Document Detail


Costs and cost-effectiveness of carotid stenting versus endarterectomy for patients at standard surgical risk: results from the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST).
MedLine Citation:
PMID:  22821614     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
BACKGROUND AND PURPOSE: The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) demonstrated similar rates of the primary composite end point between carotid artery stenting (CAS) and carotid endarterectomy (CEA), although the risk of stroke was higher with CAS, and the risk of myocardial infarction was higher with CEA. Given the large number of patients who are candidates for these procedures, an understanding of their relative cost and cost-effectiveness may have important implications for health care policy and treatment guidelines.
METHODS: We performed a formal economic evaluation alongside the CREST trial. Costs were estimated from all trial participants over the first year of follow-up using a combination of resource use data and hospital billing data. Patient-level health use scores were obtained using data from the SF-36. We then used a Markov disease-simulation model calibrated to the CREST results to project 10-year costs and quality-adjusted life expectancy for the 2 treatment groups.
RESULTS: Although initial procedural costs were $1025/patient higher with CAS, postprocedure costs and physician costs were lower such that total costs for the index hospitalization were similar for the CAS and CEA groups ($15 055 versus $14 816; mean difference, $239/patient; 95% CI for difference, -$297 to $775). Neither follow-up costs after discharge nor total 1-year costs differed significantly. For the CREST population, model-based projections over a 10-year time horizon demonstrated that CAS would result in a mean incremental cost of $524/patient and a reduction in quality-adjusted life expectancy of 0.008 years compared with CEA. Probabilistic sensitivity analysis demonstrated that CEA was economically attractive at an incremental cost-effectiveness threshold of $50 000/quality-adjusted life-year gained in 54% of samples, whereas CAS was economically attractive in 46%.
CONCLUSIONS: Despite slightly lower in-trial costs and lower rates of stroke with CEA compared with CAS, projected 10-year outcomes from this controlled clinical trial demonstrate only trivial differences in overall healthcare costs and quality-adjusted life expectancy between the 2 strategies. If the CREST results can be replicated in clinical practice, these findings suggest that factors other than cost-effectiveness should be considered when deciding between treatment options for carotid artery stenosis in patients at standard risk for surgical complications. Clinical Trial Registration- URL: http://clinicaltrials.gov. Unique Identifier: NCT00004732.
Authors:
Katherine R Vilain; Elizabeth A Magnuson; Haiyan Li; Wayne M Clark; Richard J Begg; Albert D Sam; W Charles Sternbergh; Fred A Weaver; William A Gray; Jenifer H Voeks; Thomas G Brott; David J Cohen;
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Publication Detail:
Type:  Comparative Study; Journal Article; Research Support, N.I.H., Extramural     Date:  2012-07-19
Journal Detail:
Title:  Stroke; a journal of cerebral circulation     Volume:  43     ISSN:  1524-4628     ISO Abbreviation:  Stroke     Publication Date:  2012 Sep 
Date Detail:
Created Date:  2012-08-28     Completed Date:  2012-11-05     Revised Date:  2013-09-03    
Medline Journal Info:
Nlm Unique ID:  0235266     Medline TA:  Stroke     Country:  United States    
Other Details:
Languages:  eng     Pagination:  2408-16     Citation Subset:  IM    
Affiliation:
Saint Luke's Mid America Heart Institute, 4401 Wornall Road, Kansas City, MO 64111, USA.
Data Bank Information
Bank Name/Acc. No.:
ClinicalTrials.gov/NCT00004732
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MeSH Terms
Descriptor/Qualifier:
Aged
Carotid Arteries*
Carotid Stenosis / economics,  surgery
Cost-Benefit Analysis
Costs and Cost Analysis
Endarterectomy / economics*
Health Care Costs
Hospitalization / economics
Humans
Markov Chains
Middle Aged
Models, Economic
Models, Statistical
Patient Readmission / economics,  statistics & numerical data
Prospective Studies
Quality-Adjusted Life Years
Randomized Controlled Trials as Topic
Risk
Stents / economics*
Stroke / economics*,  prevention & control*
Treatment Outcome
Grant Support
ID/Acronym/Agency:
R01 NS 038384/NS/NINDS NIH HHS; R01 NS038384/NS/NINDS NIH HHS
Comments/Corrections

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