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1 2008, Vol. 22, No. 1 (pp ) ISSN: Originl Reserch Article Modelling the Budgetry Impct nd Cost Effectiveness of Alteplse vi Telemedicine Terms nd Conditions for Use of PDF The provision of PDFs for uthors' personl use is subject to the following Terms & Conditions: The PDF provided is protected by copyright. All rights not specificlly grnted in these Terms & Conditions re expressly reserved. Printing nd storge is for scholrly reserch nd eductionl nd personl use. Any copyright or other notices or disclimers must not be removed, obscured or modified. The PDF my not be posted on n open-ccess website (including personl nd university sites). The PDF my be used s follows: to mke copies of the rticle for your own personl use, including for your own clssroom teching use (this includes posting on closed website for exclusive use by course students); to mke copies nd distribute copies (including through e-mil) of the rticle to reserch collegues, for the personl use by such collegues (but not commercilly or systemticlly, e.g. vi n e-mil list or list serve); to present the rticle t meeting or conference nd to distribute copies of such pper or rticle to the delegtes ttending the meeting; to include the rticle in full or in prt in thesis or disserttion (provided tht this is not to be published commercilly).

2 CNS Drugs 2008; 22 (1): ORIGINAL RESEARCH ARTICLE /08/ /$48.00/ Adis Dt Informtion BV. All rights reserved. Ntionl Use of Thrombolysis with Alteplse for Acute Ischemic Stroke vi Telemedicine in Denmrk A Model of Budgetry Impct nd Cost Effectiveness Lrs Ehlers, 1 Wilhelmin Mri Müskens, 2 Lotte Groth Jensen, 1 Mette Kjølby 1 nd Grethe Andersen 3 1 HTA Unit, Arhus University Hospitl, Arhus, Denmrk 2 Institute of Economics, Arhus University, Arhus, Denmrk 3 Deprtment of Neurology, Arhus University Hospitl, Arhus, Denmrk Aim: The purpose of this nlysis ws to ssess the budgetry impct nd cost effectiveness of the ntionl use of thrombolysis with lteplse (recombinnt tissue plsminogen ctivtor; rt-pa) for cute ischemic stroke vi telemedicine Abstrct in Denmrk. Methods: Computtions were bsed on Dnish helth economic model of thrombolysis tretment of cute ischemic stroke vi telemedicine. Cost dt for stroke units nd stellite clinics were tken from the first prcticl experiences in Denmrk with implementing thrombolysis vi telemedicl linkge to the Stroke Deprtment t Arhus University Hospitl. Effectiveness dt were tken from published pooled nlysis of results from rndomized controlled trils of lteplse. Results: The clcultions showed tht the dditionl totl costs to the hospitls of implementing thrombolysis with lteplse for cute ischemic stroke vi telemedicine were pproximtely $US3.0 (rnge ) million per yer in the cse of five centres nd five stellite clinics, or $US3.6 (rnge ) million per yer bsed on seven centres nd seven stellite clinics. The incrementl cost- effectiveness rtio ws clculted to be pproximtely $US when tking short time perspective (1 yer), but thrombolysis ws dominnt (both cheper nd more effective) fter s little s 2 yers nd cost effectiveness improved over longer time scles. Conclusion: The budgetry impct of using thrombolysis with lteplse for cute ischemic stroke vi telemedicine depends on the existing cpcity nd orgniztionl conditions t the locl hospitls. The helth economic model computtions suggest tht the mcroeconomic costs my blnce with svings in cre nd rehbilittion fter s little s 2 yers, nd tht potentilly lrge long-term svings

3 74 Ehlers et l. re ssocited with thrombolysis with lteplse delivered by telemedicine, lthough the long-term clcultions re uncertin. Introduction to ssess the cost effectiveness of thrombolysis for Intrvenous thrombolysis with lteplse within 3 hours of symptom onset is more effective [1] nd cost effective [2-7] thn conservtive tretment for cute ischemic stroke. No countries hve, however, cute ischemic stroke in Denmrk. [7] In the current nlysis, the model ws extended to include thrombolysis t stellite clinics linked to lrger throm- bolysis centre. All unit costs nd quntities were updted to mirror the expected price level for the implemented the widespred use of thrombolysis The model ws set up s choice between two becuse such tretment plces lrge demnds on the ntionl helthcre system. [8,9] Pilot studies using telemedicine to ssist with the use of thrombolysis for stroke ( telestroke ) in