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Routine duplex surveillance does not improve the outcome after carotid endarterectomy: a decision and cost utility
Piet N Post1, Job Kievit, Jary M van Baalen
1Department of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands. P.N.Post@lumc.nl
Insights
Routine duplex surveillance after carotid endarterectomy does not improve quality-adjusted life expectancy and increases costs. A symptom-guided follow-up strategy is recommended for optimal patient care and cost-effectiveness.
Area of Science:
- Vascular Surgery
- Health Economics
- Diagnostic Imaging
Background:
- Carotid endarterectomy is a common procedure to prevent stroke.
- Post-operative surveillance using Doppler ultrasound (duplex) is standard practice to detect recurrent stenosis.
- The optimal frequency and clinical benefit of routine duplex testing remain unclear.
Purpose of the Study:
- To investigate the costs and effects of various follow-up strategies after carotid endarterectomy.
- To determine the optimal post-operative surveillance strategy balancing costs, quality-adjusted life-years (QALYs), and stroke risk.
Main Methods:
- A decision-analytic Monte Carlo Markov model was employed.
- Probabilities and costs were synthesized from a systematic literature review.
- Disease modeling assessed the impact of duplex testing and angiography on restenosis, QALYs, stroke probability, and costs.
Main Results:
- A symptom-guided follow-up strategy yielded an average life expectancy of 6.31 years with costs of $5,600 (US) and €4,600 (Netherlands).
- Routine yearly duplex tests for up to 5 years showed similar QALYs and stroke probability but incurred higher costs.
- No tested surveillance strategy, including routine duplex surveillance or MRI confirmation, improved QALYs.
Conclusions:
- Routine duplex surveillance after carotid endarterectomy does not enhance quality-adjusted life expectancy.
- Routine surveillance increases healthcare costs without providing additional clinical benefits.
- A symptom-guided follow-up approach is considered appropriate and cost-effective after successful carotid endarterectomy.
Background:
Doppler ultrasound (duplex) tests are commonly applied after carotid endarterectomy to detect possible recurrent stenosis. The appropriate frequency and the benefits are unknown. We investigated the costs and effects of various follow-up strategies to determine the optimal strategy after carotid endarterectomy.
Methods:
Using decision-analytic methods, a Monte Carlo Markov model was constructed. Probabilities and costs were obtained by systematic literature review. From empirical data regarding restenosis, a disease model was constructed to test the effect of various follow-up strategies using duplex testing and angiography. Main outcome measures were quality-adjusted life-years (QALYs), probability of stroke, and costs (for both the Dutch and the American situation).
Results:
The average quality-adjusted life expectancy for a 66-year-old patient was 6.31 years for the symptom-guided strategy (with duplex scanning only being performed in case of symptoms of cerebral ischemia). The mean lifetime costs for this strategy were $5 600 for the US and 4 600 Euro for the Netherlands. The cumulative probability of stroke was 13%. Yearly routine duplex tests up to 5 years after operation resulted in similar QALYs and a similar probability of stroke, but higher costs ($7 300 for the US and 5 600 Euro for The Netherlands situation). No other strategy, including routine duplex surveillance, increased QALYs. When MR instead of conventional angiography was used as confirmatory test, no improvement was observed either.
Conclusions:
Routine duplex surveillance does not result in an increase in quality-adjusted life expectancy, but it does increase costs. After successful carotid endarterectomy, a symptom-guided follow-up is an appropriate approach.