Risk-based selection for carotid revascularisation using the IMPROVE score versus standard care in symptomatic...

Area of Science:

• Neurology
• Health Economics
• Clinical Decision Support

Background:

• A validated clinical prediction model, IMPROVE, exists for ipsilateral ischaemic stroke risk in symptomatic carotid disease patients.
• Current care-as-usual (CAU) involves optimal medical treatment (OMT) alone or with carotid endarterectomy (CEA).

Purpose of the Study:

• To evaluate the cost-effectiveness of using the IMPROVE model for triage compared to CAU.
• To determine optimal triage thresholds for carotid endarterectomy based on IMPROVE risk scores.

Main Methods:

• A decision-analytic model was developed using data from 678 patients with carotid disease and recent ischaemic events.
• Patients were stratified based on carotid stenosis percentage and 3-year stroke risk thresholds (IMPROVE vs. CAU).
• Monte Carlo simulations were used for probabilistic analyses over 3-year and lifetime horizons.

Main Results:

• IMPROVE-based triage reduced ipsilateral ischaemic strokes and perioperative events by 34.5% over 3 years (2.8% vs. 4.3%).
• Revascularization rates decreased by 20%, with a slight increase in Quality-Adjusted Life Years.
• Societal costs were reduced by €1441/patient (3-year) and €6101/patient (lifetime) with IMPROVE triage.

Conclusions:

• Triage using the IMPROVE model significantly prevents strokes and perioperative events in symptomatic carotid disease patients.
• IMPROVE-based triage is a cost-effective strategy, reducing both adverse events and healthcare expenditures.
• Clinical trials are recommended to validate these findings.