Cost-effectiveness of conventional and endovascular repair of abdominal aortic aneurysms: Results of a randomized trial
Received 18 January 2007; accepted 23 July 2007.
Background
Two randomized trials have shown similar mid-term outcomes for survival and quality of life after endovascular and conventional open repair of abdominal aortic aneurysms (AAA). With reduced hospital and intensive care stay, endovascular repair has been hypothesized to be more efficient than open repair. The Dutch Randomized Endovascular Aneurysm Management (DREAM) trial was undertaken to assess the balance of costs and effects of endovascular vs open aneurysm repair.
Methods
We conducted a multicenter, randomized trial comparing endovascular repair with open repair in 351 patients with an AAA and studied costs, cost-effectiveness, and clinical outcome 1 year after surgery. In addition to clinical outcome, costs and quality of life were recorded up to 1 year in 170 patients in the endovascular repair group and in 170 in the open repair group. Incremental cost-effectiveness ratios were estimated for cost per life-year, event-free life-year, and quality adjusted life-year (QALY) gained. Uncertainty regarding these outcomes was assessed using bootstrapping.
Results
Patients in the endovascular repair group experienced 0.72 QALY vs 0.73 in the open repair group (absolute difference, 0.01; 95% confidence interval [CI], −0.038 to 0.058). Endovascular repair was associated with additional €4293 direct costs (€18,179 vs €13.886; 95% CI, €2,770 to €5,830). Most of the bootstrap estimates indicated that endovascular repair resulted in slightly longer overall and event-free survival associated with respective incremental cost-effectiveness ratios of €76,100 and €171,500 per year gained. Open repair appeared the dominant strategy in costs per QALY.
Conclusion
Presently, routine use of endovascular repair in patients also eligible for open repair does not result in a QALY gain at 1 year postoperatively, provides only a marginal overall survival benefit, and is associated with a substantial, if not prohibitive, increase in costs.
aDivision of Vascular Surgery, Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
bJulius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands and Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
cDepartment of Vascular Surgery, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
dDepartment of Surgery, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
eDepartment of Surgery, Meander Medical Center, Amersfoort, The Netherlands
fDivision of Vascular Surgery, Department of Surgery, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands.
Reprint requests: Erik Buskens, MD, PhD, Department of Epidemiology, University Medical Center Groningen, University of Groningen, PO Box 30,001, 9700 RB Groningen, The Netherlands.
Additional material for this article may be found online at www.jvascsurg.org.
ABSTRACT