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

Clinical article

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  • 1 Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis; and
  • 2 Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
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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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Contributor Notes

Address correspondence to: Alberto Maud, M.D., Minnesota Stroke Initiative, University of Minnesota, 12-100 PWB MMC 295, 516 Delaware Street SE, Minneapolis, Minnesota 55455. email: maudx006@umn.edu.
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