Cost-effectiveness of surgical decompression for space-occupying hemispheric infarction.
OBJECTIVE
Surgical decompression reduces mortality and increases the probability of a favorable functional outcome after space-occupying hemispheric infarction. Its cost-effectiveness is uncertain.


METHODS
We assessed clinical outcomes, costs, and cost-effectiveness for the first 3 years in patients who were randomized to surgical decompression or best medical treatment within 48 hours after symptom onset in the Hemicraniectomy After Middle Cerebral Artery Infarction With Life-Threatening Edema Trial (HAMLET). Data on medical consumption were derived from case record files, hospital charts, and general practitioners. We calculated costs per quality-adjusted life year (QALY). Uncertainty was assessed with bootstrapping. A Markov model was constructed to estimate costs and health outcomes after 3 years.


RESULTS
Of 39 patients enrolled within 48 hours, 21 were randomized to surgical decompression. After 3 years, 5 surgical (24%) and 14 medical patients (78%) had died. In the first 3 years after enrollment, operated patients had more QALYs than medically treated patients (mean difference, 1.0 QALY [95% confidence interval, 0.6-1.4]), but at higher costs (mean difference, €127,000 [95% confidence interval, 73,100-181,000]), indicating incremental costs of €127,000 per QALY gained. Ninety-eight percent of incremental cost-effectiveness ratios replicated by bootstrapping were >€80,000 per QALY gained. Markov modeling suggested costs of ≈€60,000 per QALY gained for a patient's lifetime.


CONCLUSIONS
Surgical decompression for space-occupying infarction results in an increase in QALYs, but at very high costs.


BACKGROUND
http://www.controlled-trials.com. Unique identifier: ISRCTN94237756.
From the Department of Neurology, Rijnstate Hospital, Arnhem, The Netherlands (J.H.); Department of Clinical Neurophysiology, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands (J.H.); and Department of Neurology and Neurosurgery, UMC Utrecht Stroke Center, Rudolf Magnus Institute of Neuroscience (H.B.v.d.W., L.J.K., S.E., A.A.) and Julius Centre for Health Sciences and Primary Care (A.A., J.P.G.), University Medical Center Utrecht, Utrecht, The Netherlands.
Jeannette
J
Hofmeijer
H Bart
HB
van der Worp
L Jaap
LJ
Kappelle
Sara
S
Eshuis
Ale
A
Algra
Jacoba P
JP
Greving
D000328:Adult; D016208:Databases, Factual; D019299:Decompression, Surgical / Q000191:economics* / Q000379:methods; D018572:Disease-Free Survival; D005260:Female; D005500:Follow-Up Studies; D017048:Health Care Costs; D006801:Humans; D020244:Infarction, Middle Cerebral Artery / Q000191:economics* / Q000401:mortality / Q000601:surgery; D008297:Male; D008390:Markov Chains; D008875:Middle Aged; D018803:Models, Economic; D012189:Retrospective Studies; D015996:Survival Rate; D013997:Time Factors
cost-effectiveness analysis; decompression, surgical; hemicraniectomy; malignant infarction; space-occupying infarction