Zeenat Qureshi Stroke Research Center and Department of Neurology, University of Minnesota, Minneapolis, Minnesota 55414, USA.
J Neurosurg. 2012 Jul;117(1):89-93. doi: 10.3171/2012.3.JNS111266. Epub 2012 May 11.
The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) demonstrated that the risk of the primary composite outcome of stroke, myocardial infarction (MI), or death did not differ significantly in patients with an average surgical risk undergoing carotid artery stenting (CAS) and those undergoing carotid endarterectomy (CEA). However, the cost associated with CAS may limit its broad applicability. The authors' goal in this paper was to determine the cost-effectiveness of CAS with an embolic-protection device versus CEA in patients with moderate to severe carotid artery stenosis who are at average surgical risk.
The probability of the primary outcome was obtained from the results of the CREST trial. The quality-adjusted life years (QALYs) associated with each treatment modality were estimated by adjusting for the incidence of each quality-adjusted outcome (QALY weights of ipsilateral stroke, MI, death, and postprocedure QALYs). The total cost associated with each intervention was derived from hospitalization cost and cost associated with primary outcomes including stroke, MI, and death in each group. Costs are expressed in US dollars accounting for inflation up to October 2010. Incremental cost-effectiveness ratios (ICERs) were estimated for the 4-year period after the procedure. All values are expressed as means and 95% confidence intervals.
The estimated net costs for patients after treatment with CAS and CEA after consideration of the primary outcome were $18,335 and $13,276, respectively, from the definitive presimulation analysis. Postsimulation values were $19,210 (range $18,264-$20,156) and $14,080 (range $13,076-$15,084), respectively. Overall, QALYs for the CAS and CEA groups were 0.712 and 0.702, respectively (ranging from 0.0 [death] to 0.815 [no adverse events]). The estimated ICER for CAS versus CEA treatment was $229,429.
Although the CREST demonstrated equivalent results with CAS (compared with CEA) in patients at average surgical risk with severe carotid artery stenosis, broad applicability of CAS might be limited by the higher cost associated with this procedure.
颈动脉血管内膜切除术与支架置入术试验（CREST）表明，在平均手术风险下，接受颈动脉血管内膜切除术（CEA）和颈动脉支架置入术（CAS）的患者，其卒中、心肌梗死（MI）或死亡的主要复合终点风险无显著差异。然而，与 CAS 相关的成本可能会限制其广泛适用性。作者在本文中的目标是确定在平均手术风险的中度至重度颈动脉狭窄患者中，使用带血栓保护装置的 CAS 与 CEA 的成本效益。
主要结果的概率来自 CREST 试验的结果。通过调整每种治疗方式的质量调整生命年（QALY），估计每种治疗方式的质量调整结果的发生率（同侧卒中、MI、死亡和术后 QALY 的权重）。每个干预的总成本来自住院费用以及每组中风、MI 和死亡等主要结果的成本。成本以美元表示，考虑到截至 2010 年 10 月的通货膨胀。在手术后的 4 年内，对每个组的增量成本效益比（ICER）进行了估计。所有值均表示为平均值和 95%置信区间。
在考虑主要结果后，在确定性的预先模拟分析中，患者接受 CAS 和 CEA 治疗后的估计净成本分别为 18335 美元和 13276 美元。在事后模拟中，其值分别为 19210 美元（范围为 18264 美元至 20156 美元）和 14080 美元（范围为 13076 美元至 15084 美元）。总的来说，CAS 和 CEA 组的 QALY 分别为 0.712 和 0.702（范围为 0.0 [死亡]至 0.815 [无不良事件]）。CAS 与 CEA 治疗的估计 ICER 为 229429 美元。
尽管 CREST 在平均手术风险较高的严重颈动脉狭窄患者中，CAS（与 CEA 相比）的结果相同，但与该手术相关的较高成本可能会限制 CAS 的广泛适用性。
