Abdominal aortic aneurysms: cost-effectiveness of elective endovascular and open surgical repair

Cost-effectiveness analysis of endovascular versus open repair in patients with abdominal aortic aneurysm in Iran: a cross-sectional study

OBJECTIVES

Abdominal aortic aneurysm (AAA) is one of the most important cardiovascular diseases, especially in the elderly. People with this disease are at risk of rupture of the abdominal aorta and death. The present study was conducted with the aim of analyzing the cost-effectiveness of endovascular repair compared to open surgery in AAA patients in Iran.

METHODS

A Markov chain model was developed based on the use of endovascular repair and open surgery. The base-case patient was defined as a 65-year-old man presenting with AAA diameter greater than 5 cm. The determination of costs was from the perspective of the public sector provider. QALY was used to calculate the effectiveness. Incremental cost-effectiveness ratio (ICER) and TreeAge software were used for cost-effectiveness analysis. The follow-up period was 10 years and the willingness to pay (WTP) was determined as three times the Gross domestic product (GDP) per capita.

RESULT

At the end of year 10, the endovascular aneurysm repair (EVAR) strategy gained 1 318 313 559 Iranian Rial (IRR) (67 885.29$) in cost and 3.57 QALYs in effectiveness. In contrast, the use of the open surgery repair (OSR) strategy gained 1 186 761 858 IRR (61 111.16$) in cost and 3·32 QALYs in effectiveness. The incremental cost-effectiveness ratio, comparing EVAR versus OSR, was 53, 346, 3757 IRR (178.36$) per QALYs, which is lower than the proposed WTP, indicating that EVAR is more expensive and more effective. Based on the Monte Carlo simulation test, EVAR is the preferred strategy in 58.6% of the population.

CONCLUSION

Endovascular repair has a relative superiority compared to open surgery, and the probability of the effectiveness of endovascular repair compared to open surgery does not change with increasing willingness to pay.

Outcomes and Cost-Analysis of Open Versus Endovascular Abdominal Aortic Aneurysm Repair in a Developing Country: A 15-year Experience at a Tertiary Medical Center

BACKGROUND

Endovascular aortic aneurysm repair (EVAR) has become the most common procedure for treating abdominal aortic aneurysms based on multiple studies conducted in the western world. The implication of such findings in developing countries is not well demonstrated. The objective of this study was to compare medical outcomes and costs of EVAR and open surgical repair (OSR) in a developing country.

METHODS

This is a retrospective study of all patients undergoing elective abdominal aortic aneurysm repair between 2005 and 2020 at a tertiary medical center in a developing country. Medical records were used to retrieve demographics, comorbidities, and perioperative complications. Medical records were also used to provide data on the need of reintervention, date of last follow-up, and mortality.

RESULTS

The study included a total of 164 patients. Median follow-up time was 41 months. The mean age was 69.9 +/- 7.84 years and 90.24% (n = 148) of patients were males. Regarding long-term mortality outcomes, no significant difference was detected between both groups; OSR patients had a survival rate of 91.38% and 74.86% at 5 and 10 years, compared to 77.29% and 56.52% in the EVAR group (P value = 0.10). Both groups had comparable long-term reintervention rates (P value = 0.334). The OSR group was charged significantly less than the EVAR group ($27,666.35 vs. $44,528.04, P value = 0.008).

CONCLUSIONS

OSR and EVAR have comparable survival and reintervention outcomes. Unlike what was reported in developed countries, patients undergoing OSR in countries with low hospital stay costs incur lower treatment costs.

Endovascular aortic repair is a cost-effective option for in-hospital patients with abdominal aortic aneurysm

BACKGROUND

To investigate the cost-effectiveness of endovascular aortic repair (EVAR) versus open aortic repair (OAR) for abdominal aortic aneurysm (AAA) using incremental costs per decreased in-hospital mortality rate gained through our patients' cohort.

METHODS

Medical records and healthcare costs of patients with AAA hospitalized between 2010 and 2015 were extracted from the National Health Insurance Research Database (NHIRD) of Taiwan. Multiple regression analysis was applied to adjust for confounding factors and to compare the differences in postoperative clinical outcomes between patients who received EVAR and OAR. The incremental cost-effectiveness ratio (ICER) of EVAR was determined based on the healthcare cost obtained from the analyzed data.

