Cost-effectiveness of screening for asymptomatic carotid stenosis

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Presentation transcript:

Cost-effectiveness of screening for asymptomatic carotid stenosis Dongping Yin, PhD, Jeffrey P. Carpenter, MD Journal of Vascular Surgery Volume 27, Issue 2, Pages 245-255 (February 1998) DOI: 10.1016/S0741-5214(98)70355-6 Copyright © 1998 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

Fig. 1 Decision tree of events in month after decision to screen. Square nodes represent decisions, and circular nodes are chance nodes. Model accounts for complications of arteriography and fate of patients who had false-positive ultrasound scans. Patients enter Markov process after decision to screen (Fig. 2). Angio, carotid arteriography; Comp, complications; Dz, patient has 60% to 99% asymptomatic carotid stenosis; Surg, carotid endarterectomy. Journal of Vascular Surgery 1998 27, 245-255DOI: (10.1016/S0741-5214(98)70355-6) Copyright © 1998 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

Fig. 2 A, Markov model for fate of patients after screening. Well, Asym, Sym, AsymSurg, SymSurg, MinStk, MajStk, and Death are Markov states (Table I). Patients who are aging may move from one of eight Markov states to another (i.e., from Well to Asym). B, Markov model for monthly transition for patients who develop asymptomatic stenosis after screening has been completed. Patients may have stroke, remain asymptomatic, or develop symptoms. Those developing symptoms (i.e., transient ischemic attack) are assumed to undergo ultrasound testing and then arteriographic verification and endarterectomy in patients with confirmed 60% to 99% stenosis. Square nodes represent decisions and circular nodes are chance nodes. Angio, carotid arteriography; Comp, complications; Dz, 60% to 99% stenosis; Surg, Carotid endarterectomy. Journal of Vascular Surgery 1998 27, 245-255DOI: (10.1016/S0741-5214(98)70355-6) Copyright © 1998 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

Fig. 3 Solid line shows prevalence of disease in screening population and cost-effectiveness of screening. Screening was cost-effective if prevalence of asymptomatic carotid stenosis was more than 4.5%. Dashed line shows surgical efficacy for patients who were asymptomatic and cost-effectiveness of screening. Screening was cost-effective if surgical efficacy was more than 37%. Surgical efficacy, (rate of stroke in medical patients - rate of stroke in surgical patients)/(rate of stroke in medical patients); CE-Ratio, Cost/QALY = (cost of screening - cost of not screening)/(QALY of screening - QALY of not screening). Journal of Vascular Surgery 1998 27, 245-255DOI: (10.1016/S0741-5214(98)70355-6) Copyright © 1998 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

Fig. 4 Surgical complications and cost-effectiveness of screening. Screening was cost-effective if surgical complication rate was less than 160% of that in ACAS and NASCET. Surgical complications, rate of surgical complications compared with rates of complications in ACAS (for asymptomatic patients) and NASCET (for symptomatic patients); CE-Ratio, Cost/QALY = (cost of screening - cost of not screening )/(QALY of screening - QALY of not screening). Journal of Vascular Surgery 1998 27, 245-255DOI: (10.1016/S0741-5214(98)70355-6) Copyright © 1998 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

Fig. 5 Sensitivity and specificity of ultrasound and cost-effectiveness of screening. Cost-effectiveness of screening was independent of sensitivity of ultrasound (dashed line). Screening was cost-effective if specificity of ultrasound was more than 91% (solid line). CE-Ratio, Cost/QALY = (cost of screening - cost of not screening )/(QALY of screening - QALY of not screening). Journal of Vascular Surgery 1998 27, 245-255DOI: (10.1016/S0741-5214(98)70355-6) Copyright © 1998 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

Fig. 6 Annual rate of strokes in patients with 60% to 99% asymptomatic stenosis and cost-effectiveness of screening. Screening was cost-effective if stroke rate of patients who were medically managed and asymptomatic was more than 3.3%. CE-Ratio, Cost/QALY = (cost of screening - cost of not screening)/(QALY of screening - QALY of not screening). Journal of Vascular Surgery 1998 27, 245-255DOI: (10.1016/S0741-5214(98)70355-6) Copyright © 1998 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

Fig. 7 Cost of ultrasound and cost-effectiveness of screening. Screening was cost-effective if cost of ultrasound was less than $300. CE-Ratio, Cost/QALY = (cost of screening - cost of not screening)/(QALY of screening - QALY of not screening). Journal of Vascular Surgery 1998 27, 245-255DOI: (10.1016/S0741-5214(98)70355-6) Copyright © 1998 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

Fig. 8 Rate of carotid arteriography-related complications and cost-effectiveness of screening. Screening was cost-effective if rate of arteriographic complications was less than 1.4%. CE-Ratio, Cost/QALY = (cost of screening - cost of not screening)/(QALY of screening - QALY of not screening). Journal of Vascular Surgery 1998 27, 245-255DOI: (10.1016/S0741-5214(98)70355-6) Copyright © 1998 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions