Cost-Effectiveness of Patent Foramen Ovale Closure Versus Medical Therapy for Secondary Stroke Prevention
Cost-Effectiveness of Patent Foramen Ovale Closure Versus Medical Therapy for Secondary Stroke Prevention
复制标题
DOI：
10.1161/strokeaha.117.020322
复制
发表时间：
2018-06-01
期刊：
影响因子：
8.3
通讯作者：
Campbell, Jonathan D.
中科院分区：
文献类型：
--
作者：
Leppert, Michelle H.;Poisson, Sharon N.;Campbell, Jonathan D.
背景与目的经皮卵圆孔未闭封堵术(PFO闭合)加抗血小板治疗已被证实，与单纯药物治疗相比，在精心挑选的疑似矛盾栓塞性卒中后的隐源性卒中患者中，经皮闭合(PFO)加抗血小板治疗可降低卒中复发的风险。我们的目标是从美国医疗保健支付者的角度确定闭合PFO与保守医疗管理的成本-效果。方法决策分析马尔可夫模型估计与单纯医疗治疗相比闭合PFO的15年成本和结果。模型输入来自已发表的文献、国家数据库和对5个已发表的关于PFO闭合的随机临床试验的荟萃分析。健康结果以质量调整寿命年(QALY)衡量。成本效益使用的是每QALY获得的增量成本，而净货币收益假设支付意愿为150000美元/QALY。结果15年后，与单纯药物治疗相比，闭合治疗可使QALY提高0.33%，节省费用3,568美元，净货币收益增加52761美元(95%区间-8,284美元至158910美元)。当卒中的Meta分析风险比增加到95%区间的上限0.77时，单向敏感性分析表明，每增加一个QALY，关闭PFO的成本-效果是458558美元。概率敏感度分析显示90%的模拟运行具有成本效益。结论在正确的设置下闭合隐源性卒中的PFO具有成本效益，可带来QALY收益和潜在的成本节约。然而，患者选择仍然至关重要，因为治疗效果的边际下降会极大地影响成本效益。
Background and Purpose Percutaneous transcatheter closure of patent foramen ovale (PFO closure) plus antiplatelet therapy has been shown to reduce the risk of recurrent stroke compared with medical therapy alone in carefully selected patients after cryptogenic stroke presumed to be from paradoxical embolism. Our objective was to determine the cost-effectiveness of PFO closure after cryptogenic stroke compared with conservative medical management from a US healthcare payer perspective.Methods A decision analytic Markov model estimated the 15-year cost and outcomes associated with the additional benefit of PFO closure compared with medical management alone. Model inputs were obtained from published literature, national databases, and a meta-analysis of 5 published randomized clinical trials on PFO closure. Health outcomes were measured in quality-adjusted life years (QALY). Cost-effectiveness used the incremental cost per QALY gained, whereas the net monetary benefit assumed a willingness to pay of $150000/QALY. One-way and probabilistic sensitivity analyses estimated the uncertainty of model results.Results At 15 years, PFO closure compared with medical therapy alone improved QALY by 0.33 at a cost saving of $3568, representing an incremental net monetary benefit of $52761 (95% interval -$8284 to $158910). When the meta-analysis hazard ratio for stroke was increased to the 95% interval's upper bound of 0.77, one-way sensitivity analyses suggested that PFO closure's cost-effectiveness was $458558 per additional QALY. Probabilistic sensitivity analysis suggested cost-effectiveness in 90% of simulation runs.Conclusions PFO closure for cryptogenic strokes in the right setting is cost-effective, producing benefit in QALYs gained and potential cost savings. However, patient selection remains vitally important as marginal declines in treatment effectiveness can dramatically affect cost-effectiveness.