title: Cost-utility analysis of stenting versus endarterectomy in the International Carotid Stenting Study.
abstract: The International Carotid Stenting Study was a multicenter randomized trial in which patients with symptomatic carotid artery stenosis were randomly allocated to treatment by carotid stenting or endarterectomy. Economic evidence comparing these treatments is limited and inconsistent.
  
  
  
  We compared the cost-effectiveness of stenting versus endarterectomy using International Carotid Stenting Study data.
  
  
  
  We performed a cost-utility analysis estimating mean costs and quality-adjusted life years per patient for both treatments over a five-year time horizon based on resource use data and utility values collected in the trial. Costs of managing stroke events were estimated using individual patient data from a UK population-based study (Oxford Vascular Study).
  
  
  
  Mean costs per patient (95% CI) were US$10,477 ($9669 to $11,285) in the stenting group (N = 853) and $9669 ($8835 to $10,504) in the endarterectomy group (N = 857). There were no differences in mean quality-adjusted life years per patient (3.247 (3.160 to 3.333) and 3.228 (3.150 to 3.306), respectively). There were no differences in adjusted costs between groups (mean incremental costs for stenting versus endarterectomy $736 (95% CI -$353 to $1826)) or adjusted outcomes (mean quality-adjusted life years gained -0.010 (95% CI -0.117 to 0.097)). The incremental net monetary benefit for stenting versus endarterectomy was not significantly different from zero at the maximum willingness to pay for a quality-adjusted life year commonly used in the UK. Sensitivity analyses showed little uncertainty in these findings.
  
  
  
  Economic considerations should not affect whether patients with symptomatic carotid stenosis undergo stenting or endarterectomy.
authors.affiliation: Department of Applied Health Research, University College London, London, UK steve.morris@ucl.ac.uk.
authors.forename: Stephen
authors.initials: S
authors.lastname: Morris
authors.affiliation: Department of Applied Health Research, University College London, London, UK.
authors.forename: Nishma V
authors.initials: NV
authors.lastname: Patel
authors.affiliation: Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK.
authors.forename: Joanna
authors.initials: J
authors.lastname: Dobson
authors.affiliation: Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, UK.
authors.forename: Roland L
authors.initials: RL
authors.lastname: Featherstone
authors.affiliation: Division of Surgery and Interventional Science, University College London, London, UK.
authors.forename: Toby
authors.initials: T
authors.lastname: Richards
authors.affiliation: Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.
authors.forename: Ramon
authors.initials: R
authors.lastname: Luengo-Fernandez
authors.affiliation: Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.
authors.forename: Peter M
authors.initials: PM
authors.lastname: Rothwell
authors.affiliation: Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, UK.
authors.forename: Martin M
authors.initials: MM
authors.lastname: Brown
mesh_terms: D000368:Aged; D016893:Carotid Stenosis / Q000191:economics* / Q000601:surgery*; D003362:Cost-Benefit Analysis; D016894:Endarterectomy, Carotid / Q000191:economics*; D005260:Female; D005500:Follow-Up Studies; D017048:Health Care Costs; D006801:Humans; D008297:Male; D019057:Quality-Adjusted Life Years; D012306:Risk; D015607:Stents / Q000191:economics*; D020521:Stroke / Q000453:epidemiology; D013997:Time Factors; D016896:Treatment Outcome; D006113:United Kingdom
keywords: Cost factors; carotid endarterectomy; carotid stenosis; carotid stenting; clinical trial; economics