Wali Arvin R, Park Charlie C, Santiago-Dieppa David R, Vaida Florin, Murphy James D, Khalessi Alexander A
Departments of Neurological Surgery.
Radiology.
Neurosurg Focus. 2017 Jun;42(6):E6. doi: 10.3171/2017.3.FOCUS1749.
OBJECTIVE Rupture of large or giant intracranial aneurysms leads to significant morbidity, mortality, and health care costs. Both coiling and the Pipeline embolization device (PED) have been shown to be safe and clinically effective for the treatment of unruptured large and giant intracranial aneurysms; however, the relative cost-to-outcome ratio is unknown. The authors present the first cost-effectiveness analysis to compare the economic impact of the PED compared with coiling or no treatment for the endovascular management of large or giant intracranial aneurysms. METHODS A Markov model was constructed to simulate a 60-year-old woman with a large or giant intracranial aneurysm considering a PED, endovascular coiling, or no treatment in terms of neurological outcome, angiographic outcome, retreatment rates, procedural and rehabilitation costs, and rupture rates. Transition probabilities were derived from prior literature reporting outcomes and costs of PED, coiling, and no treatment for the management of aneurysms. Cost-effectiveness was defined, with the incremental cost-effectiveness ratios (ICERs) defined as difference in costs divided by the difference in quality-adjusted life years (QALYs). The ICERs < $50,000/QALY gained were considered cost-effective. To study parameter uncertainty, 1-way, 2-way, and probabilistic sensitivity analyses were performed. RESULTS The base-case model demonstrated lifetime QALYs of 12.72 for patients in the PED cohort, 12.89 for the endovascular coiling cohort, and 9.7 for patients in the no-treatment cohort. Lifetime rehabilitation and treatment costs were $59,837.52 for PED; $79,025.42 for endovascular coiling; and $193,531.29 in the no-treatment cohort. Patients who did not undergo elective treatment were subject to increased rates of aneurysm rupture and high treatment and rehabilitation costs. One-way sensitivity analysis demonstrated that the model was most sensitive to assumptions about the costs and mortality risks for PED and coiling. Probabilistic sampling demonstrated that PED was the cost-effective strategy in 58.4% of iterations, coiling was the cost-effective strategy in 41.4% of iterations, and the no-treatment option was the cost-effective strategy in only 0.2% of iterations. CONCLUSIONS The authors' cost-effective model demonstrated that elective endovascular techniques such as PED and endovascular coiling are cost-effective strategies for improving health outcomes and lifetime quality of life measures in patients with large or giant unruptured intracranial aneurysm.
巨大或大型颅内动脉瘤破裂会导致显著的发病率、死亡率和医疗费用。血管内栓塞术和Pipeline栓塞装置（PED）已被证明在治疗未破裂的大型和巨型颅内动脉瘤方面是安全且临床有效的；然而，相对成本效益比尚不清楚。作者进行了首次成本效益分析，以比较PED与血管内栓塞术或不治疗对大型或巨型颅内动脉瘤进行血管内治疗的经济影响。方法：构建马尔可夫模型，模拟一名60岁患有大型或巨型颅内动脉瘤的女性，考虑采用PED、血管内栓塞术或不治疗，评估其神经学结局、血管造影结局、再治疗率、手术和康复成本以及破裂率。转移概率来自先前关于PED、血管内栓塞术和不治疗动脉瘤管理的结局和成本的文献报道。定义成本效益，增量成本效益比（ICER）定义为成本差异除以质量调整生命年（QALY）差异。ICER < 50,000美元/QALY增加被认为具有成本效益。为研究参数不确定性，进行了单向、双向和概率敏感性分析。结果：基础模型显示，PED组患者的终身QALY为12.72，血管内栓塞术组为12.89，未治疗组为9.7。PED的终身康复和治疗成本为59,837.52美元；血管内栓塞术为79,025.42美元；未治疗组为193,531.
