Mid-term cost-effectiveness analysis of open and endovascular repair for ruptured abdominal aortic aneurysm

Rollins, Katie E.; Shak, J; Ambler, Graeme K.; Tang, Tjun Yip; Hayes, Paul D.; Boyle, J R

doi:10.1002/bjs.9409

Cited by 15 publications

(19 citation statements)

References 25 publications

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“…6 In agreement with a previous study, 13 the present study shows that there is no difference in re-intervention rates after an acute intervention. Because the present study (n ¼ 73) and the previous study (n ¼ 62) included limited numbers of patients treated by EVAR, more data are required before definite conclusions can be drawn.…”

Section: Midterm Outcomessupporting

confidence: 94%

“…2B). 13,15 This conclusion echoes the results after elective aortic surgery. 6 It was not recorded whether the indications for reintervention were found by routine follow up or by an acute event.…”

Section: Midterm Outcomessupporting

confidence: 84%

“…The same conflicting results can be found on assessing the outcomes of previous studies. One study 13 reported similar survival rates, whereas other studies reported lower survival rates for EVAR. 11,12,14,15 It appears probable that patient selection for EVAR significantly influences these midterm survival rates.…”

Section: Midterm Outcomesmentioning

confidence: 88%

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Midterm Re-interventions and Survival After Endovascular Versus Open Repair for Ruptured Abdominal Aortic Aneurysm

Beek

Vahl

Wisselink

et al. 2015

European Journal of Vascular and Endovascular Surgery

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Section: Midterm Outcomessupporting

confidence: 94%

Section: Midterm Outcomessupporting

confidence: 84%

See 1 more Smart Citation

Midterm Re-interventions and Survival After Endovascular Versus Open Repair for Ruptured Abdominal Aortic Aneurysm

Beek

Vahl

Wisselink

et al. 2015

European Journal of Vascular and Endovascular Surgery

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“…Another report, with the opposite conclusion, comes from a retrospective analysis of participants at a single UK centre but without QoL having been measured. 81 The French randomised trial, ECAR, 22 did not attempt to assess cost-effectiveness. Therefore, the IMPROVE trial 23 is the first study to assess the full cost-effectiveness of an endovascular strategy compared with open repair for ruptured aneurysms.…”

Section: Overviewmentioning

confidence: 99%

Strategy of endovascular versus open repair for patients with clinical diagnosis of ruptured abdominal aortic aneurysm: the IMPROVE RCT

Ulug

Hinchliffe

Sweeting

et al. 2018

Health Technol Assess

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Background Ruptured abdominal aortic aneurysm (AAA) is a common vascular emergency. The mortality from emergency endovascular repair may be much lower than the 40–50% reported for open surgery. Objective To assess whether or not a strategy of endovascular repair compared with open repair reduces 30-day and mid-term mortality (including costs and cost-effectiveness) among patients with a suspected ruptured AAA. Design Randomised controlled trial, with computer-generated telephone randomisation of participants in a 1 : 1 ratio, using variable block size, stratified by centre and without blinding. Setting Vascular centres in the UK (n = 29) and Canada (n = 1) between 2009 and 2013. Participants A total of 613 eligible participants (480 men) with a ruptured aneurysm, clinically diagnosed at the trial centre. Interventions A total of 316 participants were randomised to the endovascular strategy group (immediate computerised tomography followed by endovascular repair if anatomically suitable or, if not suitable, open repair) and 297 were randomised to the open repair group (computerised tomography optional). Main outcome measures The primary outcome measure was 30-day mortality, with 30-day reinterventions, costs and disposal as early secondary outcome measures. Later outcome measures included 1- and 3-year mortality, reinterventions, quality of life (QoL) and cost-effectiveness. Results The 30-day mortality was 35.4% in the endovascular strategy group and 37.4% in the open repair group [odds ratio (OR) 0.92, 95% confidence interval (CI) 0.66 to 1.28; p = 0.62, and, after adjustment for age, sex and Hardman index, OR 0.94, 95% CI 0.67 to 1.33]. The endovascular strategy appeared to be more effective in women than in men (interaction test p = 0.02). More discharges in the endovascular strategy group (94%) than in the open repair group (77%) were directly to home (p < 0.001). Average 30-day costs were similar between groups, with the mean difference in costs being –£1186 (95% CI –£2997 to £625), favouring the endovascular strategy group. After 1 year, survival and reintervention rates were similar in the two groups, QoL (at both 3 and 12 months) was higher in the endovascular strategy group and the mean cost difference was –£2329 (95% CI –£5489 to £922). At 3 years, mortality was 48% and 56% in the endovascular strategy group and open repair group, respectively (OR 0.73, 95% CI 0.53 to 1.00; p = 0.053), with a stronger benefit for the endovascular strategy in the subgroup of 502 participants in whom repair was started for a proven rupture (OR 0.62, 95% CI 0.43 to 0.89; p = 0.009), whereas aneurysm-related reintervention rates were non-significantly higher in this group. At 3 years, considering all participants, there was a mean difference of 0.174 quality-adjusted life-years (QALYs) (95% CI 0.002 to 0.353 QALYs) and, among the endovascular strategy group, a cost difference of –£2605 (95% CI –£5966 to £702), leading to 88% of estimates in the cost-effectiveness plane being in the quadrant showing the endovascular strategy to be ‘dominant’. Limitations Because of the pragmatic design of this trial, 33 participants in the endovascular strategy group and 26 in the open repair group breached randomisation allocation. Conclusions The endovascular strategy was not associated with a significant reduction in either 30-day mortality or cost but was associated with faster participant recovery. By 3 years, the endovascular strategy showed a survival and QALY gain and was highly likely to be cost-effective. Future research could include improving resuscitation for older persons with circulatory collapse, the impact of local anaesthesia and emergency consent procedures. Trial registration Current Controlled Trials ISRCTN48334791 and NCT00746122. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 31. See the NIHR Journals Library website for further project information.

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“…Immediate postoperative care was either in a high dependency area or the intensive care unit depending on clinical need, with step down to ward care as clinically appropriate. Data on treatment for ruptured AAA in the unit have been reported previously, including patients from the earlier portion of the study period, 5,13 but renal outcomes have not been discussed previously. Data were collected as part of routine service evaluation and no patientidentifiable data are presented, so it was not deemed necessary to seek ethical approval or retrospective consent for the study.…”

Section: Study Populationmentioning

confidence: 99%

Incidence and Outcomes of Severe Renal Impairment Following Ruptured Abdominal Aortic Aneurysm Repair

Ambler

Coughlin

Hayes

et al. 2015

European Journal of Vascular and Endovascular Surgery

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Mid-term cost-effectiveness analysis of open and endovascular repair for ruptured abdominal aortic aneurysm

Abstract: There was no significant difference in reintervention rates after EVAR or open repair for rAAA. EVAR was as cost-effective at mid-term follow-up. The increased procedural costs of open repair are not outweighed by greater surveillance and reintervention costs after EVAR.

Cited by 15 publications

References 25 publications

Midterm Re-interventions and Survival After Endovascular Versus Open Repair for Ruptured Abdominal Aortic Aneurysm

Midterm Re-interventions and Survival After Endovascular Versus Open Repair for Ruptured Abdominal Aortic Aneurysm

Strategy of endovascular versus open repair for patients with clinical diagnosis of ruptured abdominal aortic aneurysm: the IMPROVE RCT

Incidence and Outcomes of Severe Renal Impairment Following Ruptured Abdominal Aortic Aneurysm Repair

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