RESULTS

A total of 2803 AAA patients were identified (n = 559 with ruptured AAA and n = 2244 unruptured AAA). Patients with ruptured AAA who underwent EVAR compared with OAR patients had shorter hospital and intensive care unit (ICU) stays (all p < 0.05). For patients with unruptured AAA, those who received EVAR compared with OAR, the adjusted odds ratio (aOR) of postoperative complications and in-hospital mortality were 0.371 and 0.447 (all p < 0.05). The total direct surgical costs and medical expenses during hospitalization in all AAA patients were higher for the EVAR group; however, ICER was <1 per capita gross domestic product. Stratification by age groups further suggested that ICER for patients with unruptured AAA who received EVAR, compared with OAR, decreased with age.

CONCLUSION

Total direct medical costs were higher for AAA patients receiving EVAR regardless of rupture status; however, the cost is offset by lower odds of postoperative complications and in-hospital mortality. The observed decrease in ICER with age and EVAR use warrants further analysis. Our findings further validate the use of EVAR over OAR. These results provides supporting evidence for physicians and patients with AAA to inform shared decision making regarding endovascular or OAR options.

Cost-Effectiveness of Endovascular Versus Open Repair of Abdominal Aortic Aneurysm: A Systematic Review

PURPOSE

Abdominal aortic aneurysm (AAA) is a life-threatening condition which, in the absence of increasing diameter or rupture, often remains asymptomatic, and a diameter greater than 5.5 cm requires elective surgical repair. This study aimed to evaluate the cost-effectiveness of endovascular repair (EVAR) versus open surgical repair (OSR) in patients with AAA through a systematic review of published health economics studies.

METHODS

Using a systematic review method, an electronic search was conducted for cost-effectiveness studies published on AAA (both in English and Persian) on PubMed, Embase, ISI/Web of Science (WoS), SCOPUS, Global Health databases, and the national databases of Iran from 1990 to 2020 including the keywords "cost-effectiveness", "endovascular", "open surgical", and "abdominal aortic aneurysms". The quality of the studies was assessed using the Quality of Health Economic Studies (QHES) checklist.

RESULTS

In total, 958 studies were found, of which 16 were eligible for further study. All studies were conducted in developed countries, and quality-adjusted life years (QALY) and life years (LY) were used to measure the outcomes. According to the QHES checklist, most studies were of good quality. In European countries and Canada, EVAR has not been cost-effective, while most studies in the United States regard this technique as a cost-effective intervention. For example, incremental cost-effectiveness ratio (ICER) values ranged from $14,252.12 to $34,446.37 per QALY in the USA, while ICER was €116,600.40 per QALY in Portugal.

CONCLUSION

According to the results, the EVAR technique has been more cost-effective than OSR for high-risk patients, but the need for continuous follow-up, increased costs, and re-intervention over the long term and for low-risk patients has reduced the cost-effectiveness of this method. As the health systems vary among different countries (i.e. quality of care, cost of devices, etc.), and due to the heterogeneity of studies in terms of the follow-up period, time horizon, and threshold, all of which are inherent features of economic evaluation, generalizing the results should be done with much caution, and policymaking must be based on national evidence.

Longitudinal Spending on Endovascular and Open Abdominal Aortic Aneurysm Repair

BACKGROUND

Endovascular repair (EVR) has replaced open surgery as the procedure of choice for patients requiring elective abdominal aortic aneurysm (AAA) repair. Long-term outcomes of the 2 approaches are similar, making the relative cost of caring for these patients over time an important consideration.

METHODS AND RESULTS

We linked Medicare claims to Vascular Quality Initiative registry data for patients undergoing elective EVR or open AAA repair from 2004 to 2015. The primary outcome was Medicare's cumulative disease-related spending, adjusted to 2015 dollars. Disease-related spending included the index operation and associated hospitalization, surveillance imaging, reinterventions (AAA-related and abdominal wall procedures), and all-cause admissions within 90 days. We compared the incidence of disease-related events and cumulative spending at 90 days and annually through 7 years of follow-up. The analytic cohort comprised 6804 EVR patients (median follow-up: 1.85 years; interquartile range: 0.82-3.22 years) and 1889 open repair patients (median follow-up: 2.62 years; interquartile range: 1.13-4.80 years). Spending on index surgery was significantly lower for EVR (median [interquartile range]: $25 924 [$22 280-$32 556] EVR versus $31 442 [$24 669-$40 419] open; P<0.001), driven by a lower rate of in-hospital complications (6.6% EVR versus 38.0% open; P<0.001). EVR patients underwent more surveillance imaging (1.8 studies per person-year EVR versus 0.7 studies per person-year open; P<0.001) and AAA-related reinterventions (4.0 per 100 person-years EVR versus 2.1 per 100 person-years open; P=0.041). Open repair patients had higher rates of 90-day readmission (12.9% EVR versus 17.8% open; P<0.001) and abdominal wall procedures (0.6 per 100 person-years EVR versus 1.5 per 100 person-years open; P<0.001). Overall, EVR patients incurred more disease-related spending in follow-up ($7355 EVR versus $2706 open through 5 years). There was no cumulative difference in disease-related spending between surgical groups by 5 years of follow-up (-$33 EVR [95% CI: -$1543 to $1476]).

