Cost-effectiveness analysis in patients with an unruptured cerebral aneurysm treated with observation or surgery

Charlotte Dandurand MD, MSc, FRCSC1,2, Lily Zhou MD, MSc, FRCSC3,2, Swetha Prakash MSc1, Gary Redekop MD, MSc, FRCSC1, Peter Gooderham MD, FRCSC1, and Charles S. Haw MD, MSc, FRCSC1
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  • 1 Faculty of Medicine, Divisions of Neurosurgery and
  • | 3 Neurology, University of British Columbia, Vancouver, Canada; and
  • | 2 T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts
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OBJECTIVE

The main goal of preventive treatment of unruptured intracranial aneurysms (UIAs) is to avoid the morbidity and mortality associated with aneurysmal subarachnoid hemorrhage. A comparison between the conservative approach and the surgical approach combining endovascular treatment and microsurgical clipping is currently lacking. This study aimed to conduct an updated evaluation of cost-effectiveness comparing the two approaches in patients with UIA.

METHODS

A decision tree with a Markov model was developed. Quality-adjusted life-years (QALYs) associated with living with UIA before and after treatment were prospectively collected from a cohort of patients with UIA at a tertiary center. Other inputs were obtained from published literature. Using Monte Carlo simulation for patients aged 55, 65, and 75 years, the authors modeled the conservative management in comparison with preventive treatment. Different proportions of endovascular and microsurgical treatment were modeled to reflect existing practice variations between treatment centers. Outcomes were assessed in terms of QALYs. Sensitivity analyses to assess the model’s robustness and completed threshold analyses to examine the influence of input parameters were performed.

RESULTS

Preventive treatment of UIAs consistently led to higher utility. Models using a higher proportion of endovascular therapy were more cost-effective. Models with older cohorts were less cost-effective than those with younger cohorts. Treatment was cost-effective (willingness to pay < 100,000 USD/QALY) if the annual rupture risk exceeded a threshold between 0.8% and 1.9% in various models based on the proportion of endovascular treatment and cohort age. A higher proportion of endovascular treatments and younger age lowered this threshold, making the treatment of aneurysms with a lower risk of rupture more cost-effective.

CONCLUSIONS

Preventive treatment of aneurysms led to higher utility compared with conservative management. Models with a higher proportion of endovascular treatment and younger patient age were most cost-effective.

ABBREVIATIONS

aSAH = aneurysmal subarachnoid hemorrhage; ICER = incremental cost-effectiveness ratio; ISAT = International Subarachnoid Aneurysm Trial; MRA = magnetic resonance angiography; mRS = modified Rankin Scale; PSA = probabilistic sensitivity analysis; QALY = quality-adjusted life-year; UIA = unruptured intracranial aneurysm.

Supplementary Materials

    • Supplementary Fig. 1 (PDF 1,460 KB)

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Contributor Notes

INCLUDE WHEN CITING Published online May 7, 2021; DOI: 10.3171/2020.11.JNS202892.

Correspondence Charlotte Dandurand: University of British Columbia, Vancouver, BC, Canada. charlotte.dandurand@alumni.ubc.ca.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

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