Original Article
A Cost-Effectiveness Analysis of Carotid Artery Stenting Compared With Endarterectomy

https://doi.org/10.1016/j.jstrokecerebrovasdis.2009.08.003Get rights and content

Endarterectomy and angioplasty with stenting have emerged as 2 alternative treatments for carotid artery stenosis. This study's objective was to determine the cost-effectiveness of carotid artery stenting (CAS) compared with carotid endarterectomy (CEA) in symptomatic subjects who are suitable for either intervention. A Markov analysis of these 2 revascularization procedures was conducted using direct Medicare costs (2007 US$) and characteristics of a symptomatic 70-year-old cohort over a lifetime. In the base case analysis, CAS produced 8.97 quality-adjusted life-years, compared with 9.64 quality-adjusted life-years for CEA. The incremental cost of stenting was $17,700, and thus CAS was dominated by CEA. Sensitivity analyses show that the long-term probabilities of major stroke or mortality influenced the results. In the base case analysis, CEA for patients with symptomatic stenosis has a greater benefit than CAS, with lower direct costs. With 59% probability, CEA will be the optimal intervention when all of the model assumptions are varied simultaneously.

Section snippets

Methods

A Markov model was designed to compare the costs and utilities of CAS and CEA. The present analysis is based primarily on the results of a recent meta-analysis and other published trials.6, 7, 8, 9, 10, 11, 12, 13

Results

In the base case analysis, the lifetime costs of CEA were $35,200 and the quality-adjusted life-years (QALYs) were 9.64. CAS was associated with lifetime costs of $52,900 and a QALY gain of 8.97. CAS was dominated by CEA because it was associated with a smaller QALY gain at higher lifetime medical costs.

The assumptions in the model were tested through one-way deterministic sensitivity analyses. If the long-term stroke rate after CEA increased from 2.1% per year to 6.3% per year, then CAS became

Discussion

In the base case analysis, CEA was the dominant option for the treatment of symptomatic carotid stenosis in a hypothetical cohort suitable for either CEA or CAS. CEA maximizes health benefits and cost savings. Deterministic sensitivity analyses showed that the assumptions regarding long-term stroke rates and mortality influence the suitability of CEA as the most cost-effective option. With lower thresholds for cost-effectiveness, the probability that CEA is treatment of choice increased from

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    K.C.Y. was supported in part by National Institutes of Health (NIH) Grant T32HL007937 (to Dr. Thomas A. Pearson, Department of Community and Preventive Medicine, University of Rochester). R.G.H. was supported in part by National Institute of Neurological Disorders Grant K24NS42098. C.G.B. is supported in part by NIH Grant RO1HL080107. This publication was made possible in part by Grant 1UL1RR024160-01 from the National Center for Research Resources (NCRR), a component of the NIH, and the NIH Roadmap for Medical Research. Its contents are solely the responsibility of the authors and do not necessarily represent the official view of NCRR or NIH. Information on NCRR is available at http://www.ncrr.nih.gov/. Information on Reengineering the Clinical Research Enterprise can be obtained from http://nihroadmap.nih.gov/clinicalresearch/overview-translational.asp. A portion of the salary of K.C.Y., R.G.H., and C.G.B. is covered by NIH funds. W.S.B. and C.G.B. received clinical research grant support for ACT-1 (Abbott) and CREST (NIH).

    The authors had full access to the data and take responsibility for its integrity. All of the authors have read and agreed to the manuscript as written.

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