CONCLUSIONS

We observed no cumulative difference in disease-related spending on EVR and open repair patients 5 years after surgery. Generalized recommendations about which approach to offer elective AAA patients should not be based on relative cost.

Duplex scanning as an alternative to computer tomography with contrast enhancement for the control of complications after endovascular aneurysm repair

EVAR (endovascular aneurism repair) is the preferred method for the surgical treatment of ananeurysm. The advantage of this type of surgical intervention is that a smaller number of postoperative complications will occur. The main diagnostic tasks for patients after EVAR are to determine the size of the aneurysmal sac, detection of an endoleak, detection of the endoprosthesis migration and the deformation of the stent graft itself. Conclusion: early detection of complications in the postoperative period remains the main problem for monitoring patients after EVAR. Duplex scanning is a safe, non-invasive and effective method of measuring the size of an aneurysmal sac and detecting possible complications after EVAR.

Direct health costs and clinical outcomes of open surgery in patients with abdominal aortic aneurysm in Spain. The RECAPTA study

OBJECTIVE

Abdominal aortic aneurysm (AAA) is a chronic, progressive disease that often requires surgical repair. This study aimed to assess the healthcare costs and clinical outcomes of open AAA repair in Spain.

METHOD

Observational, retrospective, multicenter study with a one-year follow-up. Healthcare resource use and costs related to the surgical procedure, hospital stay, and follow-up period were assessed.

RESULTS

Ninety patients with asymptomatic AAA who underwent open repair were recruited between 2003 and 2009 at three Spanish hospitals. Four patients (4.44%) died in the first 30 postoperative days. Mean [standard deviation] procedure time was 292.83 [72.10] minutes and mean hospital length of stay was 11.44 days [5.42]. Thirty two patients (35.56%) presented in-hospital complications and three patients (3.45%) underwent re-intervention during follow-up. The mean overall cost per patient during the study period was €21,622.59, of which 42.40% (€9,168.19), 52.08% (€11,261.74), and 5.52% (€1,192.66) corresponded to the surgical procedure, the inpatient stay, and the study follow-up period, respectively.

CONCLUSIONS

Given the economic burden imposed by the treatment of patients admitted with AAA on the Spanish health system, additional efforts comparing the cost of open repair with endovascular treatments are needed to ensure greater efficiency.

Duplex Ultrasound versus Computed Tomography for the Postoperative Follow-Up of Endovascular Abdominal Aortic Aneurysm Repair. Where Do We Stand Now?

In the last decade, endovascular aneurysm repair (EVAR) has rapidly developed to be the preferred method for infrarenal abdominal aortic aneurysm repair in patients with suitable anatomy. EVAR offers the advantage of lower perioperative mortality and morbidity but carries the cost of device-related complications such as endoleak, graft migration, graft thrombosis, and structural graft failure. These complications mandate a lifelong surveillance of EVAR patients and their endografts. The purpose of this study is to review and evaluate the safety of color-duplex ultrasound (CDU) as compared with computed tomography (CT), based on the current literature, for post-EVAR surveillance. The post-EVAR follow-up modalities, CDU versus CT, are evaluated questioning three parameters: (1) accuracy of aneurysm size, (2) detection and classification of endoleaks, and (3) detection of stent-graft deformation. Studies comparing CDU with CT scan for investigation of post-EVAR complications have produced mixed results. Further and long-term research is needed to evaluate the efficacy of CDU versus CT, before CDU can be recommended as the primary imaging modality for EVAR surveillance, in place of CT for stable aneurysms.

Long-term cost-effectiveness analysis of endovascular versus open repair for abdominal aortic aneurysm based on four randomized clinical trials

Background

A number of published economic evaluations of elective endovascular aneurysm repair (EVAR) versus open repair for abdominal aortic aneurysm (AAA) have come to differing conclusions about whether EVAR is cost-effective. This paper reviews the current evidence base and presents up-to-date cost-effectiveness analyses in the light of results of four randomized clinical trials: EVAR-1, DREAM, OVER and ACE.

Methods

Markov models were used to estimate lifetime costs from a UK perspective and quality-adjusted life-years (QALYs) based on the results of each of the four trials. The outcomes included in the model were: procedure costs, surveillance costs, reintervention costs, health-related quality of life, aneurysm-related mortality and other-cause mortality. Alternative scenarios about complications, reinterventions and deaths beyond the trial were explored.