Germny, mong other countries, hve shown promis- ing results, nd telemedicine could be n opportuni- ty to overcome brriers relted to the limited time window for thrombolysis nd the lck of medicl specilists fmilir with its use t locl hospitls. [10-12] In Denmrk, intrvenous thrombolytic tretment with lteplse for cute ischemic stroke is currently vilble t five regionl stroke centres. yer 2007 nd converted into US dollrs (exchnge rte $US100 = DKK ). All quntities (includ- ing mortlity tbles) were updted ccordingly. lterntives (see figure 1). The ptient could receive either thrombolysis with lteplse or conservtive tretment. Depending on the tretment instituted, the ptient could be exposed to either lrger or smller risk of intrcrnil hemorrhge in connec- tion with the tretment. After the initil tretment t the hospitl, the ptient could be clssified ccord- At present, <200 ptients undergo thrombolysis t disbility, R3 = moderte disbility, R4 = moderte impct nd cost effectiveness of the ntionl use of thrombolysis with lteplse for cute ischemic stroke vi telemedicine in Denmrk. ing to the Modified Rnkin Scle (MRS) into one of seven different functionl sttes; R0 = no symp- the existing centres ech yer, lthough t lest 500 ptients per yer could be cndidtes for this tret- ment. [9] The Dnish Ntionl Bord of Helth hs recommended n expnsion of the service to include new stellite clinics connected to regionl stroke centre vi telecommuniction network. The purpose of this nlysis is to ssess the budgetry toms, R1 = no significnt disbility, R2 = miniml to severe disbility, R5 = severe disbility, or deth. After the primry dmission to hospitl, the ptient could be dischrged to either his/her own home, to rehbilittion or to nursing home. After dischrge, the ptient my be t risk of hving nother stroke nd being redmitted to hospitl, nd could lso die Methods from cuses other thn stroke. Dt concerning the clinicl effectiveness of both thrombolysis nd conservtive tretment were tken Model from pooled nlysis of 2775 ptients from six The present computtions were bsed on the lrge rndomized clinicl studies with lteplse (re- Dnish helth economic model tht ws erlier used combinnt tissue plsminogen ctivtor; Ac-

4 Modelling the Budgetry Impct nd Cost Effectiveness of Alteplse vi Telemedicine 75 Intrcrnil hemorrhge R0 Intrvenous thrombolysis with lteplse R1 R2 No bleeding R3 Acute ischemic stroke R4 R5 Conservtive tretment Intrcrnil hemorrhge the copyright No bleeding of the Fig. 1. Mrkow decision nlytic model for intrvenous thrombolysis with lteplse for cute ischemic stroke (reproduced from Ehlers et l., [7] with permission). voided, s thrombolysis does not result in chnged with lteplse ws ssocited with pproximtely 13 mortlity. [1] of 100 stroke ptients voiding disbility, mesured The risk of mjor intrcrnil hemorrhge is 5.9% with thrombolysis nd 1.1% with conservtive otherwise hve sustined. Since pilot studies with tretment. [1] The risk of minor hemorrhge ws not telemedicine indicte tht the sme good effect for included in the model, which ws not the cse in the thrombolysis with lteplse is obtinble through other interntionl helth economic studies, [2-7] pri- mrily becuse it ws ssumed tht this type of both thrombolysis centres nd stellite clinics linked to centre vi telecommuniction. hemorrhge is not ssocited with ny significnt costs or ny loss of QALY. The effect mesure in the model ws the number All ptients were ssumed to be 68 yers of ge t ptient received thrombolysis in plce of conservfter the time of the index stroke. The overll deth rte tive tretment. Ech of the seven different functionl the first yer ws ssumed to exceed tht of the sttes (R0 R5 nd deth) were thus trnslted into verge popultion by pproximtely 2.5-fold. The QALYs. In the bsence of Dnish preference dt risk of stroke recurrence is 5.2% per yer, [2-7] which within this field, we used n Americn study [13] in the model ws ssumed to be independent of the previously used in other helth economic studies. [2,3] result of the initil tretment with thrombolysis or The model did not clculte the number of deths the conservtive tretment. tilyse ) 1. [1] originl The nlysis showed tht thrombolysis publisher. by n MRS score of R2 R4, which they would telemedicine, [10-12] the sme effect ws ssumed for of qulity-djusted life-yers (QALY) gined if the Deth 1 The use of trde nmes is for product identifiction purposes only nd does not imply endorsement.

