DR IMRAN JAVED,

MBBS, FCPS Surgery.

INTERNATIONAL FELLOW

DR IMRAN JAVED,

MBBS, FCPS Surgery.

INTERNATIONAL FELLOW

JOURNAL CLUB JUNE 2010

JOURNAL CLUB JUNE 2010

Cost-Effectiveness Analysis of Protected Carotid Artery Stent

Placement Versus Endarterectomy in High-Risk

Patients

Cost-Effectiveness Analysis of Protected Carotid Artery Stent

Placement Versus Endarterectomy in High-Risk

Patients

Zeenat Qureshi Stroke Research Center, Department of Neurology and Division of Health Policy and Management, School of

Public Health, University ofMinnesota, Minneapolis, Minnesota, USA

Zeenat Qureshi Stroke Research Center, Department of Neurology and Division of Health Policy and Management, School of

Public Health, University ofMinnesota, Minneapolis, Minnesota, USA Alberto Maud, MD, Gabriela Vázquez PhD, John A. Nyman, PhD, Kamakshi Lakshminarayan, MD, PhD, David C. Anderson, MD, Adnan I. Qureshi, MD.

Alberto Maud, MD, Gabriela Vázquez PhD, John A. Nyman, PhD, Kamakshi Lakshminarayan, MD, PhD, David C. Anderson, MD, Adnan I. Qureshi, MD.

ObjectiveObjectiveTo determine the cost-effectiveness

of carotid angioplasty with stent placement (CAS) under emboli protection versus carotid endarterectomy (CEA) in patients with severe carotid stenosis considered to be at high surgical risk for CEA.

To determine the cost-effectiveness of carotid angioplasty with stent placement (CAS) under emboli protection versus carotid endarterectomy (CEA) in patients with severe carotid stenosis considered to be at high surgical risk for CEA.

MethodsMethodsThe probabilities of various outcomes

were adopted from the SAPPHIRE trial results. The quality-adjusted life year (QALYs) associated with each treatment modality were estimated by using the frequencies of various quality-adjusted outcomes (QALY weights of ipsilateral stroke, myocardial infarction, and death).

The probabilities of various outcomes were adopted from the SAPPHIRE trial results. The quality-adjusted life year (QALYs) associated with each treatment modality were estimated by using the frequencies of various quality-adjusted outcomes (QALY weights of ipsilateral stroke, myocardial infarction, and death).

MethodsMethodsTotal cost associated with each

intervention was computed using the frequency of stroke, myocardial infarction, and death in each group. Costs are expressed in 2006 US$. Incremental cost-effectiveness ratios (ICERs) were estimated for a 1-year postprocedure period.

Total cost associated with each intervention was computed using the frequency of stroke, myocardial infarction, and death in each group. Costs are expressed in 2006 US$. Incremental cost-effectiveness ratios (ICERs) were estimated for a 1-year postprocedure period.

SAPPHIRE TrialSAPPHIRE TrialParameters CAS CEA

No of Patients 167 167

Men 66.9% 67.1%

Age (Years) 72.5 (49-89) 72.6 (46-91)

Symptomatic 29.9% 27.7%

Risk Factors

Coronary Artery Disease

85.8% 75.5%

Class 3-4 Angina 24.1% 14.7%

Myocardial Infarction 29.7% 35.3%

COPD 17.0% 13.8%

Model variables for outcome associated with CAS & CEA

Model variables for outcome associated with CAS & CEA

Parameters CAS CEA

Input Variable Clinical

Death (1 Year) 7% 13%

Stroke at 30 Days Ipsilateral > 30 Days

Major 1% 4%

Minor 4% 2%

MI (at 30 Days)

Q-wave 0% 1%

Non Q-wave 2% 5%

Results ResultsThe mean (range) estimated net costs at 1 year for patients treated with CAS and CEA were $12,782 ($12,205–$13,563) and $8,916 ($8,267–$9,766), respectively. Overall QALYs for the CAS and CEA groups were 0.753 and 0.701 [within a range of 0.0 (meaning death) to 0.815 (meaning no adverse events)].

The mean (range) estimated net costs at 1 year for patients treated with CAS and CEA were $12,782 ($12,205–$13,563) and $8,916 ($8,267–$9,766), respectively. Overall QALYs for the CAS and CEA groups were 0.753 and 0.701 [within a range of 0.0 (meaning death) to 0.815 (meaning no adverse events)].

ResultsResultsThe mean cost per QALY gained for CAS was $16,223 ($15,315–$17,474) and the mean cost per QALY gained for CEA was $12,745 ($11,372–$14,605). The estimated median ICER for CAS versus CEA treatment was $67,891 (−$129,372 to $379,661).

The mean cost per QALY gained for CAS was $16,223 ($15,315–$17,474) and the mean cost per QALY gained for CEA was $12,745 ($11,372–$14,605). The estimated median ICER for CAS versus CEA treatment was $67,891 (−$129,372 to $379,661).

The proven non-inferiority of CAS versus CEA in high-surgical-risk patients with severe carotid stenosis might provide a marginal benefit that is offset by the higher cost associated with this procedure.

The proven non-inferiority of CAS versus CEA in high-surgical-risk patients with severe carotid stenosis might provide a marginal benefit that is offset by the higher cost associated with this procedure.

CONCLUSIONCONCLUSION