Annals of vascular surgery

Impact of Real-World Adherence with Best Medical Treatment on Cost-Effectiveness of Carotid Endarterectomy for Asymptomatic Carotid Artery Stenosis.

PMID 26407926


To present a model of decision and cost-effectiveness analysis that allows assessing the trade-off between the short-term risks of performing a carotid endarterectomy (CEA) and the rate of preventable future events and the impact of real-world adherence of best medical treatment (BMT) on cost-effectiveness of both therapeutic options. We used data from the current literature to define values for a base case and perform a sensitivity analysis. The primary end point was a comparison of the fatal and disabling stroke-free survival during a 5-year period in a cohort of hypothetical patients who presented asymptomatic severe carotid stenosis and were treated with either prophylactic CEA or adherent and nonadherent best medical treatment, respectively. The difference in estimated fatal and disabling stroke-free survival favoring endarterectomy in patients with asymptomatic severe carotid stenosis is 44 days over the course of 5 years in case of nonadherent best medical treatment. Over a 5-year time horizon, prophylactic CEA would be cost-effective in 50.8% of bootstrap replicates and nonpersistent BMT might be economically dominant in 11.1%. The probability that CEA would be cost-effective at a willingness-to-pay (WTP) threshold of Euro 50,000/quality-adjusted life year gained was 71.8%. In 17.9% prophylactic CEA would be more costly and effective than persistent BMT, but its incremental cost-effectiveness ratio was greater than the WTP, so persistent BMT would be optimal. In this model, in case of real-world drug adherence, it was likely that a strategy of early endarterectomy might be a cost-effective or even the dominant therapeutic option in comparison with a strategy of medical therapy alone (deferred surgery). If background any-territory stroke rates on contemporary medical therapy would fall substantially below 0.7%, surgery would cease to be cost-effective.