5 76 Ehlers et l. Orgniztion Model Clcultion of the totl extr costs incurred by the hospitl services in Denmrk if ntionwide throm- Denmrk hs popultion of 5 million, covered bolysis ws implemented ws bsed on two orgniby five regions of equl size. There is thrombolysis ztionl models model A with five centres nd five centre in ech region nd, in ech region, stellite stellite clinics, nd model B with seven centres nd clinic will be connected to the regionl centre in seven stellite clinics. Model A ws chosen since order to reduce ptient trnsport time to <1 hour. thrombolysis is offered in five plces within Den- The centre nd the stellite will work closely togeth- mrk t present. Model B ws chosen s n lterner with other locl stroke units in the region, nd tive to chieve better geogrphicl coverge. The emergency services will be instructed to bring cute nnul number of thrombolysis ptients treted in stroke ptients to the nerest centre or stellite nd centres nd stellite clinics ws ssumed to be p- proximtely 500 per yer. [9] A sensitivity nlysis Arhus University Hospitl ws chosen s the ws prepred for 300, 700 nd 1000 thrombolysis orgniztionl model for the cost computtions. ptients per yer. This hospitl hs extensive experience with throm- bypss the other locl stroke units. bolysis for cute ischemic stroke, [9] nd the cost l use of thrombolysis were clculted s incremen- tretment were included. Therefore, the clculted Budgetry costs were clculted s the extr vri- Budgetry Impct Anlysis The nnul (increse in) budgetry costs to the hospitls s result of the introduction of the ntion- effectiveness of using lteplse in this prticulr hospitl hs been described in detil elsewhere. [7,9] Informtion regrding telecommuniction systems nd ssumptions bout the orgniztion of thrombolysis tretment vi telemedicine were tken from the literture [10-12] nd locl plns for implementing thrombolysis t Holstebro Hospitl vi telemedicl linkge to the Stroke Deprtment t Arhus University Hospitl. All prticipting hospitls (centres nd stellites) were ssumed to be equipped with high- speed videoconferencing system, including new PC worksttions nd 32 inch monitors. It ws lso s- sumed tht the stellite clinics hd video cmers tht could be remotely controlled from the centre, nd tht CT scns could be trnsmitted t dt trnsfer rte of 2 Mbit/s. Other ssumptions were tht ll telecommuniction systems were supported by 24-hour IT-gurd service contrct; the stroke deprtments (centres) were upgrded to provide 24- hour in-house neurology coverge nd would hve the highly specilized competence nd experience needed to provide thombolysis tretment; nd the stellite clinics my drw on this competence vi dvnced telecommuniction equipment, but hve themselves the physicl fcilities to receive, exmine nd tret incoming ptients. tl (mrginl) costs. This mens tht only the ddi- tionl costs ssocited with giving the ptient throm- bolysis insted of the present (conservtive) costs correspond directly to the dditionl extr re- sources required if thrombolysis tretment vi telemedicine ws implemented in Denmrk. ble costs per ptient (extr costs for treting ptient with thrombolysis insted of conservtive tretment) nd the extr fixed costs per yer (extr costs of estblishing new stellites/stroke centres). A sensitivity nlysis ws crried out for the indi- vidul estimtes of vrible nd fixed costs s worst cse versus best cse nlysis. (Possible sv- ings resulting from fewer dischrges to nursing homes nd rehbilittion fll outside the hospitl sector in Denmrk; these svings were included in the cost-effectiveness nlysis [see below]). The estblishment of stellite linked to stroke unit will incur costs for the implementtion nd opertion of technicl necessities in connection with

