Accessed onJapanese)
        • Berkhemer OA
        • Fransen PS
        • Beumer D
        • et al.
        A randomized trial of intraarterial treatment for acute ischemic stroke.
        N Engl J Med. 2015; 372: 11-20
        • Goyal M
        • Demchuk AM
        • Menon BK
        • et al.
        Randomized assessment of rapid endovascular treatment of ischemic stroke.
        N Engl J Med. 2015; 372: 1019-1030
        • Campbell BC
        • Mitchell PJ
        • Kleinig TJ
        • et al.
        Endovascular therapy for ischemic stroke with perfusion-imaging selection.
        N Engl J Med. 2015; 12 (372): 1009-1018
        • Savor JL
        • Goyal M
        • Bonafe
        • et al.
        Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke.
        N Engl J Med. 2015; 372: 2285-2295
        • Saver JL
        • Goyal M
        • van der LA
        • et al.
        Time to treatment with endovascular thrombectomy and outcomes from ischemic stroke: a meta-analysis.
        JAMA-J Am Med Associat. 2016; 316: 1279-1288
        • Guideline for the proper use of mechanical thrombectomy device
        The Second Edition: A Guideline from the Japan Stroke Society (the 3rd version 2019).
        the Japan Neurosurgical Society and the Japanese Society for Neuroendovascular Therapy, 2021 (In Japanese)
        • Morii Y
        • Osanai T
        • Ishikawa T
        • et al.
        Cost effectiveness of drive and retrieve system in hokkaido for acute ischemic stroke patient treatment using geographic information system.
        J Stroke Cerebrovasc Dis. 2019; 28: 2292-2301
        • Hashi K.
        Present status of intravenous rt-PA therapy and regional difference in its availability in Japan.
        Jpn J Stroke. 2010; 32 (in Japanese): 770-772
        • the government of Hokkaido. Hokkaido
        Hokkaido Healthcare Plan.
        2018 ([revised edition]Available at) (Accessed May 24, 2020) (In Japanese)
        • Fujiwara K
        • Osanai T
        • Kobayashi E
        • et al.
        Accessibility to tertiary stroke centers in Hokkaido, Japan: use of novel metrics to assess acute stroke care quality.
        J Stroke aCerebrovasc Dis. 2018; 27: 177-184
      4. Hokkaido University, Department of neurosurgery, graduate school of medicine, Hokkaido University. Clinical Research Available at on November 19, 2019 ) (In Japanese).

        • Osanai T
        • Ito Y
        • Ushikoshi S
        • et al.
        Efficacy of "Drive and Retrieve" as a cooperative method for the prompt endovascular treatment for acute ischemic stroke.
        J Neurointerv Surg. 2019;
        • Fukuda T
        • Shiroiwa T
        • Ikeda S
        • et al.
        Guideline for economic evaluation of healthcare technologies in Japan.
        J Natl Inst Public Health. 2013; 62 (In Japanese): 625-640
      5. Statistics Bureau, The ministry of internal affairs and communication. The Census 2015. Available at (Accessed on November 19, 2019) (In Japanese).

        • Takashima N
        • Arima H
        • Kita Y
        • et al.
        Management and short-term outcome of stroke in a general population of 1.4 million Japanese.
        Circ J. 2017; 81: 1636-1646
        • National Institute of Health and Care Excellence
        The guideline manual. 7 Assessing cost effectiveness. 17. 2018 (Available at) (Accessed Octover)
        • Finance Yahoo
        FX Chart Rate. Available at.
        2020 (Accessed on December 4.) (In Japanese)
        • Hokkaido Division of the Japanese Society for Neuro Endovascular Therapy
        Specialists in Hokkaido.
        2017 (Available at: (Accessed June 5) (In Japanese))
        • Spokoyny I
        • Raman R
        • Ernstrom K
        • et al.
        Accuracy of first recorded “last known normal” times of stroke code patients.
        J Stroke Cerebrovasc Dis. 2015; 24: 2467-2473
        • Hattori N
        • Hirayama T
        • Katayama Y.
        Med Care Chronic-Phase Stroke Japan. 2012; 52: 175-180
      6. ELSEVIER. Today's clinical support. Available at (Accessed on December 4, 2020 ) (In Japanese).

        • Yamaga Mika
        • Ikeda Shunya
        Cost of illness after stroke.
        J Internat Univ Health Welfare. 2016; 21 (In Japanese): 82-92
        • The Ministry of Health Labour and Welfare
        Basic Survey on Wage Structure FY2018.
        2019 (Available at) (=000001011429 ) (Accessed on December 6) (In Japanese))
      7. Japan Pension Service. Insurance premiums table. Available at Accessed on December 6, 2019 (In Japanese).

      8. The Ministry of Health Labour and Welfare. Employment insurance rate FY2019. Available at (Accessed on December 6, 2019 ) (In Japanese).

      9. The Ministry of Health Labour and Welfare. Workers’ accident compensation insurance, insurance premiums table FY2018. Available at ) (Accessed on December 6, 2019 ) (In Japanese).

        • Agency for Natural Resources and Energy
        Ministry of economy, trade and industry.
        Survey on the Price of Petroleum Products. 2019 (Available at) (Accessed on December 6) (In Japanese)
        • Nogueira RG
        • Jadhav AP
        • Haussen DC
        • et al.
        Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct.
        N Engl J Med. 2018; 378: 11-21
        • Albers GW
        • Marks MP
        • Kemp S
        • et al.
        Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging.
        N Engl J Med. 2018; 378: 708-718