Echocardiographic risk stratification for early surgery with endocarditis: a cost-effectiveness analysis.
BACKGROUND
Despite widespread acceptance of echocardiography for diagnosis of infective endocarditis, few investigators have evaluated its utility as a risk-stratification tool to aid therapeutic decision-making.


METHODS
A decision tree and Markov analysis model were constructed using published and institutional data to estimate the cost-effectiveness of an echocardiographic risk-stratification strategy for infective endocarditis. The models compared surgery for high-risk patients based on clinical factors ("standard care") and surgery for high-risk patients based on echocardiographic findings ("echocardiography-guided").


RESULTS
The cost per patient for standard care and echocardiography-guided strategies was $47,766 and $53,669, respectively. The expected quality-adjusted life years (QALY) for standard care and echocardiography-guided strategies were 5.86 years and 6.10 years, respectively. Compared with standard care, the echocardiography-guided strategy cost an additional $23,867 per QALY saved. In one-way sensitivity analyses, the incremental cost of this strategy remained <$50,000/QALY across a broad range of scenarios. Baseline stroke risk had the greatest effect on cost-effectiveness. For populations with stroke risk less than 3.65%, the echocardiography-guided strategy was not cost-attractive (ICER >$50,000/QALY). At stroke risk between 3.65% and 14%, the ICER for the echocardiography-guided strategy was attractive (<$50,000 /QALY). The echocardiography-guided strategy became economically dominant at any baseline stroke risk greater than 18.3%.


CONCLUSIONS
Echo-guided risk stratification for early surgery in patients with large vegetations is a cost-attractive treatment strategy for IE, as it improves outcome for an incremental cost <$50,000/QALY.
Liao
L
L
Duke Clinical Research Institute, Duke University Medical Center, Durham, NC 27710, USA. liao0002@mc.duke.edu
Kong
D F
DF
Samad
Z
Z
Pappas
P A
PA
Jollis
J G
JG
Lin
S S
SS
Wang
A
A
Fowler
V G
VG
Chu
V H
VH
Sexton
D J
DJ
Corey
G R
GR
Cabell
C H
CH
D003362:Cost-Benefit Analysis; D042241:Early Diagnosis; D004452:Echocardiography / Q000191:economics; D004696:Endocarditis / Q000000981:diagnostic imaging* / Q000191:economics / Q000601:surgery; D006801:Humans; D008390:Markov Chains; D019057:Quality-Adjusted Life Years; D018570:Risk Assessment / Q000191:economics; D012680:Sensitivity and Specificity; D020521:Stroke / Q000191:economics / Q000517:prevention & control; D016896:Treatment Outcome