6 Modelling the Budgetry Impct nd Cost Effectiveness of Alteplse vi Telemedicine 77 telemedicl tretment. The implementtion costs of for ech ptient treted with thrombolysis insted of telecommuniction equipment cover the instllsumed conservtive tretment. [5,9] In the model, it ws s- tion, softwre nd hrdwre t the centre nd the tht ll centres (but not stellite clinics) stellite clinics, nd were deprecited on strightservice would be upgrded to provide full 24-hour medicl line bsis over 6 yers. The nnul operting costs t the Deprtment of Neurology. Thus, the cover service greement, IT stff nd lesed lines. existing neurology coverge would be expnded to Additionl costs for mbulnce trnsporttion cover evenings nd nights. Cost figures from Arhus occur for three different resons. First, the ptient University Hospitl were used s proxy for ll must be trnsported to stroke deprtment where centres in the model. thrombolysis tretment is performed insted of beby CT scnning on rrivl nd by control scnning It ws ssumed tht the ptients re exmined ptients re thus trnsported by mbulnce for 24 hours fter tretment ws initited. CT is used for dignosing nd selecting ptients eligible for thromlonger period of time. Second, ll ptients with bolysis t the vst mjority of thrombolysis cenpossible indiction of thrombolysis must be trnstres. [14] It ws ssumed tht the necessry scnning cpcity would be vilble so tht no further inthe locl hospitl. In most cses, however, contrinvestments in scnning cpcity were required. The dictions to the tretment will pper, nd only costs of CT scns were estimted from verge unit bout one-qurter of ptients cn expect to undergo prices, using the Dnish DRG-csemix system for eligible for thrombolysis will be trnsported bck to mbultory cre. their locl hospitl where tretment will be completed. Cost-Effectiveness Anlysis ing trnsported to the nerest hospitl. On verge, ported to the relevnt stroke deprtment insted of thrombolysis. [7] Thirdly, some of the ptients not The ntionl use of thrombolysis will lso require consultnt time previously clculted to be required In the clcultions of the cost effectiveness of telemedicl tretment with thrombolysis, the per- spective ws expnded from the hospitl services to embrce ll the mcroeconomic costs nd svings ssocited with introducing the ntionl use of 24-hour neurology coverge t the thrombolysis centres. This will be ssocited with physicin costs tht re beyond the pproximtely 4 extr hours of Tble I. Sensitivity nlysis of the vrible extr costs ($US) per ptient receiving thrombolysis compred with conservtive tretment Worst cse Bse cse Best cse References Alteplse (Actilyse ) ,7 Other interventions (blood tests, ECG, etc.) ,15 Consultnt time ,7,9 Nursing time ,7,9 Trnsporttion costs (per lteplse-treted ptient) More ptients trnsported for dignosis More ptients trnsported bck to own hospitl CT scnning ,7 Costs ssocited with intrcrnil hemorrhge Fewer bed dys ,2,7 Totl Dt from the Deprtment of Neurology, Arhus University Hospitl, Arhus, Denmrk.

