Cost-Effectiveness of Prehospital Delay Reduction Versus Primary Stroke Prevention in US Adults With Type 2 Diabetes

BACKGROUND: Much attention has focused on reducing prehospital delay among patients with acute ischemic stroke (AIS) to facilitate delivery of highly effective but time-sensitive treatments. The relative benefits and cost-effectiveness of minimizing treatment delays versus more fully implementing primary prevention measures for AIS are unclear in high-risk populations, including US adults with type 2 diabetes. METHODS: We used data from the National Health and Nutrition Examination Survey (2015-2018) to identify US adults ≥45 years of age with type 2 diabetes and no prior stroke (N=1232). Stroke incidence, quality-adjusted life-years, and healthcare costs over 10 years were projected using the Michigan Model for Diabetes, a validated microsimulation model. Three scenarios were compared: (1) status quo (50% of patients with AIS arrive within 24 hours; 28% within 3.5 hours; average population-level adherence to preventive strategies); (2) optimized hospital arrival time (all patients with stroke arriving within 24 hours [50%] arrive within 3.5 hours); and (3) full implementation of 4 primary prevention strategies (blood pressure control, statin therapy, smoking cessation, and aspirin). Analyses were conducted from a health system/payer perspective. RESULTS: The study population has a weighted mean age of 64 and 56.1% males. Improving hospital arrival times to 50% within 3.5 hours was cost-effective (incremental cost-effectiveness ratio: $41 624 per quality-adjusted life-year gained), preventing 10 900 cases of stroke-related major disability and 6700 stroke deaths, and yielding an increase of 18 300 quality-adjusted life-years nationwide at a cost of $0.63 billion over 10 years. Universal adoption of primary prevention strategies averted 68 900 cases of stroke-related major disability and 61 900 stroke deaths with a gain of 1 418 000 quality-adjusted life-years nationwide and savings of $13.4 billion over 10 years. CONCLUSIONS: Although reducing prehospital delay in AIS treatment may be cost-effective, broad adoption of recommended primary prevention strategies for AIS in US adults with type 2 diabetes confers substantially greater health and economic benefits. The significance of preventive medicine, such as controlling hypertension and dyslipidemia, smoking cessation, and aspirin therapy, cannot be overstated for individuals with type 2 diabetes.