Cost-effectiveness of diagnostic strategies for evaluation of suspected subarachnoid hemorrhage in the emergency department.
OBJECTIVE
Diagnosing subarachnoid hemorrhage (SAH) in emergency department (ED) patients is challenging. Potential diagnostic strategies include computed tomography (CT) only, CT followed by lumbar puncture (CT/LP), CT followed by magnetic resonance imaging and angiography (CT/MRA), and CT followed by CT angiography (CT/CTA). The objective was to determine the relative cost-effectiveness of diagnostic strategies for SAH.


METHODS
The authors created a decision model to evaluate the cost-effectiveness of SAH diagnostic strategies in ED patients with suspected SAH. Clinical probabilities were obtained from published data; sensitivity analyses were conducted across plausible ranges.


RESULTS
In the base-case scenario, CT-only had a cost of $10,339 and effectiveness of 20.25 quality-adjusted life-years (QALYs), and CT/LP had a cost of $15,120 and effectiveness of 20.366 QALYs. Among the alternative strategies, CT/CTA had a cost of $12,840 and effectiveness of 20.24 QALYs, and CT/MRA had a cost of $16,207 and effectiveness of 20.27 QALYs. In sensitivity analyses, probability of severe disability from SAH, sensitivity of noncontrast CT, and specificity of LP and MRA were key drivers of the model, and CT-only and CT/LP were preferable.


CONCLUSIONS
In the base-case scenario, CT-only was preferable to the CT/CTA and CT/MRA strategies. When considering sensitivity analyses and the current medicolegal environment, there are no overwhelming differences between the cost-effectiveness of CT/LP and the alternative strategies to suggest that clinicians should abandon the standard CT/LP approach.
Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH, USA. mward04@gmail.com
Michael J
MJ
Ward
Jordan B
JB
Bonomo
Opeolu
O
Adeoye
Ali S
AS
Raja
Jesse M
JM
Pines
D000792:Angiography / Q000191:economics*; D003362:Cost-Benefit Analysis; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D018810:Magnetic Resonance Angiography / Q000191:economics*; D008297:Male; D008875:Middle Aged; D012680:Sensitivity and Specificity; D013129:Spinal Puncture / Q000191:economics*; D013345:Subarachnoid Hemorrhage / Q000175:diagnosis* / Q000191:economics; D014057:Tomography, X-Ray Computed / Q000191:economics*