Hildick-Smith David, Turner Mark, Shaw Louise, Nakum Mitesh, Hartaigh Bríain Ó, Evans Richard M, Rhodes John F, Sondergaard Lars, Kasner Scott E
a The Sussex Cardiac Centre , Brighton & Sussex University Hospital NHS Trust , Brighton , UK.
b The Bristol Heart Institute , University Hospitals Bristol NHS Foundation Trust , Bristol , UK.
J Med Econ. 2019 Feb;22(2):131-139. doi: 10.1080/13696998.2018.1548355. Epub 2018 Nov 29.
Percutaneous closure of a patent foramen ovale (PFO) is known to lower the risk of recurrent stroke in patients with a cryptogenic stroke. However, the economic implications of transcatheter PFO closure are less well known. From a UK payer perspective, a detailed economic appraisal of PFO closure was performed for prevention of recurrent ischemic stroke in patients with a PFO who had experienced a cryptogenic stroke.
A Markov cohort model was constructed using a 5-year time-horizon with a patient mean age of 45.2 years, reflecting the characteristics reported in the REDUCE trial. Transition probabilities, clinical inputs, costs, and utility values were ascertained from published and national costing sources. Total costs, incremental costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios were calculated, utilizing a discount rate of 3.5%. A range of univariate and probabilistic sensitivity analyses were also performed.
When applying a willingness-to-pay (WTP) threshold of £20,000/QALY in accordance with NICE guidelines, PFO closure compared with antiplatelet therapy alone showed a beneficial cost/QALY of £18,584, attained at 4 years. Applying discount rates of 0% and 6% had a negligible effect on the base-case model findings. PFO closure demonstrated a 76.9% probability of being cost-effective at a WTP threshold of £20,000/QALY at a 5-year time-horizon.
This model focused specifically on UK stroke patients and typically enrolled young (mean age <65 years old) patients. Hence, caution should be taken when comparing data vs non-UK populations, and it remains unclear how older patients might have affected cost-effectiveness findings, as the risk of paradoxical embolism can persist as patients age.
Percutaneous closure of a PFO is cost-effective compared with antiplatelet therapy alone, underlining the economic benefits potentially afforded by this treatment in selected patients.
经皮闭合卵圆孔未闭（PFO）可降低不明原因卒中患者复发性卒中的风险。然而，经导管PFO闭合术的经济影响尚鲜为人知。从英国支付方的角度，对PFO闭合术预防PFO合并不明原因卒中患者复发性缺血性卒中进行了详细的经济评估。
构建一个马尔可夫队列模型，时间跨度为5年，患者平均年龄45.2岁，反映REDUCE试验报告的特征。从已发表的文献和国家成本核算来源确定转移概率、临床数据、成本和效用值。采用3.5%的贴现率计算总成本、增量成本、质量调整生命年（QALY）和增量成本效益比。还进行了一系列单变量和概率敏感性分析。
按照英国国家卫生与临床优化研究所（NICE）指南，应用每QALY支付意愿（WTP）阈值20,000英镑时，与单纯抗血小板治疗相比，PFO闭合术在4年时显示出每QALY 18,584英镑的有益成本。应用0%和6%的贴现率对基础模型结果影响可忽略不计。在5年时间跨度、每QALY支付意愿阈值20,000英镑时，PFO闭合术具有成本效益的概率为76.9%。
该模型专门针对英国卒中患者，且通常纳入年轻（平均年龄<65岁）患者。因此，与非英国人群比较数据时应谨慎，且老年患者如何影响成本效益结果仍不明确，因为矛盾性栓塞风险可能随患者年龄增长而持续存在。
与单纯抗血小板治疗相比，经皮闭合PFO具有成本效益，突显了该治疗在特定患者中潜在的经济效益。
