大動脈瘤経路への包括的老年医学的評価強化型共有意思決定の導入の費用便益分析

Aortic aneurysm repair is now considered in patients living with frailty or multimorbidity. Identifying patients who will benefit from aneurysm repair can be challenging. Integration of comprehensive geriatric assessment (CGA) enhanced shared decision making (SDM) into preoperative pathways improves patient selection and operative outcomes. The cost effectiveness of improving outcomes for patient proceeding with surgery has been described, however the cost implications, of improving patient selection prior to surgery are not yet known. This study models the marginal cost impact per patient, of implementing universal CGA enhanced SDM, into the standard pre-operative pathway at a UK based vascular surgery referral centre.

A decision-based model was developed to describe the net cost difference per referral into a vascular surgical centre between patients undergoing CGA enhanced preoperative assessment with SDM versus standard preoperative clinical care. Two scenarios were modelled utilising a mixture of local and national case-mix and cost data. Sensitivity and breakeven analysis were performed for each scenario.

The costs of conducting CGA for referrals to an aortic aneurysm surgical pathway are offset by the savings from a higher rate of non-operative management. The cost-benefit (and sensitivity analysis) in each scenario was estimated at £821 (£677-958) and £907 (£739-1076) per referral. Breakeven analysis demonstrated that a 2.9% to 3.1% absolute reduction in patients proceeding with surgical management offset the cost of intervention.

This study demonstrates that routine provision of CGA enhanced SDM in an aortic aneurysm pathway reduces total departmental costs.