Can Quality-Adjusted Life-Years and Subgroups Help Us Decide Whether to Treat Late-Arriving Stroke Patients with Tissue Plasminogen Activator?

Treatment of stroke patients is highly time-sensitive. The risk of death or disability caused by intracranial hemorrhage may increase with both stroke size and time. The effectiveness of an innovative but risky therapy for strokes, recombinant tissue plasminogen activator (rtPA), is thought to decrease with the time between symptom onset and drug administration. This tradeoff underlies the question faced by clinicians as they treat stroke patients who, as most do, arrive too late for treatment within the 3-hour window: Do the diminishing benefits of rtPA outweigh the increasing risks? This commentary examines this issue in light of recent studies and assesses the relevance of cost-effectiveness analyses in deciding whether to use rtPA. The authors conclude that with regard to the treatment of late-arriving stroke patients, the question should not be whether rtPA is cost-effective but whether it does more good than harm. In the absence of data about efficacy, this question cannot be answered.