Kallmes D F, Kallmes M H
Department of Radiology, University of Virginia Health Sciences Center, Charlottesville 22906, USA.
AJNR Am J Neuroradiol. 1997 Sep;18(8):1453-62.
To calculate the incremental cost-utility ratio for routine angiography performed during surgery for ruptured cerebral aneurysms.
Decision-tree and Markov analyses based on a cohort simulation were used to determine the incremental cost-utility ratio of routine intraoperative angiography versus no angiography. Input data from the literature were estimated for the following variables: frequency of unexpected aneurysmal rests and branch artery occlusions; annual rate of rehemorrhage of partially clipped aneurysms; prevalence of clinically relevant infarction resulting from branch artery occlusion; efficacy of clip repositioning; morbidity associated with intraoperative angiography; morbidity and mortality associated with aneurysmal rehemorrhage; sensitivity of intraoperative angiography for aneurysmal rests; and costs of intraoperative angiography, added duration of surgery, ischemic cerebral infarction, aneurysmal rehemorrhage, and rehabilitation. Sensitivity analyses were performed for all relevant input variables. A societal perspective was used, and cost-utility ratios less than $50000/quality-adjusted life years (QALY) gained were considered acceptable.
Baseline input variables resulted in an acceptable cost-utility ratio for routine intraoperative angiography ($19000/QALY). The input variables with greatest influence on the cost-utility ratio were frequency of branch artery occlusions, angiographic morbidity, and cost of angiography. However, the cost-utility ratio remained acceptable even over wide ranges of these input variables. Frequency of unexpected partially clipped aneurysms, efficacy of clip repositioning, and costs of stroke, rehemorrhage, and rehabilitation had relatively little impact on the analysis.
Routine intraoperative angiography is cost-effective if performed in a manner consistent with low morbidity in a patient cohort harboring at least some unexpected branch artery occlusions that, if uncorrected, would result in clinically relevant cerebral infarctions.
计算破裂脑动脉瘤手术期间进行常规血管造影的增量成本-效用比。
基于队列模拟的决策树和马尔可夫分析用于确定常规术中血管造影与不进行血管造影的增量成本-效用比。对以下变量估计了来自文献的输入数据：意外动脉瘤残留和分支动脉闭塞的频率；部分夹闭动脉瘤的年再出血率；分支动脉闭塞导致的临床相关梗死的患病率；夹闭重新定位的疗效；术中血管造影相关的发病率；动脉瘤再出血相关的发病率和死亡率；术中血管造影对动脉瘤残留的敏感性；以及术中血管造影、手术额外持续时间、缺血性脑梗死、动脉瘤再出血和康复的成本。对所有相关输入变量进行了敏感性分析。采用社会视角，成本-效用比低于每获得一个质量调整生命年（QALY）50000美元被认为是可接受的。
基线输入变量导致常规术中血管造影的成本-效用比可接受（19000美元/QALY）。对成本-效用比影响最大的输入变量是分支动脉闭塞的频率、血管造影发病率和血管造影成本。然而，即使在这些输入变量的广泛范围内，成本-效用比仍保持可接受。意外部分夹闭动脉瘤的频率、夹闭重新定位的疗效以及中风、再出血和康复的成本对分析的影响相对较小。
如果在至少存在一些意外分支动脉闭塞的患者队列中以低发病率的方式进行常规术中血管造影，且这些闭塞若不纠正将导致临床相关的脑梗死，那么常规术中血管造影具有成本效益。
