title: Carotid artery stenosis: cost-effectiveness of assessment of cerebrovascular reserve to guide treatment of asymptomatic patients.
abstract: OBJECTIVE
  To project and compare the lifetime health benefits, health care costs, and incremental cost-effectiveness of a decision rule based on assessment of cerebrovascular reserve (CVR) compared with medical therapy and immediate revascularization in asymptomatic patients with carotid artery stenosis for prevention of stroke.
  
  
  METHODS
  The three strategies compared included immediate revascularization (carotid endarterectomy) and ongoing medical therapy (with antiplatelet, statin, and antihypertensive agents plus lifestyle modification), medical therapy-based treatment with revascularization only for patients who progressed, and use of a CVR-based decision rule for treatment in which patients with CVR impairment undergo immediate revascularization and all others receive medical therapy. A decision analytic model was developed to project lifetime quality-adjusted life years (QALYs) and costs for asymptomatic patients with carotid stenosis with 70%-89% carotid luminal narrowing at presentation. Risks of clinical events, costs, and quality-of-life values were estimated on the basis of those in published sources. The analysis was conducted from a health care system perspective, with health and cost outcomes discounted at 3%. Results Total costs per person and lifetime QALYs were lowest for the medical therapy-based strategy ($14 597, 9.848 QALYs), followed by CVR testing ($16 583, 9.934 QALYs) and immediate revascularization ($20 950, 9.940 QALYs). The incremental cost-effectiveness ratio for the CVR-based strategy compared with the medical therapy-based strategy was $23 000 per QALY and for the immediate revascularization versus the CVR-based strategy was $760 000 per QALY.
  
  
  RESULTS
  were sensitive to variations in model inputs for revascularization costs and complication risks and baseline stroke risk.
  
  
  CONCLUSIONS
  CVR testing can be a cost-effective tool to identify asymptomatic patients with carotid stenosis who are most likely to benefit from revascularization.
authors.affiliation: From the Departments of Healthcare Policy and Research (A.P., B.R.S.), Radiology (A.G., P.C.S.), and Neurology (H.K., B.B.N.), Weill Cornell Medical College, 402 East 67th St, 2nd Floor, LA 241, New York, NY 10065.
authors.forename: Ankur
authors.initials: A
authors.lastname: Pandya
authors.forename: Ajay
authors.initials: A
authors.lastname: Gupta
authors.forename: Hooman
authors.initials: H
authors.lastname: Kamel
authors.forename: Babak B
authors.initials: BB
authors.lastname: Navi
authors.forename: Pina C
authors.initials: PC
authors.lastname: Sanelli
authors.forename: Bruce R
authors.initials: BR
authors.lastname: Schackman
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D058070:Asymptomatic Diseases; D016893:Carotid Stenosis / Q000150:complications / Q000000981:diagnostic imaging / Q000191:economics* / Q000503:physiopathology* / Q000628:therapy; D002560:Cerebrovascular Circulation; D003362:Cost-Benefit Analysis; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D020521:Stroke / Q000191:economics* / Q000209:etiology / Q000517:prevention & control*; D014463:Ultrasonography