title: Cost-effectiveness analysis of CTA and LP for evaluation of suspected SAH after negative non-contrast CT.
abstract: OBJECTIVE
  Diagnostic workup of patients presenting with thunderclap headache and negative initial head CT remains a challenge, with most commonly employed strategies being lumbar puncture (LP) and CT angiography (CTA). The objective of this study was to determine the cost-effectiveness of these options.
  
  
  METHODS
  A decision model was designed using clinical probabilities, costs, and utilities from published values in the literature. Base case analysis and Monte Carlo simulation were performed using the model to determine the cost-effectiveness of both options.
  
  
  RESULTS
  CTA was associated with an expected cost of $747 and an expected utility of 0.798603029. In comparison, LP was associated with a cost of $504 and an expected utility of 0.799259526, making it the optimal strategy from both the cost and the utility perspectives. LP was also the more cost-effective strategy in all iterations in the Monte Carlo simulation. A sensitivity analysis showed that with the 2014 US Medicare reimbursement values, LP would remain the more cost-effective strategy unless its cost exceeded 4 times its current value.
  
  
  CONCLUSIONS
  LP should remain the preferred strategy for evaluation of SAH in patients presenting with thunderclap headache and negative non-contrast head CT. CTA is not an effective replacement, from either a utility or cost perspective.
authors.affiliation: Department of Diagnostic Radiology, Yale School of Medicine, United States. Electronic address: xiao.wu@yale.edu.
authors.forename: Xiao
authors.initials: X
authors.lastname: Wu
authors.affiliation: Department of Diagnostic Radiology, Yale School of Medicine, United States. Electronic address: vivekkalramd@gmail.com.
authors.forename: Vivek B
authors.initials: VB
authors.lastname: Kalra
authors.affiliation: Department of Diagnostic Radiology, Yale School of Medicine, United States. Electronic address: howard.forman@yale.edu.
authors.forename: Howard P
authors.initials: HP
authors.lastname: Forman
authors.affiliation: Department of Diagnostic Radiology, Yale School of Medicine, United States. Electronic address: ajay.malhotra@yale.edu.
authors.forename: Ajay
authors.initials: A
authors.lastname: Malhotra
mesh_terms: D002533:Cerebral Angiography / Q000191:economics*; D000072226:Computed Tomography Angiography / Q000191:economics*; D003287:Contrast Media / Q000627:therapeutic use; D003362:Cost-Benefit Analysis; D004636:Emergency Service, Hospital / Q000191:economics*; D051270:Headache Disorders, Primary / Q000601:surgery; D006801:Humans; D013129:Spinal Puncture / Q000191:economics*; D013345:Subarachnoid Hemorrhage
chemical_list: D003287:Contrast Media
keywords: CT angiography; Cost-effectiveness analysis; Lumbar puncture; Subarachnoid hemorrhage; Thunderclap headache