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Surgical revascularization for Moyamoya disease in the United States: A cost-effectiveness analysis
Arvin R Wali1, David R Santiago-Dieppa1, Shanmukha Srinivas1
1Department of Neurological Surgery, University of California, San Diego, CA, USA.
Objective:
Moyamoya disease (MMD) is a vasculopathy of the internal carotid arteries with ischemic and hemorrhagic sequelae. Surgical revascularization confers upfront peri-procedural risk and costs in exchange for long-term protective benefit against hemorrhagic disease. The authors present a cost-effectiveness analysis (CEA) of surgical versus non-surgical management of MMD.
Methods:
A Markov Model was used to simulate a 41-year-old suffering a transient ischemic attack (TIA) secondary to MMD and now faced with operative versus nonoperative treatment options. Health utilities, costs, and outcome probabilities were obtained from the CEA registry and the published literature. The primary outcome was incremental cost-effectiveness ratio which compared the quality adjusted life years (QALYs) and costs of surgical and nonsurgical treatments. Base-case, one-way sensitivity, two-way sensitivity, and probabilistic sensitivity analyses were performed with a willingness to pay threshold of $50,000.
Results:
The base case model yielded 3.81 QALYs with a cost of $99,500 for surgery, and 3.76 QALYs with a cost of $106,500 for nonsurgical management. One-way sensitivity analysis demonstrated the greatest sensitivity in assumptions to cost of surgery and cost of admission for hemorrhagic stroke, and probabilities of stroke with no surgery, stroke after surgery, poor surgical outcome, and death after surgery. Probabilistic sensitivity analyses demonstrated that surgical revascularization was the cost-effective strategy in over 87.4% of simulations.
Conclusions:
Considering both direct and indirect costs and the postoperative QALY, surgery is considerably more cost-effective than non-surgical management for adults with MMD.
Insights
Surgical revascularization for Moyamoya disease (MMD) is more cost-effective than non-surgical management, offering better long-term outcomes and quality-adjusted life years (QALYs) despite upfront costs.
Area of Science:
- Neurology
- Neurosurgery
- Health Economics
Background:
- Moyamoya disease (MMD) is a progressive cerebrovascular disorder affecting internal carotid arteries, leading to ischemic or hemorrhagic events.
- Surgical revascularization offers long-term protection against hemorrhagic complications but involves initial risks and costs.
Purpose of the Study:
- To conduct a cost-effectiveness analysis (CEA) comparing surgical revascularization with non-surgical management for Moyamoya disease.
- To evaluate the long-term value of surgical intervention in adult MMD patients.
Main Methods:
- A Markov model simulated treatment strategies for a 41-year-old MMD patient experiencing a transient ischemic attack (TIA).
- Data on health utilities, costs, and outcome probabilities were sourced from the CEA registry and published literature.
- Analyses included base-case, sensitivity analyses, and probabilistic simulations with a $50,000 willingness-to-pay threshold.
Main Results:
- Surgery yielded 3.81 QALYs at $99,500, while non-surgical management resulted in 3.76 QALYs at $106,500.
- Sensitivity analyses identified surgery costs and hemorrhagic stroke admission costs as key variables.
- Probabilistic analyses indicated surgical revascularization as the cost-effective option in over 87.4% of simulations.
Conclusions:
- Surgical revascularization is a more cost-effective strategy for managing Moyamoya disease in adults.
- The analysis considered both direct and indirect costs, alongside postoperative quality-adjusted life years (QALYs).
- This study supports surgical intervention for improved long-term patient outcomes and economic value in MMD management.
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