Cost-effectiveness analysis of intracranial stent placement versus contemporary medical management in patients with symptomatic intracranial artery stenosis.

backgroundIntracranial angioplasty and stent placement has been increasingly evaluated as a new method for treatment of symptomatic intracranial stenosis in select patients. The Food and Drug Administration (FDA) has approved intracranial stent treatment of symptomatic atherosclerotic intracranial lesions. PURPOSE: To determine the cost-effectiveness of intracranial artery stent placement compared with contemporary medical management for secondary stroke prevention among patients with symptomatic intracranial stenosis.

methodsClinical outcome data were obtained from the aspirin treatment arm of the Comparison of Warfarin and Aspirin for Symptomatic Intracranial Disease (WASID) trial (n = 280) and 12 case series (n = 216) of patients who underwent stent placement of symptomatic intracranial stenosis with comparable characteristics. Total cost of procedure and medical management-only was calculated using the rates of major stroke, minor stroke, or death in each group. All costs are expressed in 2010 US$. The quality-adjusted life-year (QALY) of each intervention strategy was estimated using the frequency of the outcomes of major and minor stroke, death, and baseline health. An incremental cost-effectiveness ratio (ICER) was formulated for a 1-year period.

resultsThe total rate of stroke at one year was 10.2% (6.1-14.2%) and the rate of all-cause mortality was 3.7% (1.2-6.2%) in the stent group. The corresponding annualized rates of stroke and all-cause mortality in the medical management-only group were 15% (10.8-19.2%) and 2.4% (0.6-4.2%), respectively. The calculated net costs at one year for intracranial stent placement and contemporary medical management were US$16,898 and US$3,468, respectively. Overall, QALYs for the two groups were 0.82 and 0.81 (in a range of 0 to 0.89 corresponding to death and baseline health), respectively. The cost per QALY gained after intracranial stent placement and contemporary medical therapy was US$20,542 and US$4,265, respectively. The corresponding ICER for stent versus medical treatment alone was US$1,416,268.

conclusionThe reduced risk of stroke following intracranial stent placement is offset by significantly higher procedure-associated net costs. Select procedures in patients with symptomatic stenosis of 70% or greater are more likely to be cost-effective.