Results

Models based on the results of the EVAR-1, DREAM or ACE trials did not find EVAR to be cost-effective at thresholds used in the UK (up to £30 000 per QALY). EVAR seemed cost-effective according to models based on the OVER trial. These results seemed robust to alternative model scenarios about events beyond the trial intervals.

Conclusion

These analyses did not find that EVAR is cost-effective compared with open repair in the long term in trials conducted in European centres. EVAR did appear to be cost-effective based on the OVER trial, conducted in the USA. Caution must be exercised when transferring the results of economic evaluations from one country to another.

Clinical practice change requires more than comparative effectiveness evidence: abdominal aortic aneurysm management in the USA

Adoption of healthcare innovations frequently outpaces the evidence of effectiveness. Endovascular repair (EVAR) for abdominal aortic aneurysms in the USA demonstrates how comparative effectiveness research without evidence-based reimbursement changes may fail to influence clinical practice. Randomized controlled trials for small abdominal aortic aneurysms demonstrate no lasting benefits of EVAR or open surgical repair (OSR) compared with surveillance, and for large abdominal aortic aneurysms demonstrate no lasting survival benefit of EVAR over OSR, and do show poorer durability and higher costs for EVAR. Nonetheless, >50% of elective abdominal aortic aneurysm repairs in the USA use EVAR. Factors that may be driving the high use of EVAR include patient preference, surgeons’ desire to appear ‘up-to-date’ in the procedures they offer, higher hourly surgeon reimbursement for EVAR than OSR, and the expansion of physician specialties able to perform abdominal aortic aneurysm repair from only vascular surgeons with OSR, to vascular surgeons and interventional radiologists/cardiologists with EVAR. By comparison, in Canada, where government health insurance restricts EVAR coverage to high surgical risk patients, only approximately 25% of abdominal aortic aneurysm repairs are performed using EVAR. Country-specific cost studies and a prospective population-based study collecting detailed clinical data to identify patient subgroups that truly benefit from a particular management strategy are needed to inform policy regarding EVAR availability and reimbursement.

Impact of whole-body CT screening on the cost-effectiveness of CT colonography

PURPOSE

To analyze the impact of adding computed tomographic (CT) imaging of the chest on the clinical effectiveness and cost-effectiveness of CT colonography to determine whether performing CT colonography and whole-body CT is a more clinically and cost-effective strategy than CT colonography alone when screening average-risk subjects.

MATERIALS AND METHODS

A Markov model simulated the occurrence of colorectal neoplasia, extracolonic abominal-pelvic malignancy, lung cancer, coronary artery disease (CAD), and abdominal aortic aneurysm (AAA) in a cohort of 100,000 U.S. subjects aged 50 to 100 years. Cost-effectiveness of CT colonography and whole-body CT was compared with that of CT colonography alone; each test was assumed to be repeated every 10 years between ages of 50 and 80 years.

RESULTS

Performing CT colonography and whole-body CT was more effective and costly than was CT colonography alone. The addition of chest CT was associated with a 22% increase in efficacy (life-years gained: 14,662 vs 11,990) and with a 48% increase in cost per person ($13,605 vs $9,223). Both strategies were cost effective as compared with no screening, with an incremental cost-effectiveness ratio (ICER) of $17,672 (CT colonography alone) and $44,337 (CT colonography and whole-body CT), respectively, but performing CT colonography and whole-body CT was not a cost-effective option when compared with CT colonography alone (ICER, $164,020). This was mainly a result of the high cost of false-positive follow-up for CAD and to the poor efficacy of lung cancer screening. Expected value of perfect information was $520 per patient.

CONCLUSION

The addition of chest CT to CT colonography does not appear to be a cost-effective alternative. Further research is needed before whole-body CT can be recommended in clinical practice.

A cost-effectiveness model comparing endovascular repair to open surgical repair of abdominal aortic aneurysms in Canada

OBJECTIVES

The primary risk of abdominal aortic aneurysms (AAAs) is rupture, which is associated with a high mortality rate. Elective surgical options for AAA include open repair (OR) and endovascular aneurysm repair (EVAR). EVAR is less invasive than OR, and therefore may have less surgical risk than OR. However, the graft used for EVAR is much more expensive then the graft used for OR.

METHODS

A decision model with a 10-year time horizon was used to assess the cost-effectiveness of EVAR versus OR. The primary outcome measure was quality-adjusted life-years (QALYs). The model incorporated the costs and benefits of both perioperative outcomes and postoperative outcomes. A systematic review was conducted to derive clinical outcome rates. Cost and utility model variables were based on various literature sources and data from a recent Canadian observational study. Parameter uncertainty was assessed using probabilistic sensitivity analysis.

