From the Departments of Neurology (T.Y.C., F.C.C.K., D.W.J.D., B.R.), Epidemiology (M.M.G.H.), Radiology & Nuclear Medicine (M.M.G.H., B.R.), Neurosurgery (R.D., V.V.), and Erasmus MC University Medical Center (T.Y.C., F.C.C.K., D.W.J.D., B.R., R.D.), Rotterdam, the Netherlands; Centre for Health Decision Sciences (M.M.G.H.), Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA; Department of Radiology (A.C.G.M.v.E.), Leiden University Medical Center, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor.
Neurology. 2022 Aug 30;99(9):e890-e903. doi: 10.1212/WNL.0000000000200785. Epub 2022 Jun 2.
No consensus exists on adequate surveillance of conservatively managed unruptured intracranial aneurysms (UIAs). We aimed to determine optimal MRI surveillance strategies for the growth of UIAs using cost-effectiveness analysis. A secondary aim was to develop a clinical tool for personalizing UIA surveillance.
We designed a microsimulation model from a health care perspective simulating 100,000 55-year-old women to estimate costs and quality-adjusted life years (QALYs) over a lifetime horizon in the United States, the United Kingdom, and the Netherlands, using literature-derived model parameters. Country-specific costs and willingness-to-pay thresholds ($100,000/QALY for the United States, £30,000/QALY for the United Kingdom, and €80,000/QALY for the Netherlands) were used. Lifetime costs and QALYs were annually discounted at 3% for the United States, 3.5% for the United Kingdom, or 4% (costs) and 1.5% (QALYs) for the Netherlands. Strategies were no follow-up surveillance, follow-up with MRI in the first and fifth year after UIA discovery, every 5 years, every 2 years, or annually, or immediate intervention (i.e., clipping or coiling). Using the microsimulation model, we developed a tool for personalizing UIA surveillance for men and women, with different ages and varying aneurysm characteristics. Uncertainty in the input parameters was modeled with probabilistic sensitivity analysis.
Among 55-year-old women, 2,222 individuals in the United States, 1,910 in the United Kingdom, and 2,040 in the Netherlands needed to undergo an annual MRI scan to prevent 1 case of subarachnoid hemorrhage per year. No surveillance MRI was most cost-effective in the United States (in 47% of the simulations) and United Kingdom (in 54% of simulations), whereas annual MRI was most cost-effective in the Netherlands (in 53% of simulations). In the United States and United Kingdom, annual surveillance or surveillance in the first and fifth year after discovery was cost-effective in patients <60 years and at increased risk of aneurysm growth. The optimal, personalized, surveillance strategies were summarized in a look-up table for use in clinical practice.
Generally, the US and UK physicians should refrain from assigning patients, particularly older patients and those with few risk factors for aneurysm growth or rupture, to frequent MRI surveillance. In the Netherlands, annual follow-up is generally most cost-effective.
对于保守治疗的未破裂颅内动脉瘤（UIAs），目前尚无充分的监测共识。本研究旨在通过成本效益分析，确定 MRI 监测 UIAs 生长的最佳策略。次要目的是开发一种用于个性化 UIA 监测的临床工具。
我们从医疗保健角度设计了一个微观模拟模型，模拟了 10 万名 55 岁女性，以估计在美国、英国和荷兰的终生成本和质量调整生命年（QALYs）。使用文献中推导的模型参数。采用特定国家的成本和支付意愿阈值（美国为 100,000 美元/QALY，英国为 30,000 英镑/QALY，荷兰为 80,000 欧元/QALY）。在美国，终生成本和 QALYs 每年按 3%贴现，在英国，每年按 3.5%贴现，而在荷兰，每年按 4%（成本）和 1.5%（QALYs）贴现。监测策略包括不进行随访监测、在发现 UIA 后第一年和第五年进行 MRI 随访、每 5 年、每 2 年或每年进行一次随访，或进行即刻干预（即夹闭或栓塞）。我们使用微观模拟模型，为不同年龄和不同动脉瘤特征的男性和女性开发了一种个性化 UIA 监测工具。使用概率敏感性分析对输入参数的不确定性进行建模。
在 55 岁的女性中，美国需要进行每年 MRI 扫描的人数为 2222 人，英国为 1910 人，荷兰为 2040 人，以预防每年 1 例蛛网膜下腔出血。在美国（47%的模拟）和英国（54%的模拟），不进行 MRI 监测最具成本效益，而在荷兰（53%的模拟），每年进行 MRI 监测最具成本效益。在美国和英国，在 60 岁以下且动脉瘤生长风险较高的患者中，每年进行监测或在发现后第一年和第五年进行监测具有成本效益。最佳的、个性化的监测策略被总结在一个用于临床实践的查询表中。
一般来说，美国和英国的医生应避免对年龄较大的患者或动脉瘤生长或破裂风险较低的患者进行频繁的 MRI 监测。在荷兰，每年进行随访通常最具成本效益。