7 78 Ehlers et l. Tble II. Sensitivity nlysis of the extr fixed costs ($US) per yer per thrombolysis centre with n ffilited stellite clinic Worst cse Bse cse Best cse References Duty t the Deprtment of Neurology Extr nurses on duty b NA NA Telemedicl linkge Trining of helth professionls ,10 Totl b Dt from the Deprtment of Neurology, Arhus University Hospitl, Arhus, Denmrk. In the worst cse, employment of the extr nurses on duty (in ddition to the 8 hours of extr nursing time per ptient) re included. The cost is clculted s one extr emergency bed per thrombolysis centre/stellite clinic with 2.3 nurses per emergency bed nd prt-time costs for secretry nd socil worker. Extr nurses on duty hve been included in the worst cse becuse relloction of cpcity nd resources in the short-term my be difficult in prctice. thrombolysis in Denmrk. This mens tht the costs nd svings to both the hospitl system nd the socil services were included. The totl costs fter initil hospitliztion were tken from 1-yer follow-up study of 588 stroke ttion, outptient visits, generl prctitioner visits, medicine, etc., s well s socil services such s NA = not pplicble. The results of the computtions re shown in ptients t Hvidovre Hospitl [15] nd covered helth- for cute ischemic stroke cn be seen in tble I. servtive tretment, the cost of the Dnish DRG- nursing homes, residentil homes, dy centres/dy nurseries, ids nd pplinces, mel deliveries, trnsport services, etc. In the model, it ws ssumed tht the nnul socil service costs remined t Results tbles I, II, III nd IV. The extr vrible costs per ptient receiving thrombolysis s opposed to conservtive tretment cre services such s further dmission for rehbili- Tble II shows the extr fixed costs per yer per thrombolysis centre with n ffilited stellite clinic. As n estimte of the totl verge costs of con- constnt level for nd ech of the subsequent distribution yers (t pproximtely one-third of the level for the first level tht equlled the costs of the first yer), while the nnul helthcre costs dropped to level of yer. [7,9] Incrementl (mrginl) cost-effectiveness rtios (ICERs) were clculted s the dditionl costs upon thrombolysis per QALY gined with time horizon of 1, 2 nd 30 yers. All costs nd helth consequences in the long-term clcultions were discounted t rte of 5%, to reflect the present vlue to society. Tble III. Sensitivity nlysis of the totl costs ($US) per yer for model A (five centres nd five stellite clinics) nd model B (seven centres nd seven stellite clinics) Model A Worst cse Bse cse Best cse Vrible costs Fixed costs Totl Model B Vrible costs Fixed costs Totl b The bse cse hs been clculted on n ssumption of 500 ptients per yer (the totl mounts to $US for 300 ptients, $US for 700 ptients nd $US for 1000 ptients). b The bse cse hs been clculted on n ssumption of 500 ptients per yer (the totl mounts to $US for 300 ptients, $US for 700 ptients nd $US for 1000 ptients).

8 Modelling the Budgetry Impct nd Cost Effectiveness of Alteplse vi Telemedicine 79 Tble IV. Incrementl cost-effectiveness rtio (ICER) Time horizon Costs ($US) QALY Chnge ICER lteplse conservtive lteplse conservtive QALY $US $US per QALY tretment tretment Expected vlue (1 yer) Expected vlue (2 yers) Dominnce Expected vlue (30 yers) Dominnce The costs nd QALY re clculted cumultively on the ssumption of 500 ptients nnully. QALY = qulity-djusted life-yers. Our clcultions indicte tht incresing the n- tionl use of thrombolysis with lteplse for cute ischemic stroke vi telemedicine is cost effec- tive. [2-7] Also, the budgetry costs of estblishing new stellites seem fir. However, there re number of uncertinties tht must be ddressed. We do not hve the empiricl dt needed to give good estimte of the vrition in costs nd cost effectiveness of telestroke. A mthemticl nlysis such s tive tretment; however, the cost will decrese to $US if he/she is treted with thrombolysis. equl shre of the extr fixed costs per yer It should be noted tht this