Ruptüre Olmamış Serebral Anevrizmaların Tedavisinde Cerrahi Klipleme Ve Endovasküler Koil Yöntemlerinin Maliyet Etkililiğinin Değerlendirilmesi

Abstract

The aim of the study is to assess the cost effectiveness of endovascular coiling and surgical clipping in the treatment of unruptured cerebral aneurysms. The patients with ICD 10 I67.1 and one of the two treatment methods applied at Hacettepe University Hospitals between January 2013 and December 2015 were included in the study. The cost data of the study was obtained by analyzing patient invoices through the automation program of the university hospital. Costs of index operation are classified as surgery, anesthesia, service, medicine, examination, laboratory, materials, medical imaging and hospital bed fee. The effectiveness and costs of treatments were assessed by using Markov Model with Social Security Institution’s perspective. To generate the cost input in the model, the lifetime costs obtained based on the expert opinions were added to the amounts obtained from patient invoices. Transitions among health states of patients with unruptured cerebral aneurysm simulated in Markov Model by using monthly cycles. Good health status, hemorrhage, stroke and dead status are considered in the model. The costs of hemorrhage and stroke and the transition probabilities among states are obtained from literature. EQ-5D Scale and Cognitive Function Short Form of NeuroQol Scale were applied to patients with telephone calls to assess the effectiveness outcomes of treatment methods. In addition, Duke University Disease Severity Scale was filled by specialist doctors by reviewing patient files to determine whether health status of the patients are similar before operation. According to the endovascular coiling treatment patients’ response, average QALY score with UK value set was found as 0.76. This score was 0.59 for the surgical clipping patients. While cognitive function of the patients for the coiling group after discharge was calculated as 34.26 out of 40, this score was found as 27.46 for the patients in the clipping group. The cost effectiveness analysis was performed by using the obtained cost and effectiveness data on hypothetical 1000 patient cohort in the Markov model. The study results were presented as incremental cost effectiveness ratio. When 3% reduction rate was applied to the costs and effectiveness data, QALY was calculated as 4.393 for coiling method and 1.844 for clipping method. Lifetime cost was 180.780,46 ₺ for the coiling method and 21.488,76 ₺ for the clipping method. The cost per QALY was 41.152,25 ₺ for the endovascular coiling method and 11.656,38 ₺ for the surgical clipping method. The threefold of GDP 75.390 ₺ was accepted as cost effectiveness threshold. The incremental cost effectiveness rate of endovascular coiling method was 62.481. The endovascular coiling method was found as cost effective because this score was below the threshold. While technologic developments in the endovascular coiling technology allow patients to prefer this method compared to the surgical clipping, the developing technology also causes high costs. Despite its high cost, endovascular coiling method is cost effectiveness because it offers high quality life years compared to the surgical clipping method. Price reduction in the basic cost factors such as material costs will bring this method forefront in terms of reimbursing institutions.