PURPOSE: To project and compare the lifetime health benefits, health care costs, and incremental cost-effectiveness of a decision rule based on assessment of cerebrovascular reserve (CVR) compared with medical therapy and immediate revascularization in asymptomatic patients with carotid artery stenosis for prevention of stroke. MATERIALS AND METHODS: The three strategies compared included immediate revascularization (carotid endarterectomy) and ongoing medical therapy (with antiplatelet, statin, and antihypertensive agents plus lifestyle modification), medical therapy-based treatment with revascularization only for patients who progressed, and use of a CVR-based decision rule for treatment in which patients with CVR impairment undergo immediate revascularization and all others receive medical therapy. A decision analytic model was developed to project lifetime quality-adjusted life years (QALYs) and costs for asymptomatic patients with carotid stenosis with 70%-89% carotid luminal narrowing at presentation. Risks of clinical events, costs, and quality-of-life values were estimated on the basis of those in published sources. The analysis was conducted from a health care system perspective, with health and cost outcomes discounted at 3%. Results Total costs per person and lifetime QALYs were lowest for the medical therapy-based strategy ($14 597, 9.848 QALYs), followed by CVR testing ($16 583, 9.934 QALYs) and immediate revascularization ($20 950, 9.940 QALYs). The incremental cost-effectiveness ratio for the CVR-based strategy compared with the medical therapy-based strategy was $23 000 per QALY and for the immediate revascularization versus the CVR-based strategy was $760 000 per QALY. RESULTS: were sensitive to variations in model inputs for revascularization costs and complication risks and baseline stroke risk. CONCLUSION: CVR testing can be a cost-effective tool to identify asymptomatic patients with carotid stenosis who are most likely to benefit from revascularization.
School of Medicine