Kilaru Sashi, Korn Peter, Kasirajan Karthikeshwar, Lee Thomas Y, Beavers Frederick P, Lyon Ross T, Bush Harry L, Kent K Craig
Division of Vascular Surgery, New York Presbyterian Hospital, New York, NY 10021, USA.
J Vasc Surg. 2003 Feb;37(2):331-9. doi: 10.1067/mva.2003.124.
Carotid angioplasty and stenting (CAS) has been advocated as a minimally invasive and inexpensive alternative to carotid endarterectomy (CEA). However, a precise comparative analysis of the immediate and long-term costs associated with these two procedures has not been performed. To accomplish this, a Markov decision analysis model was created to evaluate the relative cost effectiveness of these two interventions.
Procedural morbidity/mortality rate for CEA and costs (not charges) were derived from a retrospective review of consecutive patients treated at New York Presbyterian Hospital/Cornell (n = 447). Data for CAS were obtained from the literature. We incorporated into this model both the immediate procedural costs and the long-term cost of morbidities, such as stroke (major stroke in the first year = $52,019; in subsequent years = $27,336/y; minor stroke = $9419). We determined long-term survival rate in quality-adjusted life years and lifetime costs for a hypothetic cohort of 70-year-old patients undergoing either CEA or CAS. Our measure of outcome was the cost-effectiveness ratio.
The immediate procedural costs of CEA and CAS were $7871 and $10,133 respectively. We assumed major plus minor stroke rates for CEA and CAS of 0.9% and 5%, respectively. We assumed a 30-day mortality rate of 0% for CEA and 1.2% for CAS. In our base case analysis, CEA was cost saving (lifetime savings = $7017/patient; increase in quality-adjusted life years saved = 0.16). Sensitivity analysis revealed major stroke and death rates as the major contributors to this differential in cost effectiveness. Procedural costs were less important, and minor stroke rates were least important. CAS became cost effective only if its major stroke and mortality rates were made equivalent to those of CEA.
CEA is cost saving compared with CAS. This is related to the higher rate of stroke with CAS and the high cost of stents and protection devices. To be economically competitive, the mortality and major stroke rates of CAS must be at least equivalent if not less than those of CEA.
颈动脉血管成形术和支架置入术（CAS）已被提倡作为颈动脉内膜切除术（CEA）的一种微创且低成本的替代方案。然而，尚未对这两种手术相关的近期和长期成本进行精确的比较分析。为实现这一目标，创建了一个马尔可夫决策分析模型来评估这两种干预措施的相对成本效益。
CEA的手术发病率/死亡率以及成本（非收费）来自对纽约长老会医院/康奈尔大学连续治疗患者（n = 447）的回顾性研究。CAS的数据来自文献。我们将手术近期成本和诸如中风等并发症的长期成本纳入该模型（第一年的重大中风 = 52,019美元；后续年份 = 每年27,336美元；轻微中风 = 9419美元）。我们确定了接受CEA或CAS的70岁假设队列患者在质量调整生命年中的长期生存率和终身成本。我们的结果衡量指标是成本效益比。
CEA和CAS的手术近期成本分别为7871美元和10,133美元。我们假设CEA和CAS的重大加轻微中风发生率分别为0.9%和5%。我们假设CEA的30天死亡率为0%，CAS为1.2%。在我们的基础病例分析中，CEA节省成本（每位患者终身节省 = 7017美元；质量调整生命年节省增加 = 0.16）。敏感性分析显示重大中风和死亡率是成本效益差异的主要因素。手术成本不太重要，轻微中风发生率最不重要。仅当CAS的重大中风和死亡率与CEA相当时，CAS才具有成本效益。
与CAS相比，CEA节省成本。这与CAS较高的中风发生率以及支架和保护装置的高成本有关。为了在经济上具有竞争力，CAS的死亡率和重大中风发生率必须至少与CEA相当，甚至更低。