figure ssumes tht Monte Crlo simultion to evlute the robustness the true ICER. cse of $US7244 per ptient cn be pplied. The extr totl costs for treting n cute stroke ptient with intrvenous thrombolysis insted of conservtive tretment is $US6039 (clculted s the sum of the vrible costs per ptient [see tble I] nd n [see tble II]). Hence, the totl verge costs per telestroke tretment in our model mounted to $US( ) = $US per ptient. telestroke costs re shred eqully between stroke centres nd stellite clinics. The result of the clcultions of cost effective- ness cn be seen in tble IV. The computtions were mde using time horizon of 1, 2 nd 30 yers, with the ssumption tht by the ltter timepoint pproxi- mtely 98.5% of the treted ptients would be ded. The computtions show the expected totl verge Discussion Tble III outlines the totl budgetry impct per yer of implementing the ntionl use of thromboly- sis for cute ischemic stroke in Denmrk. of the ICER could give flse sense of precision nd hs not been performed. More empiricl dt on costs nd cost effectiveness re needed to evlute In our model, the budgetry impct ws clculted s $US3.0 (rnge ) million per yer bsed on five centres nd five stellite clinics, or $US3.6 (rnge ) million per yer with seven centres nd seven stellite clinics. The dditionl resources needed t individul locl centres/stellite clinics my, however, exceed this mount considerbly. This is primrily due to the fct tht for every thrombolysis ptient, two or three extr ptients will need to be trnsported to the centre/stellite clinic in order to identify the ptient eligible for thromboly- sis. These extr ptients will need conservtive tretment insted. [7,9] In this cse, the resources must, in principle, follow the ptient nd there will cost per ptient with cute ischemic stroke, depen- ding on whether the ptient received thrombolysis with lteplse or the present (conservtive) tretment. Tble IV lso shows tht, on verge, ptient with cute ischemic stroke costs society pproximtely $US in the first yer fter stroke if he/she is treted conservtively nd $US if he/she is treted with thrombolysis. Over the rest of his/her life expectncy, the ptient will cost pproximtely $US (present vlue) with conserv-

9 80 Ehlers et l. be need for relloction of the cpcities/resour- (rnge ) million per yer. The helth ecoces between regionl/locl hospitls. Our comput- nomic model computtions suggest tht the tions only cover the vlue of the extr resources tht mcroeconomic costs my blnce with the svings re consumed t ntionl level s result of the in cre nd rehbilittion fter s little s 2 yers, introduction of thrombolysis not the need for nd tht potentilly lrge long-term svings re dding resources t the individul hospitl. ssocited with thrombolysis. However, the necessry The costs to the individul stroke unit will deble Dnish dt re not vilble to crry out reli- pend on the existing competences nd the cpcity computtions of the possible long-term svings. of the unit. Different types of extr costs my occur, depending on the locl circumstnces, if the unit is Acknowledgements not s redily prepred to hndle the tsk s the most well equipped deprtments nd hospitls in the tion nd the Arhus University Hospitl, Arhus, Denmrk. country. Potentilly lrge economic dvntges cn The uthors hve no conflicts of interest tht re directly be chieved through ntionl coordintion of the relevnt to the content of this study. number of (nd the geogrphicl loction of) stroke References ment. 1. Hcke W, Donnn G, Fieschi C, et l. Assocition of outcome It is possible tht the introduction of thrombolywith erly stroke tretment: pooled nlysis of ATLANTIS, ECASS, nd NINDS rt-pa stroke trils. ATLANTIS Trils sis my spur further debte on the other inititives Investigtors, ECASS Trils Investigtors, NINDS rt-pa tht my benefit individuls who hve hd stroke. 