Cost-effectiveness of carotid endarterectomy in asymptomatic patients

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Presentation transcript:

Cost-effectiveness of carotid endarterectomy in asymptomatic patients Jack L. Cronenwett, MD, John D. Birkmeyer, MD, Gary B. Nackman, MD, Mark F. Fillinger, MD, Fritz R. Bech, MD, Robert M. Zwolak, MD, PhD, Daniel B. Walsh, MD Journal of Vascular Surgery Volume 25, Issue 2, Pages 298-311 (February 1997) DOI: 10.1016/S0741-5214(97)70351-3 Copyright © 1997 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

Fig. 1 Markov decision analysis model (simplified) comparing medical management versus surgical treatment of asymptomatic carotid stenosis. (*Surgery only if no previous stroke) Journal of Vascular Surgery 1997 25, 298-311DOI: (10.1016/S0741-5214(97)70351-3) Copyright © 1997 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

Fig. 2 Lifetime cost estimates (discounted at 5%) for medical and surgical treatment of 67-year-old patients. Medical patients experienced total costs that were $2000 less than surgical patients, heavily allocated to care after major stroke. Costs for surgical patients were predominantly influenced by initial procedural costs. Journal of Vascular Surgery 1997 25, 298-311DOI: (10.1016/S0741-5214(97)70351-3) Copyright © 1997 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

Fig. 3 Cost-effectiveness of surgical treatment compared with medical management as a function of age in the base-case analysis. Shading indicates three categories of cost-effectiveness: less than $20,000/QALY, clearly cost-effective; $20,000 to $100,000, intermediate cost-effectiveness; greater than $100,000, not cost-effective. By these definitions, surgical treatment is “cost-effective” until at least age 72, and perhaps age 79. Journal of Vascular Surgery 1997 25, 298-311DOI: (10.1016/S0741-5214(97)70351-3) Copyright © 1997 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

Fig. 4 Cost-effectiveness of surgical treatment as a function of ipsilateral stroke rate during medical management for three different age groups. For young patients (age 55), surgery is cost-effective even at low annual stroke risk (1.5% per year). For older patients (age 75), surgery is cost-effective only if medical stroke risk is high (>2.5% per year). The broken line at 2.3% annual stroke risk indicates the base-case assumption based on ACAS. Journal of Vascular Surgery 1997 25, 298-311DOI: (10.1016/S0741-5214(97)70351-3) Copyright © 1997 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

Fig. 5 Cost-effectiveness of surgical treatment as a function of perioperative stroke or death rate for three different age groups. For young patients, surgery is cost-effective even at higher operative event rates. For older patients, however, perioperative event rate must be much lower for surgical treatment to be cost-effective. The broken line at 2.3% indicates the base-case assumption for perioperative event rate based on ACAS. Journal of Vascular Surgery 1997 25, 298-311DOI: (10.1016/S0741-5214(97)70351-3) Copyright © 1997 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

Fig. 6 Extreme estimates (shaded range) for cost-effectiveness of surgical treatment as a function of age, based on varying cost for surgical and medical care. High cost estimate uses the lowest cost for stroke care and the highest cost for surgery. Low cost estimate uses the highest cost for stroke care and the lowest cost for surgery (Table I). Journal of Vascular Surgery 1997 25, 298-311DOI: (10.1016/S0741-5214(97)70351-3) Copyright © 1997 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions