[Show abstract][Hide abstract] ABSTRACT: Background. This paper presents unpublished clinical and economic data associated with open surgical repair (OSR) in low risk (LR) patients and how it compares with EVAR and OSR in high risk (HR) patients with an AAA > 5.5 cm. Design. Data from a 1-year prospective observational study was used to compare EVAR in HR patients versus OSR in HR and LR patients. Results. Between 2003 and 2005, 140 patients were treated with EVAR and 195 with OSR (HR: 52; LR: 143). The 1-year mortality rate with EVAR was statistically lower than HR OSR patients and comparable to LR OSR patients. One-year health-related quality of life was lower in the EVAR patients compared to OSR patients. EVAR was cost-effective compared to OSR HR but not when compared to OSR LR patients. Conclusions. Despite a similar clinical effectiveness, these results suggest that, at the current price, EVAR is more expensive than open repair for low risk patients.
International journal of vascular medicine 01/2011; 2011:308685.
Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 02/2009; 49(1):277-8. · 3.52 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Abdominal aortic aneurysm (AAA) is a prevalent health condition affecting up to 14% of men and 6% of women. The objective of this study was to estimate the cost-effectiveness and cost-utility of elective endovascular aneurysm repair (EVAR) compared with open surgical repair (OSR) in patients at a high risk of surgical complications.
Patient-level cost and outcome data from a 1-year prospective observational study conducted at London Health Sciences Centre, London, Ontario, Canada, was used to determine the incremental cost per life-year gained and the incremental cost per quality-adjusted life year (QALY) gained of EVAR compared with OSR in patients with an AAA >5.5 cm and a high risk of surgical complications. The analysis was taken from a societal perspective and the time horizon was 1 year. To measure sampling uncertainty on costs and effects, nonparametric bootstrap techniques were applied. Uncertainty results were expressed using cost-effectiveness acceptability curves. Extrapolations of the 1-year results to a 5-year time horizon were conducted in sensitivity analyses.
Between August 11, 2003, and April 3, 2005, 192 patients at a high risk of surgical complications were enrolled: 140 received EVAR and 52 OSR. Point estimates during a 1-year period showed that EVAR dominated OSR for high-risk patients in terms of incremental cost per life-year gained and incremental cost per QALYs. However, bootstrap estimates for the two cost-effectiveness measures indicated there was a great deal of uncertainty regarding the costs and the QALYs and less uncertainty regarding life-years gained. If society was willing to pay $50,000 per life-year gained or per QALY gained, the probability of EVAR being cost-effective was found to be 0.76 and 0.55, respectively. Five-year extrapolations indicated that EVAR was cost-effective compared with OSR.
According to this 1-year observational study, EVAR may be a cost-effective strategy compared with OSR for high-risk patients. Longer-term data are needed to decrease the uncertainty associated with the results.
Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 10/2008; 48(4):779-87. · 3.52 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The primary risk of abdominal aortic aneurysms (AAAs) is rupture, which is associated with a high mortality rate. Elective surgical options for AAA include open repair (OR) and endovascular aneurysm repair (EVAR). EVAR is less invasive than OR, and therefore may have less surgical risk than OR. However, the graft used for EVAR is much more expensive then the graft used for OR.
A decision model with a 10-year time horizon was used to assess the cost-effectiveness of EVAR versus OR. The primary outcome measure was quality-adjusted life-years (QALYs). The model incorporated the costs and benefits of both perioperative outcomes and postoperative outcomes. A systematic review was conducted to derive clinical outcome rates. Cost and utility model variables were based on various literature sources and data from a recent Canadian observational study. Parameter uncertainty was assessed using probabilistic sensitivity analysis.
In the base-case model, the incremental cost per QALY of EVAR was estimated to be $268,337, whereas the incremental cost per life-year was found to be $444,129. The incremental cost per QALY of EVAR remained above $295,715 under different assumptions of cohort age and model time horizon.
Based on commonly quoted willingness-to-pay thresholds, EVAR was not found to be cost-effective compared to OR.
Value in Health 10/2008; 12(2):245-52. · 2.19 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To investigate if study design factors such as randomization, multi-center versus single center evidence, institutional surgical volume, and patient selection affect the outcomes for endovascular repair (EVAR) versus open surgical repair (OSR). Finally, we investigate trends over time in EVAR versus OSR outcomes.
Search strategies for comparative studies were performed individually for: OVID's MEDLINE, EMBASE, CINAHL, HAPI, and Evidence Based Medicine (EBM) Reviews (including Cochrane DSR, ACP Journal Club, DARE and CCTR), limited to 1990 and November 2006.
Identified literature: 84 comparative studies pertaining to 57,645 patients. These include 4 randomized controlled trials (RCTs), plus 2 RCTs with long-term follow-up. The other 78 comparative studies were nonrandomized with 75 reporting perioperative outcomes, of which 16 were multi-center, and 59 single-center studies. Of the single-center studies 31 were low-volume and 28 were high-volume centers. In addition, 5 studies had all patients anatomically eligible for EVAR, and 8 studies included high-risk patients only. Finally, 25 long term observational studies reported outcomes up to 3 years.
Lower perioperative mortality and rates of complications for EVAR versus OSR varied across study designs and patient populations. EVAR adverse outcomes have decreased in recent times.
EVAR highlights the problem of performing meta-analysis when the experience evolves over time.
Vascular Health and Risk Management 02/2008; 4(5):1011-22.