Cost-effectiveness analysis of endovascular versus neurosurgical treatment for ruptured intracranial aneurysms in the United States

Clinical article

Alberto MaudZeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis; and

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Kamakshi LakshminarayanZeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis; and

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 M.D., Ph.D.
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M. Fareed K. SuriZeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis; and

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Gabriela VazquezZeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis; and

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Giuseppe LanzinoDepartment of Neurosurgery, Mayo Clinic, Rochester, Minnesota

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Adnan I. QureshiZeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis; and

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Object

The results of the International Subarachnoid Aneurysm Trial (ISAT) demonstrated lower rates of death and disability with endovascular treatment (coiling) than with open surgery (clipping) to secure the ruptured intracranial aneurysm. However, cost-effectiveness may not be favorable because of the greater need for follow-up cerebral angiograms and additional follow-up treatment with endovascular methods. In this study, the authors' goal was to compare the cost-effectiveness of endovascular and neurosurgical treatments in patients with ruptured intracranial aneurysms who were eligible to undergo either type of treatment.

Methods

Clinical data (age, sex, frequency of retreatment, and rebleeding) and quality of life values were obtained from the ISAT. Total cost included those associated with disability, hospitalization, retreatment, and rebleeding. Cost estimates were derived from the Premier Perspective Comparative Database, data from long-term care in stroke patients, and relevant literature. Incremental cost-effectiveness ratios (ICERs) were estimated during a 1-year period. Parametric bootstrapping was used to determine the uncertainty of the estimates.

Results

The median estimated costs of endovascular and neurosurgical treatments (in US dollars) were $45,493 (95th percentile range $44,693–$46,365) and $41,769 (95th percentile range $41,094–$42,518), respectively. The overall quality-adjusted life years (QALY) in the endovascular group was 0.69, and for the neurosurgical group it was 0.64. The cost per QALY in the endovascular group was $65,424 (95th percentile range $64,178–$66,772), and in the neurosurgical group it was $64,824 (95th percentile range $63,679–$66,086). The median estimated ICER at 1 year for endovascular treatment versus neurosurgical treatment was $72,872 (95th percentile range $50,344–$98,335) per QALY gained. Given that most postprocedure angiograms and additional treatments occurred in the 1st year and the 1-year disability status is unlikely to change in the future, ICER for endovascular treatment will progressively decrease over time.

Conclusions

Using outcome and economic data obtained in the US at 1 year after the procedure, endovascular treatment is more costly but is associated with better outcomes than the neurosurgical alternative among patients with ruptured intracranial aneurysms who are eligible to undergo either procedure. With accrual of additional years with a better outcome status, the ICER for endovascular coiling would be expected to progressively decrease and eventually reverse.

Abbreviations used in this paper:

ICD-9-CM = International Classification of Diseases, 9th Revision, Clinical Modification; ICER = incremental cost-effectiveness ratio; ISAT = International Subarachnoid Aneurysm Trial; mRS = modified Rankin Scale; QALY = quality-adjusted life years; SAH = subarachnoid hemorrhage; WFNS = World Federation of Neurosurgical Societies.
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  • 1

    Bairstow P, , Dodgson A, , Linto J, & Khangure M: Comparison of cost and outcome of endovascular and neurosurgical procedures in the treatment of ruptured intracranial aneurysms. Australas Radiol 46:249251, 2002

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2

    Campi A, , Ramzi N, , Molyneux AJ, , Summers PE, , Kerr RS, & Sneade M, et al.: Retreatment of ruptured cerebral aneurysms in patients randomized by coiling or clipping in the International Subarachnoid Aneurysm Trial (ISAT). Stroke 38:15381544, 2007

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 3

    Fenwick E, , Marshall DA, , Levy AR, & Nichol G: Using and interpreting cost-effectiveness acceptability curves: an example using data from a trial of management strategies for atrial fibrillation. BMC Health Serv Res 6:52, 2006

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 4

    Gage BF, , Cardinalli AB, , Albers GW, & Owens DK: Cost-effectiveness of warfarin and aspirin for prophylaxis of stroke in patients with nonvalvular atrial fibrillation. JAMA 274:18391845, 1995

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 5

    Harbaugh RE, , Heros RC, & Hadley MN: More on ISAT. Lancet 361:783784, 2003

  • 6

    Javadpour M, , Jain H, , Wallace MC, , Willinsky RA, , ter Brugge KG, & Tymianski M: Analysis of cost related to clinical and angiographic outcomes of aneurysm patients enrolled in the international subarachnoid aneurysm trial in a North American setting. Neurosurgery 56:886894, 2005

    • Search Google Scholar
    • Export Citation
  • 7

    Johnston SC, , Gress DR, & Kahn JG: Which unruptured cerebral aneurysms should be treated? A cost-utility analysis. Neurology 52:18061815, 1999

  • 8

    Kallmes DF, , Kallmes MH, , Lanzino G, , Kassell NF, , Jensen ME, & Helm GA: Routine angiography after surgery for ruptured intracranial aneurysms: a cost versus benefit analysis. Neurosurgery 41:629641, 1997

    • Search Google Scholar
    • Export Citation
  • 9

    Mandelblatt JS, , Fryback DG, , Weinstein MC, , Russell LB, & Gold MR: Assessing the effectiveness of health interventions for cost-effectiveness analysis. Panel on Cost-Effectiveness in Health and Medicine. J Gen Intern Med 12:551558, 1997

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 10

    Molyneux A, , Kerr R, , Stratton I, , Sandercock P, , Clarke M, & Shrimpton J, et al.: International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet 360:12671274, 2002

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 11

    Molyneux AJ, , Kerr RS, , Yu LM, , Clarke M, , Sneade M, & Yarnold JA, et al.: International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet 366:809817, 2005

    • Search Google Scholar
    • Export Citation
  • 12

    Premier's Perspective Comparative Database: Charlotte, NC. USA, 2006 (http://www.premierinc.com) [Accessed 6 August 2007]

  • 13

    Qureshi AI, , Hutson AD, , Harbaugh RE, , Stieg PE, & Hopkins LN: Methods and design considerations for randomized clinical trials evaluating surgical or endovascular treatments for cerebrovascular diseases. Neurosurgery 54:248264, 2004

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 14

    Qureshi AI, , Janardhan V, , Hanel RA, & Lanzino G: Comparison of endovascular and surgical treatments for intracranial aneurysms: an evidence-based review. Lancet Neurol 6:816825, 2007

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 15

    Qureshi AI, , Suri MF, , Nasar A, , Kirmani JF, , Ezzeddine MA, & Divani AA, et al.: Changes in cost and outcome among US patients with stroke hospitalized in 1990 to 1991 and those hospitalized in 2000 to 2001. Stroke 38:21802184, 2007

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 16

    Rasanen P, , Roine E, , Sintonen H, , Semberg-Konttinen V, , Ryynanen OP, & Roine R: Use of quality-adjusted life years for the estimation of effectiveness of health care: a systematic literature review. Int J Technol Assess Health Care 22:235241, 2006

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 17

    Wiebers DO, , Whisnant JP, , Huston J III, , Meissner I, , Brown RD Jr, & Piepgras DG, et al.: Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet 362:103110, 2003

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 18

    Wolstenholme J, , Rivero-Arias O, , Gray A, , Molyneux AJ, , Kerr RS, & Yarnold JA, et al.: Treatment pathways, resource use, and costs of endovascular coiling versus surgical clipping after aSAH. Stroke 39:111119, 2008

    • Crossref
    • Search Google Scholar
    • Export Citation

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