RESULTS

In the base-case model, the incremental cost per QALY of EVAR was estimated to be $268,337, whereas the incremental cost per life-year was found to be $444,129. The incremental cost per QALY of EVAR remained above $295,715 under different assumptions of cohort age and model time horizon.

CONCLUSIONS

Based on commonly quoted willingness-to-pay thresholds, EVAR was not found to be cost-effective compared to OR.

Aggressive vascular surgery in asymptomatic patients is a bad idea

The reflections of a non-surgeon

Modelling the long-term cost-effectiveness of endovascular or open repair for abdominal aortic aneurysm

Background

Recent randomized trials have shown that endovascular abdominal aortic aneurysm repair (EVAR) has a 3 per cent aneurysm-related survival benefit in patients fit for open surgery, but it also has uncertain long-term outcomes and higher costs. This study assessed the cost-effectiveness of EVAR.

Methods

A decision model was constructed to estimate the lifetime costs and quality-adjusted life years (QALYs) with EVAR and open repair in men aged 74 years. The model includes the risks of death from aneurysm, other cardiovascular and non-cardiovascular causes, secondary reinterventions and non-fatal cardiovascular events. Data were taken largely from the EVAR trial 1 and supplemented from other sources.

Results

Under the base-case (primary) assumptions, EVAR cost £3800 (95 per cent confidence interval (c.i.) £2400 to £5200) more per patient than open repair but produced fewer lifetime QALYs (mean − 0·020 (95 per cent c.i. − 0·189 to 0·165)). These results were sensitive to alternative model assumptions.

Conclusion

EVAR is unlikely to be cost-effective on the basis of existing devices, costs and evidence, but there remains considerable uncertainty.

Evidence-based practice in radiology education: why and how should we teach it?

Evidence-based practice in radiology (EBR) is becoming firmly established as a method to enhance the knowledge and fill the need for further knowledge within the profession. It has been identified as an essential part of the training program, both at medical school and at the resident and/or fellowship level. This review aims to describe the essential components of EBR, to describe the educational theories that may be applied to developing EBR within the curriculum, and to give several models that have been shown to result in greater student and resident participation in the search and exploration of evidence-based practice.

Long-term postplacement cost after endovascular aneurysm repair

BACKGROUND

Previous studies have demonstrated that the initial hospital cost associated with endovascular aneurysm repair (EVAR) is approximately $20,000. However, the cost of long-term surveillance and secondary procedures is poorly characterized.

METHODS

Between December 1998 and June 2006, 259 patients underwent EVAR for infrarenal aneurysms at a single institution. Follow-up costs were calculated using a relative value unit based hospital cost accounting system, which incorporates departmental direct and indirect costs. Institutional overhead costs were included using a conversion factor. Costs for professional services were determined by a cost-to-charge ratio, and outpatient visits were calculated with a time-based formula. Year 2006 costs were applied to prior years. To minimize costs associated with the early learning curve, the initial 50 EVAR patients between December 1995 and 1998 were excluded. Patients with <1 year follow-up were also excluded. Data are expressed as mean +/- standard error.

RESULTS

The mean follow-up after EVAR for 136 patients was 34.7 +/- 1.8 months. The cumulative 5-year postplacement cost per patient was $11,351. The 27 patients (19.9%) who required secondary procedures had a 5-year cumulative cost of $31,696 compared with $3668 for 109 patients without secondary procedures (8.6-fold increase, P < .05). The 5-year cost for patients with endoleak was $26,739 compared with $5706 for those without endoleak (4.7-fold increase, P < .05). Overall, major cost components were 57.4% for secondary procedures and 32.5% for radiologic studies.

CONCLUSIONS

During a 5-year period, the postplacement cost of EVAR increases the global cost by 44%. The subgroups of patients with endoleaks and those requiring secondary procedures generate a disproportionate share of postplacement costs. Efforts at minimizing cost should emphasize technical and device modifications aimed at reducing endoleaks and the need for secondary procedures.

Cost-effectiveness of abdominal aortic aneurysm repair: A systematic review

Objectives: A systematic review of the cost-effectiveness of abdominal aortic aneurysm (AAA) repair was conducted. Although open surgery has been considered the gold standard for prevention of AAA rupture, emerging less-invasive endovascular treatments have led to increased interest in evaluating the cost and cost-effectiveness of treatment options.

