Stroke: carotid endarterectomy and warfarin were cost-effective.

Clinical bottom line (level 1b)

  1. In patients with stroke, carotid endarterectomy was cost-effective compared with aspirin.
  2. In patients with stroke, anticoagulation with warfarin in atrial fibrillation was more cost-effective in patients at high or medium risk than aspirin.
  3. In patients with stroke, screening and imaging strategies for mild carotid stenosis may be cost-effective.
Holloway et al: Stroke 1999; 30: 1340-1349
Expires January 2003

The study

Systematic review of comparative analyses of
  • Patients: stroke
  • Intervention: preventative, diagnostic and therapeutic interventions
  • Outcome: costs and effects


    • Articles found in unspecified languages using MEDLINE, HealthSTAR, EMBASE and SCI-EXPANDED, ? (search terms: detailed in appendix ) and cited references were searched for first authors, to identify other articles. Bibliographies of relevant studies were searched.

    Selection criteria: as above
    Appraisal criteria: detailed in text
    Articles excluded if: health effect not described as quality-adjusted life-years, not two competing strategies compared and primary prevention strategies of antihypertensive treatment or cholesterol management (as they have been studied before).

    26 studies were included.
    The results of the individual studies were heterogeneous.

    The evidence

    • Cost-effectiveness of carotid endarterectomy in symptomatic patients in one trial (versus aspirin) was $4715 cost/QALY, but in another (versus no work-up) was $46746.
    • Cost-effectiveness of carotid endarterectomy in asymptomatic patients in one trial (versus aspirin) was $8484 cost/QALY, and in another was $60605. Neither included the cost of screening.
    • Cost-effectiveness of anticoagulation in atrial fibrillation and other ischaemic stroke interventions (warfarin versus aspirin) was $9200 cost/QALY in medium risk patients and $425500 in low risk. Warfarin dominated (more effective and costs less) in high risk patients.
    • Cost-effectiveness of screening and imaging strategies for carotid stenosis (one-time screening in asymptomatic 4-5% stenosis) was $41864, $57847 and $138000 cost/QALY, in each of 3 studies.

    Comments

    1. Costs were adjusted to 1998 US $
    2. The results of the studies were not combined, so this was not really a meta-analysis.

    Citation

    1. Holloway RG, Benesch CG, Rahilly CR: A systematic review of cost-effectiveness research of stroke evaluation and treatment. Stroke 1999; 30: 1340-1349
    Contributor: Clare Wotton & Lee Bailey, January 2000
    Reviewer: Rowan Harwood

    Clinical Question.
    Patient stroke
    Intervention or Exposure preventative, diagnostic and therapeutic interventions
    Outcome cost-effectiveness