Almekhlafi M A, Hill M D, Wiebe S, Goyal M, Yavin D, Wong J H, Clement F M
From the Departments of Clinical Neurosciences (M.A.A., M.D.H., S.W., M.G., D.Y., J.H.W.).
AJNR Am J Neuroradiol. 2014 Feb;35(2):327-32. doi: 10.3174/ajnr.A3682. Epub 2013 Aug 8.
Carotid revascularization procedures can be complicated by stroke. Additional disability adds to the already high costs of the procedure. To weigh the cost and benefit, we estimated the cost-utility of carotid angioplasty and stenting compared with carotid endarterectomy among patients with symptomatic carotid stenosis, with special emphasis on scenario analyses that would yield carotid angioplasty and stenting as the cost-effective alternative relative to carotid endarterectomy.
A cost-utility analysis from the perspective of the health system payer was performed by using a Markov analytic model. Clinical estimates were based on a meta-analysis. The procedural costs were derived from a microcosting data base. The costs for hospitalization and rehabilitation of patients with stroke were based on a Canadian multicenter study. Utilities were based on a randomized controlled trial.
In the base case analysis, carotid angioplasty and stenting were more expensive (incremental cost of $6107) and had a lower utility (-0.12 quality-adjusted life years) than carotid endarterectomy. The results are sensitive to changes in the risk of clinical events and the relative risk of death and stroke. Carotid angioplasty and stenting were more economically attractive among high-risk surgical patients. For carotid angioplasty and stenting to become the preferred option, their costs would need to fall from more than $7300 to $4350 or less and the risks of the periprocedural and annual minor strokes would have to be equivalent to that of carotid endarterectomy.
In the base case analysis, carotid angioplasty and stenting were associated with higher costs and lower utility compared with carotid endarterectomy for patients with symptomatic carotid stenosis. Carotid angioplasty and stenting were cost-effective for patients with high surgical risk.
颈动脉血运重建手术可能并发中风。额外的残疾会增加该手术本已高昂的费用。为权衡成本与效益，我们评估了有症状颈动脉狭窄患者中行颈动脉血管成形术和支架置入术相对于颈动脉内膜切除术的成本效用，特别着重于情景分析，该分析将使颈动脉血管成形术和支架置入术成为相对于颈动脉内膜切除术而言具有成本效益的选择。
采用马尔可夫分析模型，从卫生系统支付方的角度进行成本效用分析。临床评估基于一项荟萃分析。手术成本源自微观成本数据库。中风患者的住院和康复成本基于一项加拿大多中心研究。效用基于一项随机对照试验。
在基础病例分析中，颈动脉血管成形术和支架置入术比颈动脉内膜切除术费用更高（增量成本为6107美元）且效用更低（质量调整生命年减少0.12）。结果对临床事件风险以及死亡和中风的相对风险变化敏感。在高风险手术患者中，颈动脉血管成形术和支架置入术在经济上更具吸引力。要使颈动脉血管成形术和支架置入术成为首选方案，其成本需从超过7300美元降至4350美元或更低，且围手术期和年度轻微中风的风险必须与颈动脉内膜切除术相当。
在基础病例分析中，对于有症状颈动脉狭窄患者，颈动脉血管成形术和支架置入术相对于颈动脉内膜切除术而言，成本更高且效用更低。颈动脉血管成形术和支架置入术对于手术风险高的患者具有成本效益。
