Abstract Body: Introduction: Disparities across race, ethnicity and socioeconomic factors exist in acute ischemic stroke (AIS) incident risk, treatment and outcomes. Tenecteplase, given within 4.5 hours of AIS symptom onset, has been shown to be noninferior to alteplase in reducing post-AIS disability, but its equity impacts are unknown. Distributional Cost Effectiveness Analysis (DCEA) is an established method for estimating health equity impacts by evaluating the distribution of health outcomes across equity-relevant subgroups before and after an intervention.
Objective: Using DCEA, evaluate the impact of tenecteplase use within 4.5 hours of AIS symptom onset on health equity in the US.
Methods: Leveraging published CEAs of alteplase, a DCEA of tenecteplase given within 4.5 hours of AIS symptom onset was built from a US payer perspective. The US population was divided into 25 equity-relevant subgroups based on race and ethnicity (5 census-based groups) and county-level social vulnerability index (quintiles). Inputs for AIS outcomes, incidence and receipt of tenecteplase were varied across subgroups based on published estimates obtained from a targeted literature review. Scenarios explored robustness of findings to variations in inputs and access assumptions.
Results: Annually in the US, use of tenecteplase is predicted to improve population health (54,550 QALYs gained) and reduce existing overall inequities. Larger relative health gains are expected in more vulnerable subgroups, specifically within historically marginalized groups and those in geographic areas with higher social vulnerability. Health benefits are driven by cost savings from reduced disability post hospital discharge, while equity benefits are driven by the higher risk of incident AIS in patients who currently have larger health disparities in life expectancy and quality of life. Conclusions were robust to scenario testing. Scenarios that reduced treatment gaps (eg, closing disparities in receipt of treatment and treatment timing) led to larger gains in health and further reduced existing inequalities.
Conclusions: Under current AIS incidence and thrombolytic utilization patterns in the US, use of tenecteplase given within 4.5 hours of AIS symptom onset is predicted to increase population health while also improving health equity. Closing care gaps to enable more timely and equitable thrombolytic access across race, ethnicity and geography can further improve equity benefits from tenecteplase use.