Cost-effectiveness of carotid endarterectomy in asymptomatic patients

Cronenwett, Jack L.; Birkmeyer, John D.; Nackman, Gary B.; Fillinger, Mark F.; Bech, Fritz; Zwolak, Robert M.; Walsh, Daniel B.

doi:10.1016/s0741-5214(97)70351-3

Cited by 125 publications

(115 citation statements)

References 48 publications

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“…16 Longterm care costs were estimated from the literature. [17][18][19][20][21][22] Utility data. Health state preferences were obtained from the literature and represented utilities that describe the mRS scores used in our study.…”

Section: Methods Model Descriptionmentioning

confidence: 99%

Cost-effectiveness of multimodal CT for evaluating acute stroke

Young¹,

Benesch²,

Jahromi³

2010

Neurology

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Objective: Multimodal CT, including noncontrast CT (NCCT), CT with contrast, CT angiography (CTA), and perfusion CT (CTP), is increasingly used in acute stroke patients to identify candidates for endovascular therapy. Our goal is to explore the cost-effectiveness of multimodal CT as a diagnostic test.Methods: A Markov model compared multimodal CT to NCCT in a hypothetical cohort of nonhemorrhagic stroke patients presenting within 3 hours of symptom onset who were potential IV tPA candidates. Patients who failed to improve after IV tPA or in whom IV tPA was contraindicated were candidates for endovascular therapy. Direct costs (2008 USD), outcomes, and probabilities were obtained from the literature.Results: For the 3-month time horizon, multimodal CT had lower costs (Ϫ$1,716), had greater quality-adjusted life-years (QALYs, 0.004), and was the cost-effective choice 100% of the time for a willingness-to-pay of $100,000/QALY (probabilistic sensitivity analysis). The number needed to screen with multimodal CT to avoid 1 diagnostic angiogram was 2. Over a lifetime, multimodal CT had lower costs (Ϫ$2,058), had greater QALYs (0.008), and was cost-effective, with a 90.1% likelihood, for a willingness-to-pay of $100,000/QALY. Conclusions:Multimodal CT appears to be a cost-saving screening tool over the short term. However, additional data regarding clinical outcomes following multimodal CT-guided intra-arterial treatment are needed before the long-term cost-effectiveness can be suitably addressed. This analysis can be incorporated into future discussions of multimodal CT as a diagnostic test for unselected patients, within and beyond the 3-hour IV tPA time window. Neurology ® 2010;75:1678-1685 GLOSSARY CTA ϭ CT angiography; CTP ϭ perfusion CT; IA ϭ intra-arterial; ICER ϭ incremental cost-effectiveness ratio; mRS ϭ modified Rankin Scale; NCCT ϭ noncontrast CT; NE ϭ northeast; NW ϭ northwest; QALY ϭ quality-adjusted life-year; SE ϭ southeast; SW ϭ southwest; tPA ϭ tissue plasminogen activator; WTA ϭ willingness to accept; WTP ϭ willingness to pay.Recommendations for treatment of acute ischemic stroke emphasize timely IV tissue plasminogen activator (tPA) administration. The minimum requirement is imaging excluding hemorrhage while allowing for other MR or CT-based imaging so long as IV tPA is not delayed.1 At some institutions, multimodal CT imaging is performed prior to intra-arterial (IA) procedures. CT-based imaging is typically utilized because it requires less time to complete than MR-based imaging, thus minimizing the time to IA procedures in the setting of acute stroke. Multimodal CT imaging including CT with and without contrast, CT angiography (CTA), and perfusion CT (CTP) rapidly identifies the presence or absence of clot suitable for extraction and salvageable ischemic tissue. 2,3At centers providing endovascular therapies for stroke, multimodal CT rapidly identifies candidates for these therapies in lieu of conventional angiography. However, multimodal CT is a costly screening tool where a proportion o...

