title: Cost-effectiveness of CT angiography and perfusion imaging for delayed cerebral ischemia and vasospasm in aneurysmal subarachnoid hemorrhage.
abstract: OBJECTIVE
  Delayed cerebral ischemia and vasospasm are significant complications following SAH leading to cerebral infarction, functional disability, and death. In recent years, CTA and CTP have been used to increase the detection of delayed cerebral ischemia and vasospasm. Our aim was to perform comparative-effectiveness and cost-effectiveness analyses evaluating CTA and CTP for delayed cerebral ischemia and vasospasm in aneurysmal SAH from a health care payer perspective.
  
  
  METHODS
  We developed a decision model comparing CTA and CTP with transcranial Doppler sonography for detection of vasospasm and delayed cerebral ischemia in SAH. The clinical pathways were based on the "Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association" (2012). Outcome health states represented mortality and morbidity according to functional outcomes. Input probabilities of symptoms and serial test results from CTA and CTP, transcranial Doppler ultrasound, and digital subtraction angiography were directly derived from an SAH cohort by using a multinomial logistic regression model. Expected benefits, measured as quality-adjusted life years, and costs, measured in 2012 US dollars, were calculated for each imaging strategy. Univariable, multivariable, and probabilistic sensitivity analyses were performed to determine the independent and combined effect of input parameter uncertainty.
  
  
  RESULTS
  The transcranial Doppler ultrasound strategy yielded 13.62 quality-adjusted life years at a cost of $154,719. The CTA and CTP strategy generated 13.89 quality-adjusted life years at a cost of $147,097, resulting in a gain of 0.27 quality-adjusted life years and cost savings of $7622 over the transcranial Doppler ultrasound strategy. Univariable and multivariable sensitivity analyses indicated that results were robust to plausible input parameter uncertainty. Probabilistic sensitivity analysis results yielded 96.8% of iterations in the right lower quadrant, representing higher benefits and lower costs.
  
  
  CONCLUSIONS
  Our model results suggest that CTA and CTP are the preferred imaging strategy in SAH, compared with transcranial Doppler ultrasound, leading to improved clinical outcomes and lower health care costs.
authors.affiliation: From the Departments of Radiology (P.C.S., A.G., J.I., K.K., D.M.) Public Health (P.C.S., A.P., S.H.-R., A.I.M.) pcs9001@med.cornell.edu.
authors.forename: P C
authors.initials: PC
authors.lastname: Sanelli
authors.affiliation: Public Health (P.C.S., A.P., S.H.-R., A.I.M.).
authors.forename: A
authors.initials: A
authors.lastname: Pandya
authors.affiliation: Neurology (A.Z.S.), Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York.
authors.forename: A Z
authors.initials: AZ
authors.lastname: Segal
authors.affiliation: From the Departments of Radiology (P.C.S., A.G., J.I., K.K., D.M.).
authors.forename: A
authors.initials: A
authors.lastname: Gupta
authors.affiliation: Public Health (P.C.S., A.P., S.H.-R., A.I.M.).
authors.forename: S
authors.initials: S
authors.lastname: Hurtado-Rua
authors.affiliation: From the Departments of Radiology (P.C.S., A.G., J.I., K.K., D.M.).
authors.forename: J
authors.initials: J
authors.lastname: Ivanidze
authors.affiliation: From the Departments of Radiology (P.C.S., A.G., J.I., K.K., D.M.).
authors.forename: K
authors.initials: K
authors.lastname: Kesavabhotla
authors.affiliation: From the Departments of Radiology (P.C.S., A.G., J.I., K.K., D.M.).
authors.forename: D
authors.initials: D
authors.lastname: Mir
authors.affiliation: Public Health (P.C.S., A.P., S.H.-R., A.I.M.).
authors.forename: A I
authors.initials: AI
authors.lastname: Mushlin
authors.affiliation: Departments of Radiology and Epidemiology (M.G.M.H.), Erasmus University Medical Center, Rotterdam, the Netherlands.
authors.forename: M G M
authors.initials: MG
authors.lastname: Hunink
mesh_terms: D015901:Angiography, Digital Subtraction; D002545:Brain Ischemia / Q000175:diagnosis* / Q000209:etiology; D002533:Cerebral Angiography / Q000191:economics* / Q000379:methods; D003362:Cost-Benefit Analysis; D006801:Humans; D016015:Logistic Models; D055420:Perfusion Imaging / Q000191:economics* / Q000379:methods; D013345:Subarachnoid Hemorrhage / Q000150:complications* / Q000175:diagnosis*; D014057:Tomography, X-Ray Computed / Q000191:economics / Q000379:methods; D017585:Ultrasonography, Doppler, Transcranial / Q000191:economics / Q000379:methods; D014481:United States; D020301:Vasospasm, Intracranial / Q000175:diagnosis* / Q000209:etiology