U-King-Im Jean Marie, Hollingworth William, Trivedi Rikin A, Cross Justin J, Higgins Nicholas J, Graves Martin J, Gutnikov Sergei, Kirkpatrick Peter J, Warburton Elizabeth A, Antoun Nagui M, Rothwell Peter M, Gillard Jonathan H
Department of Radiology, Addenbrooke's Hospital and the University of Cambridge, Cambridge, United Kingdom.
Ann Neurol. 2005 Oct;58(4):506-15. doi: 10.1002/ana.20591.
The main objective of this study was to assess the long-term cost-effectiveness of five alternative diagnostic strategies for identification of severe carotid stenosis in recently symptomatic patients. A decision-analytical model with Markov transition states was constructed. Data sources included a prospective study involving 167 patients who had screening Doppler ultrasound (DUS), confirmatory contrast-enhanced magnetic resonance angiography (CEMRA) and confirmatory digital subtraction angiography (DSA), individual patient data from the European Carotid Surgery Trial and other published clinical and cost data. A "selective" strategy, whereby all patients receive DUS and CEMRA (only proceeding to DSA if the CEMRA is positive and the DUS is negative), was most cost-effective. This was both the cheapest imaging and treatment strategy (35,205 dollars per patient) and yielded 6.1590 quality-adjusted life years (QALYs), higher than three alternative imaging strategies. Probabilistic sensitivity analysis demonstrated that there was less than a 10% probability that imaging with either DUS or DSA alone are cost-effective at the conventional 50,000 dollars/QALY threshold. In conclusion, DSA is not cost-effective in the routine diagnostic workup of most patients. DUS, with additional imaging in the form of CEMRA, is recommended, with a strategy of "CEMRA and selective DUS review" being shown to be the optimal imaging strategy.
本研究的主要目的是评估五种用于识别近期出现症状患者严重颈动脉狭窄的替代诊断策略的长期成本效益。构建了一个具有马尔可夫转移状态的决策分析模型。数据来源包括一项前瞻性研究，该研究涉及167例接受筛查性多普勒超声（DUS）、确诊性对比增强磁共振血管造影（CEMRA）和确诊性数字减影血管造影（DSA）的患者，欧洲颈动脉手术试验的个体患者数据以及其他已发表的临床和成本数据。一种“选择性”策略，即所有患者均接受DUS和CEMRA检查（仅在CEMRA为阳性且DUS为阴性时才进行DSA检查），是最具成本效益的。这既是最便宜的成像和治疗策略（每位患者35,205美元），又产生了6.1590个质量调整生命年（QALY），高于三种替代成像策略。概率敏感性分析表明，在传统的50,000美元/QALY阈值下，单独使用DUS或DSA成像具有成本效益的概率低于10%。总之，DSA在大多数患者的常规诊断检查中不具有成本效益。建议采用DUS，并辅以CEMRA形式的额外成像检查，“CEMRA和选择性DUS复查”策略被证明是最佳成像策略。
