Surgical Revascularization for Moyamoya Disease: A Cost-Effectiveness Analysis. (16th November 2020)

• Record Type: Journal Article
• Authors: Srinivas, Shanmukha; Wali, Arvin R; Santiago, David; Brandel, Michael; Steinberg, Jeffrey; Rennert, Robert; Mandeville, Ross; Murphy, James; Olson, Scott E; Pannell, Jeffrey S; Khalessi, Alexander A
• Is Part Of: Neurosurgery. Volume 67(2010)Supplement 1
• Publication Date: 2020-11-16
• Subjects: Nervous system -- Surgery -- Periodicals; 617.48005
• DOI: 10.1093/neuros/nyaa447_290
• Languages: English
• ISSNs: 0148-396X

Abstract

Abstract: INTRODUCTION: Moyamoya disease is a vasculopathy of the internal carotid arteries that has ischemic and hemorrhagic sequelae. Surgical revascularization confers peri-procedural risk and cost for long-term protective benefit against hemorrhagic disease. METHODS: The authors used a Markov Model to simulate a 41 year old suffering a TIA secondary to Moyamoya disease and now faced with surgical or nonsurgical treatment options. Data on health utilities, costs, and outcome probabilities were obtained from the cost-effectiveness analysis (CEA) registry and the PubMed database. The primary outcome measured was the incremental cost-effectiveness ratio (ICER) which compared both the quality adjusted life years (QALY) and costs of surgical and nonsurgical treatments. Base-case, one-way sensitivity, two-way sensitivity, and probabilistic sensitivity analyses were performed with a willingness to pay (WTP) threshold of $50, 000. RESULTS: The base case model yielded 3.81 QALYs with a cost of $99, 500 for surgical treatment and 3.76 QALYs with a cost of $106, 500 for nonsurgical treatment. Overall, surgical treatment added .05 QALYs while saving $7, 000. One-way sensitivity analysis demonstrated the greatest sensitivity in assumptions to cost of surgery and admission for hemorrhagic stroke, and probability of stroke with no surgery, stroke after surgery, poor surgical outcome, and death after surgery. Two-way sensitivity analyses demonstrated that surgical revascularization for Moyamoya remained the cost-effective strategy when the probability of stroke without pursuing surgery was greater than 3.6% and when the probability of causing stroke with surgery remained less than 3.8%. Probabilistic sensitivity analyses suggested that through 100, 000 simulations at a WTP threshold of $50, 000, surgical revascularization was the cost-effective strategy over 87.4% of simulations. CONCLUSION: Considering both direct and indirect costs and the postoperative QALY, surgery is considerably more cost-effective than observation for adults with Moyamoya Disease.