Is coiling really more costly than clipping in patients with ruptured intracraneal aneurysm?

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Abstract

BACKGROUND

Current analyses of the cost-effectiveness of endovascular coiling versus surgical clipping in patients with ruptured aneurysmal subarachnoid hemorrhage (SAH) are based on limited cost information from retrospective or small prospective studies.

OBJECTIVE

To compare treatment pathways, resource utilization and costs associated with endovascular coiling and surgical clipping in patients with ruptured aneurysmal SAH.

DESIGN AND INTERVENTION

The current analysis used data from UK patients who participated in the International Su barachnoid Aneurysm Trial (ISAT), a prospective study in which patients with ruptured intracranial aneurysms were randomly assigned to undergo neurosurgical clipping, or endovascular treatment by use of detachable platinum coils. The final sample included 835 patients in the neurosurgery group and 809 patients in the endovascular-treatment group. The investigators collected information on treatment pathways, resource use and costs incurred at 12 and 24 months after randomization. All analyses were b-y intention to treat. Costs were expressed in 2004 pounds sterling and were discounted at a rate of 3.5%.The significance level was set at P <0.05.

OUTCOME MEASURES

The outcome variables were the costs related to initial and subsequent procedures (number of ward days, time in intensive care unit, equipment, staff and consumables), and the costs related to adverse events, complications and follow-up at 12 and 24 months after randomization.

RESULTS

The total cost (staff, equipment and consumables) of the intial procedure was significantly higher in the endovascular-treatment group than in the neurosurgery group(£4,520 vs £3,146 per patient; difference £1,374 [95% CI £1,230-1,499]),a result that was largely due to the cost of coils. The mean total costs of subsequent procedures (£267 vs £72;difference £195 [95% CI £ 114-285 ])and follow-up angiograms (£409 vs £121;difference £288 [95% CI £259 -317 ])were also higher with endovascular coiling. However, the mean 12-month cost of hospital stay associated with the initial procedure was significantly lower with coiling than with clipping (£11,547 vs £15,311;difference -£3,764 [95%CI -£5,482 to-£2,099 ]).The groups did not differ in terms of mean costs of complications and adverse events (£532 endovascular treatment vs £584 neurosurgery).The total mean 12-month cost of treatment was estimated to be £18,436 ± 15,849 with coiling and £20,176 ± 21,984 with clipping, but the difference in favor of the endovascular procedure (-£1,740 [95%CI -£3,582 to £32 ]) was not statistically significant. During the 12-24-month period after randomization, the mean costs for subsequent procedures, angiograms, complications and adverse events were greater in the endovascular group, reducing the difference in mean cost per patient to -£ 1,228 (95% CI -£3,199 to £786)over the first 24 months of follow-up. The mean number of days in paid employment following randomization was 59 days at 1 year and 148 days at 2 years among patients who underwent coiling, and 43 days and 119 days respectively among patients who underwent clipping.

CONCLUSION

The overall cost of coiling and that of clipping incurred at 1 and 2 years after intervention seem to be comparable.

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