Methods: A systematic review of studies published in MEDLINE between 1999 and 2005 reporting the cost and/or cost-effectiveness of endovascular and/or open surgical repair of nonruptured AAAs was conducted. Case series studies with less than fifty patients per treatment were excluded.

Results: Of twenty eligible articles, three were randomized controlled trials, twelve case series, four Markov models, and one systematic review. Regardless of time frame, all studies found that endovascular repair costs more than open surgery. Although the high cost of the endovascular prosthesis was partially offset by reduced intensive care, hospital length of stay, operating time, blood transfusions, and perioperative complications, hospital costs were still greater for endovascular than open surgical repair. For patients medically fit for open surgery, mid-term costs were greater for endovascular repair with no difference in overall survival or quality of life. For patients medically unfit for open surgery, endovascular repair costs more than no intervention with no difference in survival.

Conclusions: Although conclusions regarding the cost-effectiveness of AAA treatment options are time dependent and vary by institutional perspective, from a societal perspective, endovascular repair is not currently cost-effective for patients with large AAA regardless of medical fitness.

Review of Interventional Repair for Abdominal Aortic Aneurysm

Abdominal aortic aneurysm is associated with high mortality rate. For over 50 years, open surgical repair was the standard approach for large aneurysms. However, over the past decade, endovascular aneurysm repair (EVAR) has emerged as a viable alternative. EVAR is associated with lower operative and short-term morbidity and mortality and similar long-term survival (up to 4 years) compared with surgical repair. Endoleak remains a significant limitation associated with aneurysm expansion and reintervention. With newer, more versatile endograft designs, improvements in durability, and better surveillance techniques, the utilization of EVAR is likely to continue to expand.

Follow-up costs increase the cost disparity between endovascular and open abdominal aortic aneurysm repair

OBJECTIVE

This study compared the hospital and follow-up costs of patients who have undergone endovascular (EVAR) or open (OR) elective abdominal aortic aneurysm repair.

METHODS

The records of 195 patients (EVAR, n = 55; OR, n = 140) who underwent elective aortic aneurysm repair between 1995 and 2004 were reviewed. Primary costing data were analyzed for 54 EVAR and 135 OR patients. Hospital costs were divided into preoperative, operative, and postoperative costs. Follow-up costs for EVAR patients were recorded, with a median follow-up time of 12 months.

RESULTS

Mean preoperative costs were slightly higher in the EVAR group (AU $961/US $733 vs AU $869/US $663; not significant). Operative costs were significantly higher in the EVAR group (AU $16,124/US $12,297 vs AU $6077/US $4635; P < .001); this was entirely due to the increased cost of the endograft (AU $10,181/US $7,765 for EVAR vs AU $476/US $363 for OR). Postoperative costs were significantly reduced in the EVAR group (AU $4719/US $3599 vs AU $11,491/US $8,764; P < .001). Total hospital costs were significantly greater in the EVAR group (AU $21,804/US $16,631 vs AU $18,437/US $14,063; P < .001). The increase in total hospital costs was due to a significant difference in graft costs, which was not offset by reduced postoperative costs. The average follow-up cost per year after EVAR was AU $1316/US $999. At 1 year of follow-up, EVAR remained significantly more expensive than OR (AU $23,120/US $17,640 vs AU $18,510/US $14,122; P < .001); this cost discrepancy increased with a longer follow-up.

CONCLUSIONS

EVAR results in significantly greater hospital costs compared with OR, despite reduced hospital and intensive care unit stays. The inclusion of follow-up costs further increases the cost disparity between EVAR and OR. Because EVAR requires lifelong surveillance and has a high rate of reintervention, follow-up costs must be included in any cost comparison of EVAR and OR. The economic cost, as well as the efficacy, of new technologies such as EVAR must be addressed before their widespread use is advocated.

Cost-effectiveness of whole-body CT screening

PURPOSE

To make preliminary estimates of the effectiveness (in life-years) and cost-effectiveness (in costs per life-year) of whole-body computed tomographic (CT) screening.

MATERIALS AND METHODS

Costs and effectiveness (in life-years) of onetime whole-body CT screening relative to those of no screening were calculated by using a decision-analytic model. It was assumed that any benefits from screening were due to earlier detection of disease and improvement in survival relative to survival with routine care. Eight conditions were included in the model: ovarian, pancreatic, lung, liver, kidney, and colon cancer; abdominal aortic aneurysm; and coronary artery disease. Costs of the screening examination, follow-up tests, and patient care were estimated. The base-case analysis was performed for a hypothetical cohort of 500 000 self-referred asymptomatic 50-year-old men. For sensitivity analyses, the age and sex of the cohort were varied. Results were expressed in 2001 U.S. dollars per life-year gained.

