Renal artery stenosis: cost-effectiveness of diagnosis and treatment

To use a decision analytic model to determine the cost-effectiveness of performing diagnostic digital subtraction angiography (DSA), computed tomographic (CT) angiography, or magnetic resonance (MR) angiography or proceeding immediately to tentative percutaneous revascularization in patients suspected of having renovascular hypertension.

With use of a Markov-Monte Carlo decision model, cost-effectiveness analysis was performed from a societal perspective. Data were derived from the Renal Artery Diagnostic Imaging Study in Hypertension and from published literature. The base-case analyses were used to evaluate a 50-year-old patient with a diastolic blood pressure higher than 95 mm Hg and one or more clinical clues suggestive of renovascular hypertension. Outcome measures were quality-adjusted life-year (QALY), lifetime costs, and incremental cost-effectiveness.

For a 50-year-old male patient, immediate tentative revascularization was the least costly (euro54 415) and most effective (12.265 QALYs) strategy. For the other strategies, costs and QALYs, respectively, were euro55 570 and 12.195 for DSA, euro55 191 and 12.163 for CT angiography, and euro56 890 and 12.088 for MR angiography. For a 50-year-old female patient, costs and QALYs, respectively, were euro66 731 and 13.731 for MR angiography, euro63 970 and 13.749 for CT angiography, and euro63 079 and 13.902 for DSA. Immediate tentative revascularization yielded more QALYs (13.937) and was more costly (euro63 329) than DSA. The incremental cost-effectiveness ratio was euro7143 per QALY. As the prior probability increased, use of a more invasive diagnostic imaging strategy became justified. Also, the sensitivities of CT angiography and MR angiography and the costs of DSA influenced the results.

Given currently accepted incremental cost-effectiveness ratios, immediate tentative percutaneous revascularization is a cost-effective strategy for the diagnosis of renal artery stenosis. Management decisions should be conditional on the prior probability.