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Abdominal Aortic Aneurysms: Cost-effectiveness of Elective Endovascular and Open Surgical Repair¹

¹ From the Departments of Radiology (J.L.B., J.A.K., M.T.B., M.E.A.P.M.A., G.S.G.) and Vascular Surgery (D.C.B.), Massachusetts General Hospital, Harvard Medical School, Zero Emerson Pl, Suite 2H, Boston, MA 02114; Department of Health Policy and Management, Harvard School of Public Health, Boston, Mass (G.S.G.); Department of Epidemiology and Biostatistics, Erasmus University Medical Center, Rotterdam, the Netherlands (J.L.B., M.E.A.P.M.A.); and Dotter Interventional Institute, Portland, Ore (J.A.K.). Received October 15, 2001; revision requested December 26; revision received January 29, 2002; accepted April 2. Supported in part by the U.S. Department of the Army under DAMD 17-99-2-9001. Address correspondence to J.L.B. (e-mail: johanna@the-data-group.org).

PURPOSE: To evaluate the cost-effectiveness of elective endovascular and open surgical repair of infrarenal abdominal aortic aneurysms (AAAs) by taking into account short- and long-term outcomes.

MATERIALS AND METHODS: A Markov decision model was developed to evaluate quality-adjusted life-years (QALYs) and lifetime costs of endovascular and open surgical repair. The incremental cost-effectiveness ratio (CER) was calculated for endovascular repair relative to open surgery in a cohort of 70-year-old men with an AAA between 5 and 6 cm in diameter. Clinically effectiveness data were derived from the literature. Cost data were derived from Medicare reimbursement rates, the hospital database, and the literature. One- and multiple-way sensitivity analyses were performed on uncertain model parameters. Costs were converted to year 2000 U.S. dollars; future costs and outcomes were discounted at 3%.

RESULTS: The incremental CER of endovascular repair was $9,905 per QALY. QALYs and lifetime costs were higher for endovascular repair than for open surgery (6.74 vs 6.52 and $39,785 vs $37,606, respectively). In sensitivity analyses, the incremental CER was insensitive to immediate conversion rate and procedure mortality rate. The incremental CER was sensitive (ie, more than $75,000 per QALY or endovascular repair was ruled out by dominance) to systemic-remote complications, long-term failures, and ruptures.

CONCLUSION: The results suggest that endovascular repair is a cost-effective alternative compared with open surgery for the elective repair of AAA. The benefits and cost-effectiveness are highly dependent on uncertain outcomes, however, particularly long-term failure and rupture rates.

Index terms: Aneurysm, abdominal, 981.73 • Aorta, grafts and prostheses, 981.1286 • Aorta, interventional procedures, 981.1286 • Cost-effectiveness • Economics, medical

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