Cost-effectiveness analysis of intracranial stent placement versus contemporary medical management in patients with symptomatic intracranial artery stenosis

Abstract

Background: Intracranial angioplasty and stent placement has been increasingly evaluated as a new
method for treatment of symptomatic intracranial stenosis in select patients. The Food and Drug Administration (FDA) has approved intracranial stent treatment of symptomatic atherosclerotic intracranial lesions.
Purpose: To determine the cost-effectiveness of intracranial artery stent placement compared with contemporary medical management for secondary stroke prevention among patients with symptomatic intracranial stenosis.
Methods: Clinical outcome data were obtained from the aspirin treatment arm of the Comparison of Warfarin and Aspirin for Symptomatic Intracranial Disease (WASID) trial (n = 280) and 12 case series (n =
216) of patients who underwent stent placement of symptomatic intracranial stenosis with comparable characteristics. Total cost of procedure and medical management-only was calculated using the rates of major
stroke, minor stroke, or death in each group. All costs are expressed in 2010 US$. The quality-adjusted lifeyear (QALY) of each intervention strategy was estimated using the frequency of the outcomes of major and
minor stroke, death, and baseline health. An incremental cost-effectiveness ratio (ICER) was formulated for
a 1-year period.
Results: The total rate of stroke at one year was 10.2% (6.1–14.2%) and the rate of all-cause mortality
was 3.7% (1.2–6.2%) in the stent group. The corresponding annualized rates of stroke and all-cause mortality in the medical management-only group were 15% (10.8–19.2%) and 2.4% (0.6–4.2%), respectively.
The calculated net costs at one year for intracranial stent placement and contemporary medical management were US$16,898 and US$3,468, respectively. Overall, QALYs for the two groups were 0.82 and 0.81
(in a range of 0 to 0.89 corresponding to death and baseline health), respectively. The cost per QALY
gained after intracranial stent placement and contemporary medical therapy was US$20,542 and US$4,265,
respectively. The corresponding ICER for stent versus medical treatment alone was US$1,416,268.
Conclusion: The reduced risk of stroke following intracranial stent placement is offset by significantly
higher procedure-associated net costs. Select procedures in patients with symptomatic stenosis of 70% or
greater are more likely to be cost-effective.