A comparison of open and endovascular revascularization for chronic mesenteric ischemia in a clinical decision model.
OBJECTIVE
Open revascularization (OR) has been the treatment of choice for chronic mesenteric ischemia (CMI) for many years, but endovascular revascularization (EV) has been increasingly used with good short-term results. In this study, we evaluated the comparative effectiveness and cost-effectiveness of EV and OR in patients with CMI refractory to conservative management.


METHODS
A Markov-state transition model was developed using TreeAge Pro 2012 (TreeAge Inc, Williamstown, Mass) to simulate a hypothetical cohort of 10,000 65-year-old female patients with CMI requiring treatment with either OR or EV. Data for the model, including perioperative and long-term overall mortality risks, disease-specific mortality risks, complications, and reintervention and patency rates, were retrieved from original studies and systematic reviews about CMI. Costs were analyzed with the 2013 Medicare database. Outcomes evaluated were quality-adjusted life-years (QALYs), costs from the health care perspective, and the incremental cost-effectiveness ratio. Extensive sensitivity analyses were performed and different clinical scenarios evaluated. Probabilistic sensitivity analysis was performed to assess robustness of the model.


RESULTS
For a reference-case 65-year-old female patient with CMI and an average risk for operation, EV is preferred with 10.03 QALYs (95% credibility interval [CI], 9.76-10.29) vs 9.59 after OR (95% CI, 9.29-9.87). The difference is comparable to 5 months in perfect health: 0.44 QALY (95% CI, 0.13-0.76). For 65-year-old men, this was 8.71 QALYs (95% CI, 8.48-8.94) for EV vs 8.42 (95% CI, 8.14-8.63) for OR. Sensitivity analysis showed that for younger patients, EV results in a higher increase in QALYs compared with older patients. Total expected reinterventions per patient are 1.70 for EV vs 0.30 for OR. Total expected health care costs for the reference-case patient were $39,942 (95% CI, $28,509-$53,380) for OR and $38.217 (95% CI, $29,329-$48,309) for EV. For men, this was $39,375 (95% CI, $28,092-$52,853) for OR and $35,903 (95% CI, $27,685-$45,597) for EV. For patients younger than 60 years, EV is a more expensive treatment strategy compared with OR, but with an incremental cost-effectiveness ratio for EV of less than $60,000/QALY. For patients 60 years and older, EV dominated OR as preferential treatment because effectiveness was higher than for OR and costs were lower.


CONCLUSIONS
The results of this decision analysis model suggest that EV is favored over OR for patients with CMI in all age groups. Although EV is associated with more expected reinterventions, EV appears to be cost-effective for all age groups.
Section of Vascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn; Section of Vascular Surgery, Department of Surgery, University Medical Center, Utrecht, The Netherlands.
Wouter
W
Hogendoorn
Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Health Policy and Management, Harvard School of Public Health, Boston, Mass.
M G Myriam
MG
Hunink
Section of Vascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn.
Felix J V
FJ
Schlösser
Section of Vascular Surgery, Department of Surgery, University Medical Center, Utrecht, The Netherlands.
Frans L
FL
Moll
Section of Vascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn.
Bart E
BE
Muhs
Section of Vascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn. Electronic address: bauer.sumpio@yale.edu.
Bauer E
BE
Sumpio
D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D057186:Comparative Effectiveness Research; D003198:Computer Simulation; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D057510:Endovascular Procedures / Q000009:adverse effects / Q000191:economics / Q000401:mortality; D005260:Female; D017048:Health Care Costs; D006801:Humans; D007511:Ischemia / Q000175:diagnosis / Q000191:economics / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D008297:Male; D008390:Markov Chains; D065666:Mesenteric Ischemia; D008875:Middle Aged; D018579:Patient Selection; D011237:Predictive Value of Tests; D011788:Quality of Life; D019057:Quality-Adjusted Life Years; D012086:Reoperation; D018570:Risk Assessment; D012307:Risk Factors; D012737:Sex Factors; D013997:Time Factors; D016896:Treatment Outcome; D014652:Vascular Diseases / Q000175:diagnosis / Q000191:economics / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D014654:Vascular Patency; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000191:economics / Q000401:mortality