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)

Katherine R. Vilain, Elizabeth A. Magnuson, Haiyan Li, Wayne 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

Research output: Contribution to journalArticle

49 Citations (Scopus)

Abstract

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.

Original languageEnglish (US)
Pages (from-to)2408-2416
Number of pages9
JournalStroke
Volume43
Issue number9
DOIs
StatePublished - Sep 2012

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Endarterectomy
Carotid Endarterectomy
Cost-Benefit Analysis
Costs and Cost Analysis
Carotid Arteries
Life Expectancy
Stroke
Quality of Life
Quality-Adjusted Life Years
Carotid Stenosis
Controlled Clinical Trials
Health Policy
Health Care Costs
Health Status
Hospitalization
Therapeutics
Myocardial Infarction
Clinical Trials
Guidelines

Keywords

  • economics
  • endarterectomy
  • prevention
  • quality of life
  • stenting
  • stroke care

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Clinical Neurology
  • Advanced and Specialized Nursing

Cite this

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). / Vilain, Katherine R.; Magnuson, Elizabeth A.; Li, Haiyan; Clark, Wayne; Begg, Richard J.; Sam, Albert D.; Sternbergh, W. Charles; Weaver, Fred A.; Gray, William A.; Voeks, Jenifer H.; Brott, Thomas G.; Cohen, David J.

In: Stroke, Vol. 43, No. 9, 09.2012, p. 2408-2416.

Research output: Contribution to journalArticle

Vilain, Katherine R. ; Magnuson, Elizabeth A. ; Li, Haiyan ; Clark, Wayne ; Begg, Richard J. ; Sam, Albert D. ; Sternbergh, W. Charles ; Weaver, Fred A. ; Gray, William A. ; Voeks, Jenifer H. ; Brott, Thomas G. ; Cohen, David J. / 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). In: Stroke. 2012 ; Vol. 43, No. 9. pp. 2408-2416.
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abstract = "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.",
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T1 - Costs and cost-effectiveness of carotid stenting versus endarterectomy for patients at standard surgical risk

T2 - Results from the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST)

AU - Vilain, Katherine R.

AU - Magnuson, Elizabeth A.

AU - Li, Haiyan

AU - Clark, Wayne

AU - Begg, Richard J.

AU - Sam, Albert D.

AU - Sternbergh, W. Charles

AU - Weaver, Fred A.

AU - Gray, William A.

AU - Voeks, Jenifer H.

AU - Brott, Thomas G.

AU - Cohen, David J.

PY - 2012/9

Y1 - 2012/9

N2 - 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.

AB - 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.

KW - economics

KW - endarterectomy

KW - prevention

KW - quality of life

KW - stenting

KW - stroke care

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