RESULTS

Compared with routine care, whole-body CT screening provided minimal gains in life expectancy (0.016 6 years or 6 days) at an average additional cost of 2513 dollars per patient, or an incremental cost-effectiveness ratio of 151 000 dollars per life-year gained. Most patients (90.8%) had at least one positive finding, but only 2.0% had disease; work-up in patients with a false-positive result of screening accounted for 32.3% of total costs (1720 dollars of 5332 dollars). Results were sensitive to the prevalence of disease, the effect of screening on stage of disease at diagnosis, the specificity of screening, and the costs of follow-up for false-positive findings.

CONCLUSION

Even with assumptions favorable to whole-body CT, implementation of onetime screening would not be cost-effective compared with currently funded medical interventions; follow-up for false-positive findings would add a substantial financial burden to the health care system.

A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms

BACKGROUND

Although the initial results of endovascular repair of abdominal aortic aneurysms were promising, current evidence from controlled studies does not convincingly show a reduction in 30-day mortality relative to that achieved with open repair.

METHODS

We conducted a multicenter, randomized trial comparing open repair with endovascular repair in 345 patients who had received a diagnosis of abdominal aortic aneurysm of at least 5 cm in diameter and who were considered suitable candidates for both techniques. The outcome events analyzed were operative (30-day) mortality and two composite end points of operative mortality and severe complications and operative mortality and moderate or severe complications.

RESULTS

The operative mortality rate was 4.6 percent in the open-repair group (8 of 174 patients; 95 percent confidence interval, 2.0 to 8.9 percent) and 1.2 percent in the endovascular-repair group (2 of 171 patients; 95 percent confidence interval, 0.1 to 4.2 percent), resulting in a risk ratio of 3.9 (95 percent confidence interval, 0.9 to 32.9). The combined rate of operative mortality and severe complications was 9.8 percent in the open-repair group (17 of 174 patients; 95 percent confidence interval, 5.8 to 15.2 percent) and 4.7 percent in the endovascular-repair group (8 of 171 patients; 95 percent confidence interval, 2.0 to 9.0 percent), resulting in a risk ratio of 2.1 (95 percent confidence interval, 0.9 to 5.4).

CONCLUSIONS

On the basis of the overall results of this trial, endovascular repair is preferable to open repair in patients who have an abdominal aortic aneurysm that is at least 5 cm in diameter. Long-term follow-up is needed to determine whether this advantage is sustained.

Open Versus Endovascular Repair of Abdominal Aortic Aneurysms: What Does Each Really Cost?

Endovascular repair (EVAR) of abdominal aortic aneurysm (AAA) has emerged as an alternative to open repair (OR). The aim of this study was to compare the clinical outcomes and specific costs of these procedures since commercialization.A retrospective analysis of 119 consecutive infrarenal AAA repaired via an EVAR or an OR between July 2000 and September 2001 was performed. Patient charts were reviewed. Diagnostic-related group (DRG) classification and payer mix were identified. The hospital cost accounting system was accessed to obtain actual variable direct cost (AVDC) for the two groups. Percentages of the mean AVDC for the two groups were compared in the following cost categories: graft, operating room, radiology procedures and supplies, pharmacy, respiratory therapy, clinical laboratories, surgical floor, and monitored unit. Hospital profit margins were determined. Fifty-five patients underwent EVAR and 64 patients underwent OR. Mean aneurysm size was 5.5A cm (EVAR) and 6.1A cm (OR). Mean intensive care unit (ICU) stay was 0.09 days for EVAR vs. 3.5 days for OR ( p < 0.05). Mean length of stay (LOS) was 1.96 days for EVAR vs. 7.3 days for OR ( p < 0.05). Reimbursement was based on DRG 110, 47.3% in the EVAR and 79.7% in the OR group ( p < 0.05), and DRG 111, 50.9% in the EVAR group and 12.5% in the OR group ( p < 0.05). The payer mix showed no significant differences between the two groups. Mean AVDC for EVAR was 1.74 times that of OR. Significant differences in the distribution of costs were found in the following: graft costs (58% vs. 6.3%, p < 0.05), radiology procedures and supplies (3.9% vs. 0.1%, p < 0.05), pharmacy (1.9% vs. 10.5%, p < 0.05), and monitored unit (7.3% vs. 24.65%, p < 0.05) comparing EVAR vs. OR, respectively. Median cost of an endovascular graft was 22.4 times that of the standard graft for OR. Average hospital profit margins for an EVAR case was 49.5% vs. 88.6% for OR. Despite significant differences in monitored unit utilization, pharmacy services, and respiratory therapy services by the OR group, the cost of EVAR is appreciably more expensive. Furthermore, increased DRG reimbursement, and decreased ICU use and LOS do not compensate for the cost of EVAR. The main cost of EVAR is the cost of the graft itself. Hospital profit margins are acceptable with both the EVAR and OR procedures at this time; however, with proposed reductions in reimbursement, the ability to cover the cost of this new technology may be threatened.

