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Imaging of carotid arteries in symptomatic patients: cost-effectiveness of diagnostic strategies.

Abstract：

PURPOSE:To assess the cost-effectiveness of noninvasive imaging strategies in patients who have had a transient ischemic attack (TIA) or minor stroke and are suspected of having significant carotid artery stenosis. MATERIALS AND METHODS:From 1997 through 2000, 350 patients were included in a multicenter blinded consecutive cohort study. The sensitivities and specificities of duplex ultrasonography (US), magnetic resonance (MR) angiography, and these two examinations combined were estimated by using digital subtraction angiography (DSA) as the reference standard. The actual costs (from a societal perspective) of performing imaging and endarterectomy were estimated. The survival, quality of life, and costs associated with stroke were based on data reported in the literature. Markov modeling was used to predict long-term outcomes. Subsequently, a decision model was used to calculate costs, quality-adjusted life-years (QALYs), and incremental costs per QALY gained for 62 examination-treatment strategies. Extensive sensitivity analyses were performed. RESULTS:Duplex US had 88% sensitivity and 76% specificity with use of conventional cutoff criteria. MR angiography had comparable values: 92% sensitivity and 76% specificity. Combined concordant duplex US and MR angiography had superior diagnostic performance: 96% sensitivity and 80% specificity. Duplex US alone was the most efficient strategy. Adding MR angiography led to a marginal increase in QALYs gained but at prohibitive costs (cost-effectiveness ratio > 1 500 000 per QALY gained). Performing DSA owing to discordant duplex US and MR angiographic findings and to confirm duplex US and MR angiographic findings led to extra costs and QALY loss owing to complications. Sensitivity analyses revealed that duplex US as a stand-alone examination remained the preferred strategy while estimates and assumptions were varied across plausible ranges. CONCLUSION:Duplex US performed without additional imaging is cost-effective in the selection of symptomatic patients suitable for endarterectomy. Adding MR angiography increases effectiveness slightly at disproportionately high costs, whereas DSA is inferior because of associated complications.

journal_name

Radiology

journal_title

Radiology

authors

Buskens E,Nederkoorn PJ,Buijs-Van Der Woude T,Mali WP,Kappelle LJ,Eikelboom BC,Van Der Graaf Y,Hunink MG

doi

10.1148/radiol.2331030863

subject

Has Abstract

pub_date

2004-10-01 00:00:00

pages

101-12

issue

eissn

0033-8419

issn

1527-1315

pii

2331030863

journal_volume

233

pub_type

临床试验,杂志文章,多中心研究

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Imaging of carotid arteries in symptomatic patients: cost-effectiveness of diagnostic strategies.