title: Cost-Effectiveness of Carotid Plaque MR Imaging as a Stroke Risk Stratification Tool in Asymptomatic Carotid Artery Stenosis.
abstract: OBJECTIVE
  To evaluate the cost-effectiveness of a decision-making rule based on the magnetic resonance (MR) imaging assessment of intraplaque hemorrhage (IPH) in patients with asymptomatic carotid artery stenosis.
  
  
  METHODS
  Two competing stroke prevention strategies were compared: (a) an intensive medical therapy-based management strategy versus (b) an imaging-based strategy in which the subset of patients with asymptomatic carotid artery stenosis with IPH on MR images would undergo immediate carotid endarterectomy in addition to ongoing intensive medical therapy. Patients in the medical therapy-only group could undergo carotid endarterectomy only with substantial carotid artery stenosis disease progression. Lifetime quality-adjusted life years (QALYs) and costs were modeled for patients with asymptomatic carotid artery stenosis with 70%-89% and 50%-69% carotid artery stenosis at presentation. Risks of stroke and complications from carotid endarterectomy, costs, and quality of life values were estimated from published sources.
  
  
  RESULTS
  The medical therapy-based strategy had a lower life expectancy (12.65 years vs 12.95 years), lower lifetime QALYs (9.96 years vs 10.05 years), and lower lifetime costs ($13 699 vs $15 297) when compared with the MR imaging IPH-based strategy. The incremental cost-effectiveness ratio (ICER) for the MR imaging IPH strategy compared with the medical therapy-based strategy was $16 000 per QALY by using a base-case 70-year-old patient. When using starting patient ages of 60 and 80 years, the ICERs for the MR imaging IPH strategy were $3100 per QALY and $73 000 per QALY, respectively. The ICERs for the MR imaging IPH strategy were slightly higher at all ages for 50%-69% stenosis but remained below a willingness-to-pay threshold of $100 000 per QALY for starting ages of 60 and 70 years.
  
  
  CONCLUSIONS
  MR imaging IPH can be used as a cost-effective tool to identify patients with asymptomatic carotid artery stenosis most likely to benefit from carotid endarterectomy.
authors.affiliation: From the Departments of Radiology (A.G.), Neurology (H.K., B.B.N.), and Healthcare Policy and Research (A.I.M., A.P.), Weill Cornell Medical College, 1300 York Ave, New York, NY 10065.
authors.forename: Ajay
authors.initials: A
authors.lastname: Gupta
authors.affiliation: From the Departments of Radiology (A.G.), Neurology (H.K., B.B.N.), and Healthcare Policy and Research (A.I.M., A.P.), Weill Cornell Medical College, 1300 York Ave, New York, NY 10065.
authors.forename: Alvin I
authors.initials: AI
authors.lastname: Mushlin
authors.affiliation: From the Departments of Radiology (A.G.), Neurology (H.K., B.B.N.), and Healthcare Policy and Research (A.I.M., A.P.), Weill Cornell Medical College, 1300 York Ave, New York, NY 10065.
authors.forename: Hooman
authors.initials: H
authors.lastname: Kamel
authors.affiliation: From the Departments of Radiology (A.G.), Neurology (H.K., B.B.N.), and Healthcare Policy and Research (A.I.M., A.P.), Weill Cornell Medical College, 1300 York Ave, New York, NY 10065.
authors.forename: Babak B
authors.initials: BB
authors.lastname: Navi
authors.affiliation: From the Departments of Radiology (A.G.), Neurology (H.K., B.B.N.), and Healthcare Policy and Research (A.I.M., A.P.), Weill Cornell Medical College, 1300 York Ave, New York, NY 10065.
authors.forename: Ankur
authors.initials: A
authors.lastname: Pandya
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D016893:Carotid Stenosis / Q000175:diagnosis* / Q000628:therapy; D003362:Cost-Benefit Analysis; D003657:Decision Making; D018450:Disease Progression; D016894:Endarterectomy, Carotid; D006801:Humans; D008017:Life Expectancy; D008279:Magnetic Resonance Imaging / Q000191:economics; D008875:Middle Aged; D008962:Models, Theoretical; D011788:Quality of Life; D018570:Risk Assessment; D020521:Stroke / Q000209:etiology