The UK Endovascular Aneurysm Repair (EVAR) Trials: Design, Methodology and Progress

OBJECTIVES

The endovascular aneurysm repair (EVAR) trials aim to assess the efficacy of EVAR in the treatment of AAA in terms of mortality, quality of life, durability and cost-effectiveness.

DESIGN

Male and female patients aged at least 60 years with an AAA diameter measuring at least 5.5 cm on a computed tomography (CT) scan are assessed for anatomical suitability for EVAR. Suitable patients are offered entry either into EVAR Trial 1 if they are considered fit for conventional open repair or EVAR Trial 2 if they are considered unfit. EVAR 1 randomly allocates patients to EVAR or open repair and EVAR 2 randomly allocates patients to EVAR with best medical treatment or best medical treatment alone. Target recruitment for EVAR Trials 1 and 2 is 900 and 280 patients, respectively.

PROGRESS

Recruitment began in September 1999 and there are currently 40 UK centres participating in the trials. Monthly targets are being exceeded in EVAR Trial 1 with 1037 patients randomised by October 2003. EVAR Trial 2 is also meeting monthly targets with a total of 319 patients randomised. When recruitment closes in December 2003 patients will need to be followed for at least 1 year from their operation. Publication of full results for both trials is expected in mid 2005.

Cost-Effectiveness of Uterine Artery Embolization and Hysterectomy for Uterine Fibroids

PURPOSE

To compare the cost-effectiveness of uterine artery embolization (UAE) with that of hysterectomy for women with symptomatic uterine fibroids.

MATERIALS AND METHODS

The authors developed a decision model to compare the costs and effectiveness of UAE and hysterectomy. In the model, a cohort of women aged 40 years with a diagnosis of uterine fibroids and no desire for future pregnancy was followed up until menopause. The analysis was performed from a societal perspective, including all costs and effects, regardless of who incurs them. Transition probability and quality-of-life estimates were obtained from the literature and a gynecologist, whereas costs (in 1999 U.S. dollars) were estimated by using rates of Medicare reimbursement for hospital costs and physician fees. Sensitivity analyses of key estimates were performed. Results were expressed in costs per quality-adjusted life-year (QALY).

RESULTS

UAE was more effective (8.29 vs 8.18 QALYs) and less expensive (US dollars 6916 vs US dollars 7847) than hysterectomy. Cost-effectiveness results, with the exception of quality-of-life data, were robust to changes in most model assumptions. When the quality-of-life adjustment was eliminated, the two procedures were equally effective.

CONCLUSION

UAE is a cost-effective alternative to hysterectomy across a wide range of assumptions about the costs and effectiveness of the two procedures. However, the study results were sensitive to changes in quality-of-life values.

Abdominal aortic aneurysms: elective endovascular repair versus conventional surgery--evaluation with evidence-based medicine techniques

PURPOSE

To use evidence-based techniques to compare elective open surgical repair of abdominal aortic aneurysms with endovascular repair by means of stent placement.

MATERIALS AND METHODS

A focused clinical question formed the basis of a literature search. Evidence-based criteria were used to appraise and assign a "level of evidence" to retrieved articles. The following data were determined from the best studies: systemic, local, and/or vascular complications; graft failure rates; blood loss; mortality; length of intensive care and/or hospital stay; mid- and long-term outcomes; cost of endovascular repair versus that of surgery; and eligibility for endovascular repair. Absolute risk reductions and/or increases and numbers needed to treat or harm were calculated.

RESULTS

The best current evidence came from 22 studies, which showed that there is slight, if any, difference between mortality rates of endovascular repair and surgery. Hospital and/or intensive care stay is shorter, blood loss less, and systemic complications fewer (numbers needed to treat, two to 12) with endovascular repair. Some authors reported a significant increase in local and/or vascular complications with endovascular repair (numbers needed to harm, two to six). Graft failure is significantly more common with endovascular repair (numbers needed to harm, four), and substantive adjunctive interventions are needed. Endovascular repair is more expensive than surgery.

CONCLUSION

Elective endovascular repair has short-term benefits compared with surgery. There is slight, if any, difference in mortality. Endovascular repair costs more than surgery. At follow-up, surgical grafts performed better.