<ul><li>DR IMRAN JAVED, </li></ul><ul><li>MBBS, FCPS Surgery. </li></ul><ul><li>INTERNATIONAL FELLOW </li></ul>JOURNAL CLUB JUNE 2010
Cost-Effectiveness Analysis of Protected Carotid Artery Stent Placement Versus Endarterectomy in High-Risk Patients
Zeenat Qureshi Stroke Research Center, Department of Neurology and Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA <ul><li>Alberto Maud, MD, </li></ul><ul><li>Gabriela Vázquez PhD, </li></ul><ul><li>John A. Nyman, PhD, </li></ul><ul><li>Kamakshi Lakshminarayan, MD, PhD, </li></ul><ul><li>David C. Anderson, MD, </li></ul><ul><li>Adnan I. Qureshi, MD. </li></ul>
Objective <ul><li>To determine the cost-effectiveness of carotid angioplasty with stent placement (CAS) under emboli protection versus carotid endarterectomy (CEA) in patients with severe carotid stenosis considered to be at high surgical risk for CEA. </li></ul>
Methods <ul><li>The probabilities of various outcomes were adopted from the SAPPHIRE trial results. The quality-adjusted life year (QALYs) associated with each treatment modality were estimated by using the frequencies of various quality-adjusted outcomes (QALY weights of ipsilateral stroke, myocardial infarction, and death). </li></ul>
Methods <ul><li>Total cost associated with each intervention was computed using the frequency of stroke, myocardial infarction, and death in each group. Costs are expressed in 2006 US$. Incremental cost-effectiveness ratios (ICERs) were estimated for a 1-year postprocedure period. </li></ul>
SAPPHIRE Trial 13.8% 17.0% COPD 35.3% 29.7% Myocardial Infarction 14.7% 24.1% Class 3-4 Angina 75.5% 85.8% Coronary Artery Disease Risk Factors 27.7% 29.9% Symptomatic 72.6 (46-91) 72.5 (49-89) Age (Years) 67.1% 66.9% Men 167 167 No of Patients CEA CAS Parameters
Model variables for outcome associated with CAS & CEA 5% 2% Non Q-wave 1% 0% Q-wave MI (at 30 Days) 2% 4% Minor 4% 1% Major Ipsilateral > 30 Days Stroke at 30 Days 13% 7% Death (1 Year) Clinical Input Variable CEA CAS Parameters
Results <ul><li>The mean (range) estimated net costs at 1 year for patients treated with CAS and CEA were $12,782 ($12,205–$13,563) and $8,916 ($8,267–$9,766), respectively. Overall QALYs for the CAS and CEA groups were 0.753 and 0.701 [within a range of 0.0 (meaning death) to 0.815 (meaning no adverse events)]. </li></ul>
Results <ul><li>The mean cost per QALY gained for CAS was $16,223 ($15,315–$17,474) and the mean cost per QALY gained for CEA was $12,745 ($11,372–$14,605). The estimated median ICER for CAS versus CEA treatment was $67,891 (−$129,372 to $379,661). </li></ul>
<ul><li>The proven non-inferiority of CAS versus CEA in high-surgical-risk patients with severe carotid stenosis might provide a marginal benefit that is offset by the higher cost associated with this procedure. </li></ul>CONCLUSION
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