Selective preoperative cardiac screening improves five-year survival in patients undergoing major vascular surgery: a cost-effectiveness analysis.
OBJECTIVE
To evaluate the long-term outcomes (5-year survival) and cost-effectiveness of selective coronary revascularization before major vascular surgery.


METHODS
A decision-tree model was constructed to compare the cost-effectiveness of four preoperative screening strategies from the perspective of the health care system.


METHODS
Based on patient mortality, morbidity, and cost data from a literature review.


METHODS
Hypothetical cohort of patients scheduled for elective abdominal aortic aneurysm repair followed up over a 5-year period.


METHODS
Patients either proceeded directly to surgery or were screened using one of three possible preoperative screening strategies. In the first strategy, all patients were screened with a dipyridamole-thallium test. In the second strategy, all patients underwent coronary angiography. The third strategy, selective screening, first divided patients into high-, intermediate-, and low-risk groups using clinical criteria. High-risk patients underwent preoperative angiography. Intermediate-risk patients were screened noninvasively, and low-risk patients proceeded directly to surgery without further testing.


RESULTS
Proceeding directly to vascular surgery resulted in the poorest 5-year survival rate (77.4%) compared with preoperative risk stratification followed by selective coronary revascularization, routine noninvasive testing (86.1%), selective testing (86.0%), and routine angiography (87.9%; p = 0.00). The incremental cost-effectiveness ratio for selective testing was significantly lower than for routine angiography ($44,800/years of life saved (YLS) v $93,300/YLS; p < 0.02). Routine noninvasive testing was not cost-effective. Thirty-day mortality was the same for all four strategies (p = 0.84).


CONCLUSIONS
Selective screening before vascular surgery may improve 5-year survival and be cost-effective. Neither routine noninvasive testing nor routine angiography appears to be cost-effective compared with currently accepted medical therapies.
Department of Anesthesiology, University of Rochester, NY, USA.
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Glance
D017544:Aortic Aneurysm, Abdominal / Q000401:mortality / Q000601:surgery*; D017023:Coronary Angiography; D003362:Cost-Benefit Analysis; D004176:Dipyridamole; D006801:Humans; D008875:Middle Aged; D009204:Myocardial Revascularization; D015996:Survival Rate; D013794:Thallium Radioisotopes
D013794:Thallium Radioisotopes; D004176:Dipyridamole