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Page 10 of 12 Zhao et al. Vessel Plus 2021;5:10 I http://dx.doi.org/10.20517/2574-1209.2020.77

However, there were a number of statistically significant secondary outcomes including increased return to
[10]
ambulation (modified Rankin Scale 0-3, 83% vs. 74%, P = 0.004) and reduced mortality (6% vs. 10%, P = 0.22) . This
study is likely to be underpowered and will need confirmation by upcoming trials. As previously mentioned,
the Berlin MSUs do not have the opportunity to provide EVT bypass and triage, therefore the results reflect
earlier thrombolysis only.

Health economic analysis
Preliminary health economic analyses of the Melbourne MSU have been carried out for the first full
[42]
calendar year of operation . The overall cost of running the MSU service was calculated by adding
expenditure from setup, wages, maintenance, and depreciation offset by savings from improved triage and
streamlining of in-hospital workflow. This was then divided by the disability-adjusted life years avoided
by earlier reperfusion therapy on the MSU. The overall cost to save one disability-adjusted life year was
[42]
estimated in this manner to be between $19,003-$44,255 (Australian dollars) in 95% of model iterations ,
which was below the general $50,000 threshold for approval of medicines to the Australian Government
[43]
funded Pharmaceuticals Benefits Scheme . These assumptions, however, still rely on the accuracy of
translating time savings to clinical benefit as well as the assumed linearity of this translation, which may
not necessarily be the case with thrombolysis where benefit decays faster with time delays during the early
[26]
time windows .

Similar analyses of potential cost-effectiveness have been conducted by the Berlin MSU service, which
[44]
showed an incremental cost-effectiveness ratio of €32,456 per quality-adjusted life year . This study also
relied on estimating improved functional outcome from time savings and utilized running costs unique
to this MSU service. In contrast, cost modelling work carried out with the Cleveland MSU showed that,
independent of improved outcomes, using a MSU to transport most stroke patients could potentially
[45]
be cost neutral by avoiding secondary transfers and bypassing emergency department attendance .
Assumptions here, however, are firmly grounded in a US-based system with very different costs and mix of
private funding, which may have limited translatability to other countries.

Overall, initial estimates of the cost-effectiveness of MSUs appear to be comparable with many
interventions outside of stroke. Of note, these analyses largely comprise the effect of reperfusion therapy
for ischemic stroke without consideration of benefits in other areas, such as intracranial hemorrhage. No
doubt the upcoming randomized control trials will provide confirmatory evidence of clinical benefits and
allow a wider analysis of cost-effectiveness.

CONCLUSION
The Melbourne MSU service provides an exciting frontier of pre-hospital stroke care management. The
service has been successfully integrated into local Ambulance Victoria operations and has delivered
substantial benefits for reperfusion therapy in ischemic stroke and management of intracranial hemorrhage.
Future research directions involve evolution of imaging and technical capabilities of MSU services in
addition to long term health and cost benefits.

DECLARATIONS
Authors’ contributions
Substantial contribution to conception, design of the project, and performed data analysis and
interpretation: Zhao H, Campbell BCV, Foster S, Stephenson M, Coote S, Langenberg F, Easton D, Donnan
GA, Davis SM