title: Costs and cost-effectiveness of carotid stenting versus endarterectomy for patients at increased surgical risk: results from the SAPPHIRE trial.
abstract: OBJECTIVE
  To evaluate the cost-effectiveness of carotid stenting vs. carotid endarterectomy using data from the SAPPHIRE trial.
  
  
  BACKGROUND
  Carotid stenting with embolic protection has been introduced as an alternative to carotid endarterectomy for prevention of cerebrovascular and cardiovascular events among patients at increased surgical risk.
  
  
  METHODS
  Between August 2000 and July 2002, 310 patients with an accepted indication for carotid endarterectomy but at high risk of complications were randomized to and subsequently underwent either carotid stenting (n = 159) or endarterectomy (n = 151). Clinical outcomes, resource use, costs, and quality of life were assessed prospectively for all patients over a 1-year period. Life expectancy, quality-adjusted life expectancy, and health care costs beyond the follow-up period were estimated for patients alive at 1 year, based on observed clinical events during the first year of follow-up.
  
  
  RESULTS
  Although initial procedural costs were significantly higher for stenting than for endarterectomy (mean difference: $4,081/patient; 95% CI, $3,849-$4,355), mean post-procedure length of stay was shorter for stenting (1.9 vs. 2.9 days; P < 0.001) with significant associated cost offsets. As a result, initial hospital costs were just $559/patient higher with stenting (95% CI, $3,470 less to $2,289 more). Neither follow-up costs after discharge nor total 1-year costs differed significantly. The incremental cost-effectiveness ratio for stenting compared with endarterectomy was $6,555 per quality-adjusted life year (QALY) gained, with over 98 percent of bootstrap estimates < $50,000/QALY gained.
  
  
  CONCLUSIONS
  Although carotid stenting with embolic protection is more costly than carotid endarterectomy, by commonly accepted standards, stenting is an economically attractive alternative to endarterectomy for patients at high surgical risk.
authors.affiliation: Cardiovascular Research Center, Saint Luke's Mid America Heart and Vascular Institute, Kansas City, Missouri, USA.
authors.forename: Elizabeth M
authors.initials: EM
authors.lastname: Mahoney
authors.forename: Dan
authors.initials: D
authors.lastname: Greenberg
authors.forename: Tara A
authors.initials: TA
authors.lastname: Lavelle
authors.forename: Amy
authors.initials: A
authors.lastname: Natarajan
authors.forename: Ronna
authors.initials: R
authors.lastname: Berezin
authors.forename: K Jack
authors.initials: KJ
authors.lastname: Ishak
authors.forename: Jamie J
authors.initials: JJ
authors.lastname: Caro
authors.forename: Jay S
authors.initials: JS
authors.lastname: Yadav
authors.forename: William A
authors.initials: WA
authors.lastname: Gray
authors.forename: Mark H
authors.initials: MH
authors.lastname: Wholey
authors.forename: David J
authors.initials: DJ
authors.lastname: Cohen
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000553:Ambulatory Care; D017130:Angioplasty / Q000009:adverse effects / Q000191:economics* / Q000295:instrumentation; D016893:Carotid Stenosis / Q000150:complications / Q000191:economics / Q000601:surgery / Q000628:therapy*; D003362:Cost-Benefit Analysis; D057505:Embolic Protection Devices / Q000191:economics; D004636:Emergency Service, Hospital / Q000191:economics; D016894:Endarterectomy, Carotid / Q000009:adverse effects / Q000191:economics*; D005260:Female; D017048:Health Care Costs; D017721:Hospital Costs; D006801:Humans; D007902:Length of Stay / Q000191:economics; D008017:Life Expectancy; D008297:Male; D018803:Models, Economic; D010359:Patient Readmission; D018579:Patient Selection; D011446:Prospective Studies; D011788:Quality of Life; D019057:Quality-Adjusted Life Years; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D015607:Stents / Q000191:economics*; D020521:Stroke / Q000191:economics / Q000209:etiology / Q000628:therapy; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States