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Section: Methods Model Descriptionmentioning

confidence: 99%

Cost-effectiveness of multimodal CT for evaluating acute stroke

Young¹,

Benesch²,

Jahromi³

2010

Neurology

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“…Research Question Of the full economic evaluation studies, only 2 modeling articles, 16,19 which investigated the cost-effectiveness of CEA, formulated satisfactory research questions and addressed the 3 elements needed for well-formulated questions in economic studies. 4 Of the cost analysis studies, 8 -15 which were primarily concerned with methods to reduce the cost of CEA, only 1 study 15 formulated a satisfactory research question.…”

Section: Methodsmentioning

confidence: 99%

“…34,35 Complication rates, risk rates and mortality rate, and benefit of CEA were obtained from the ACAS. 36 The corresponding rates reported from the 17 Nussbaum et al 18 Cronenwett et al 16 Lavender NASCET were used in the modeling for symptomatic populations. 31 …”

Section: Effectiveness Datamentioning

confidence: 99%

“…16 -18 Cost-effectiveness was reported as the "incremental cost of surgery per QALY gained" when compared with medical treatment 16 and the lifetime cost in terms of "quality adjusted life expectancy." 18 The outcome measures in the unpublished reports were the estimated cost per stroke prevented.…”

Section: Benefit Measurement and Valuationmentioning

confidence: 99%

“…The costs in the modeling studies were expressed in US dollars ($), and the reference years were 1993 18 and 1996. 16 Only 1 of these retrospective cost analysis and cost description studies mentioned the reference year for which calculations were performed. 20 The cost of CEA in 4 similar cost analysis studies 8,9,11,13 varied from a minimum of $7608 (1997) 24 to a maximum of $11 546 (1997) 20 for the standard accepted practice at the time, which incorporated CA before CEA, admission to the hospital 1 or 2 days before surgery, general anesthesia, routine admission to an intensive or high-dependency unit immediately after surgery, and discharge from the hospital 4 to 5 days after surgery.…”

Section: Costingmentioning

confidence: 99%

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Costs and Benefits of Carotid Endarterectomy and Associated Preoperative Arterial Imaging

Benade

Warlow

2002

Stroke

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Background and Purpose-Carotid endarterectomy (CEA) reduces the risk of stroke in patients with severe stenosis of the internal carotid artery. However, the cost implications of this procedure have not yet been satisfactorily addressed. The objective of this systematic review was to critically appraise the studies addressing the economic implications of CEA and the associated preoperative arterial imaging. Methods-A systematic search strategy was developed to identify research articles related to the economic evaluation of CEA and the associated preoperative imaging. MEDLINE, EMBASE, and BIOSIS were electronically searched, and reference lists from identified studies were searched manually. Methods used to critically appraise these studies followed proposed guidelines for an economic evaluation that addresses 10 distinct aspects under 3 separate headings. Results-Studies identified were either partial economic or full economic evaluations, with the majority coming from the United States. The methodological quality seems to have improved over time. The studies that assessed costeffectiveness of CEA were all modeling studies; although the same baseline parameters were used, divergent conclusions were reached. Variation in the cost estimates of CEA ($9500 to $11 500) in the same health care system was also observed in the studies reporting only on the cost of carotid surgery. For a symptomatic patient, the benefit of CEA ranged from 0.35 quality adjusted life years (QALYs) (4.2 months) at a cost of $4100 per QALY to 0.93 QALYs (11.2 months) at a cost of $434 per QALY. For an asymptomatic patient, the cost-effectiveness of CEA varied from 0.15 QALYs (1.8 months) at a cost of $52 700 per QALY to 0.25 QALYs (3 months) at a cost of $8004 per QALY. Conclusions-Divergent conclusions of the cost-effectiveness of CEA were reported from studies that addressed the same questions and using similar parameters in their models. The cost estimates of the procedure and the different time periods used in the studies might explain these inconsistencies. Modeling studies in hypothetical cohorts might also be to blame. The cost-effectiveness of CEA will only definitively be assessed when real patient data are used. (Stroke. 2002;33:629-638.)

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Cost Effectiveness Issues

Hickenbottom¹

2004

Transient Ischemic Attacks

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Cost-effectiveness of carotid endarterectomy in asymptomatic patients

Cited by 125 publications

References 48 publications

Cost-effectiveness of multimodal CT for evaluating acute stroke

Cost-effectiveness of multimodal CT for evaluating acute stroke

Costs and Benefits of Carotid Endarterectomy and Associated Preoperative Arterial Imaging

Cost Effectiveness Issues

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