Secondary transfer of emergency stroke patients eligible for mechanical thrombectomy by air in rural England: Economic evaluation and considerations

DIarmuid Coughlan, Peter McMeekin, Darren Flynn, Gary A. Ford, Hannah Lumley, David Burgess, Joyce Balami, Andrew Mawson, Dawn Craig, Stephen Rice, Phil White*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review


Background Mechanical thrombectomy (MT) is a time-sensitive emergency procedure for patients who had ischaemic stroke leading to improved health outcomes. Health systems need to ensure that MT is delivered to as many patients as quickly as possible. Using decision modelling, we aimed to evaluate the cost-effectiveness of secondary transfer by helicopter emergency medical services (HEMS) compared with ground emergency medical services (GEMS) of rural patients eligible for MT in England. Methods The model consisted of (1) a short-run decision tree with two branches, representing secondary transfer transportation strategies and (2) a long-run Markov model for a theoretical population of rural patients with a confirmed ischaemic stroke. Strategies were compared by lifetime costs: quality-adjusted life years (QALYs), incremental cost per QALY gained and net monetary benefit. Sensitivity and scenario analyses explored uncertainty around parameter values. Results We used the base case of early-presenting (<6 hours to arterial puncture) patient aged 75 years who had stroke to compare HEMS and GEMS. This produced an incremental cost-effectiveness ratio (ICER) of £28 027 when a 60 min reduction in travel time was assumed. Scenario analyses showed the importance of the reduction in travel time and futile transfers in lowering ICERs. For late presenting (>6 hours to arterial puncture), ground transportation is the dominant strategy. Conclusion Our model indicates that using HEMS to transfer patients who had stroke eligible for MT from remote hospitals in England may be cost-effective when: travel time is reduced by at least 60 min compared with GEMS, and a £30 000/QALY threshold is used for decision-making. However, several other logistic considerations may impact on the use of air transportation.

Original languageEnglish
Pages (from-to)33-39
Number of pages7
JournalEmergency Medicine Journal
Issue number1
Early online date10 Nov 2020
Publication statusPublished - 1 Jan 2021

Bibliographical note

Funding Information:
Competing interests This paper summarises independent research funded by the NIHR under its Programme Grant for Applied Research Programme (RP-PG-1211-20012). PW is the co-principal investigator for two randomised thrombectomy trials (PISTE and STABILISE) in acute stroke. Start-up phase of PISTE was mainly funded by the Stroke Association but was also part-funded by unrestricted educational grants from Covidien (now Medtronic) and Codman who manufacture stroke thrombectomy devices. STABILISE is part-funded by Microvention grant to Newcastle University. PW has undertaken consultancy work for Stryker, Codman and Microvention who manufacture stroke thrombectomy devices. GAF’s previous institution has received research grants from Boehringer Ingelheim (manufacturer of alteplase), and honoraria from Lundbeck for stroke-related activities. GAF has also received personal remuneration for educational and advisory work from Boehringer Ingelheim and Lundbeck.

© Author(s) (or their employer(s)) 2021.


  • emergency ambulance systems
  • emergency care systems
  • helicopter retrieval
  • management
  • remote and rural medicine
  • stroke
  • thromboembolic diseasex

Cite this