| Suspected carotid artery stenosis: cost-effectiveness of CT angiography in work-up of patients with recent TIA or minor ischemic stroke. | |
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MedLine Citation:
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PMID: 20656842 Owner: NLM Status: MEDLINE |
Abstract/OtherAbstract:
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PURPOSE: To assess the effectiveness and cost-effectiveness of state-of-the-art noninvasive diagnostic imaging strategies in patients with a transient ischemic attack (TIA) or minor stroke who are suspected of having carotid artery stenosis (CAS). MATERIALS AND METHODS: All prospectively evaluated patients provided informed consent, and the local ethics committee approved this study. Diagnostic performance, treatment, long-term events, quality of life, and costs resulting from strategies employing duplex ultrasonography (US), computed tomographic (CT) angiography, contrast material-enhanced magnetic resonance (MR) angiography, and combinations of these modalities were modeled in a decision tree and Markov model. Data sources included a prospective diagnostic cohort study, a meta-analysis, and a review of the literature. Outcomes were costs, quality-adjusted life-years (QALYs), incremental cost-effectiveness ratios, and net health benefits (QALY-equivalents), with a willingness-to-pay threshold of euro 50,000 per QALY and a societal perspective. The strategy with the highest net health benefit was considered the most cost effective. Extensive one-way, two-way, and probabilistic sensitivity analyses to explore the effect of varying parameter values were performed. The reference case analysis assumed that patients underwent surgery 2-4 weeks after the first symptoms, and the effect of earlier intervention was explored. RESULTS: The reference case analysis showed that duplex US combined with CT angiography and surgery for 70%-99% stenoses was the most cost-effective strategy, with a net health benefit of 13.587 and 15.542 QALY-equivalents in men and women, respectively. In men, the CT angiography strategy with a 70%-99% cutoff yielded slightly more QALYs, at an incremental cost of euro 71,419 per QALY, compared with duplex US combined with CT angiography. In patients with a high-risk profile, in patients with a high prior probability of disease, and when patients could be treated within 2 weeks after the first symptoms, the CT angiography strategy with surgery for 50%-99% stenoses was the most cost-effective strategy. CONCLUSION: In diagnosing CAS, duplex US should be the initial test, and, if its results are positive, CT angiography should be performed; patients with 70%-99% stenoses should then undergo carotid endarterectomy. In patients with a high-risk profile, a high probability of CAS, or who can undergo surgery without delay, immediate CT angiography and surgery for 50%-99% stenoses is indicated. |
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Authors:
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Aletta T R Tholen; Cécile de Monyé; Tessa S S Genders; Erik Buskens; Diederik W J Dippel; Aad van der Lugt; M G Myriam Hunink |
Publication Detail:
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Type: Journal Article; Research Support, Non-U.S. Gov't |
Journal Detail:
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Title: Radiology Volume: 256 ISSN: 1527-1315 ISO Abbreviation: Radiology Publication Date: 2010 Aug |
Date Detail:
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Created Date: 2010-07-26 Completed Date: 2010-09-24 Revised Date: - |
Medline Journal Info:
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Nlm Unique ID: 0401260 Medline TA: Radiology Country: United States |
Other Details:
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Languages: eng Pagination: 585-97 Citation Subset: AIM; IM |
Affiliation:
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Department of Radiology, Erasmus University Medical Center, PO Box 2040, 3000 CA Rotterdam, the Netherlands. |
Export Citation:
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| MeSH Terms | |
Descriptor/Qualifier:
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Adult Aged Aged, 80 and over Angiography / economics*, statistics & numerical data* Carotid Stenosis / economics*, epidemiology, radiography* Comorbidity Cost-Benefit Analysis Female Health Care Costs / statistics & numerical data* Humans Ischemic Attack, Transient / economics*, epidemiology, radiography* Male Middle Aged Prevalence Reproducibility of Results Sensitivity and Specificity Tomography, X-Ray Computed / economics*, statistics & numerical data Young Adult |
From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine
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