2. Fgn SC, Morgenstern LB, Petitt A, et l. Cost-effectiveness In this regrd, the discussion concerning mbulnce of tissue plsminogen ctivtor for cute ischemic stroke. helicopters/lnding grounds nd informtion cm- NINDS rt-pa Stroke Study Group. Neurology 1998; 50: pigns towrds the public might be relevnt. These 3. Sinclir S, Frighetto L, Loewen P, et l. Cost-utility nlysis of conditions were not included in this model. stroke: Cndin helthcre perspective. Phrmcoeco- The ICER with time horizon of 1 yer ws nomics 2001; 19 (9): clculted to be $US per QALY. Since 4. Sndercock P, Berge E, Dennis M, et l. A systemtic review of thrombolysis with lteplse increses short-term the effectiveness, cost-effectiveness nd brriers to implemen- This study hs been funded by The Dnish Hert Found- deprtments nd stellite clinics tht offer this tretthe copyright of the Study Group Investigtors. Lncet 2004; 363: tissue plsminogen ctivtor therpy for cute ischemic costs but results in long-term svings, it is misled- ischemic stroke in the NHS. Helth Technol Assess 2002; 6 Dnish follow-up studies exist in which thrombolyis prohibited. ing to only consider the ICER clculted for the first yer. The problem with dopting time perspective of severl yers is the consequent uncertinty. No ttion of thrombolytic nd neuroprotective therpy for cute (26): Sndercock P, Berge E, Dennis M, et l. Cost-effectiveness of thrombolysis with recombinnt tissue plsminogen ctivtor for cute ischemic stroke ssessed by model bsed on UK NHS costs. Stroke 2004; 35: Mr J, Begiristin JM, Arrzol A. Cost-effectiveness nlysis sis ptients hve been followed-up over severl of thrombolytic tretment for stroke. Cerebrovsc Dis 2005; yers nd costs relted to the outcomes fter the 20: Ehlers L, Andersen G, Clusen LB, et l. Cost-effectiveness of tretment mesured. This mkes long-term compuintrvenous thrombolysis with lteplse within 3-hour window fter cute ischemic stroke. Stroke 2007; 38 (1): ttions uncertin Demerschlk BM, Yip TR. Economic benefit of incresing utiliztion of intrvenous tissue plsminogen ctivtor for Conclusion cute ischemic stroke in the United Sttes. Stroke 2005; 36: The extr costs to the hospitl services for impletherpy in ptients with cute ischemic stroke [in Dnish]. 9. Bech M, Ehlers L, Andersen G, et l. HTA of thrombolytic Arhus: HTA Unit, Arhus University Hospitl, Deprtment menting telestroke t five new stellite clinics in Denmrk were clculted to mount to $US3.0 of Public Helth, 2005

10 Modelling the Budgetry Impct nd Cost Effectiveness of Alteplse vi Telemedicine Audebert HJ, Kukl C, von Clrnu SC, et l. Telemedicine for window fter stroke onset: cohort study. Lncet Neurol 2006; sfe nd extended use of thrombolysis in stroke: the telemedic 5: pilot project for integrtive stroke cre (TEMPis) in Bvri. 15. Porsdl V, Boysen G. Direct costs of trnsient ischemic ttcks: Stroke 2005; 36: Dubinsky R, Li SM. Mortlity of stroke ptients treted with hospitl-bsed study of resource use during the first yer thrombolysis: nlysis of ntionwide inptient smple. Neuro- fter trnsient ischemic ttcks in Denmrk. Stroke 1998; 29: logy 2006; 66: Dvis S, Lees K, Donnn G. Treting the cute stroke ptient s n emergency: current prctices nd future opportunities. Int J Clin Prct 2006; 60: Correspondence: Dr Lrs Ehlers, HTA Unit, Arhus Univer- 13. Solomon NA, Glick HA, Russo CJ, et l. Ptient preferences for sity Hospitl, Olof Plmes Allé 15, 8200 Arhus N, Denstroke outcomes. Stroke 1994; 25: Köhrmnn M, Jüttler E, Fiebch JB, et l. MRI versus CT-bsed mrk. thrombolysis tretment within nd beyond the 3-hour time E-mil: Errtum Vol. 20, No. 6, 2006, pge 454: The second sentence of the second prgrph of section sttes tht idebenone hs been pproved for use in Jpn to tret the MELAS syndrome. This sttement is incorrect, s idebenone is not pproved for use in ny disorder, including mitochondril disorders, in Jpn. [Scgli F, Northrop JL. The Mitochondril Myopthy Encephlopthy, Lctic Acidosis with Stroke-Like Episodes (MELAS) Syndrome: A Review of Tretment Options. CNS Drugs 2006; 20 (6): ]

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