REVIEW ARTICLES Richard P. Cambria, MD, Section Editor
The role of cost-effectiveness for vascular surgery service provision in the United Kingdom Rishi Mandavia, BSc, Brahman Dharmarajah, MA, Mahim I. Qureshi, MA, and Alun H. Davies, DM, London, United Kingdom Objective: The cost of health care is increasingly becoming an international issue, with many health care systems requiring evaluation of cost when agreeing to fund health care. In the United Kingdom (UK), for example, the National Institute for Health and Care Excellence highlights the importance of using cost-effectiveness analyses to facilitate the effective use of resources. This study evaluates the use of cost-effectiveness analyses and the provision of vascular surgery. Methods: A systematic review of published literature was performed. UK-based studies assessing cost-effectiveness or costutility of superficial venous interventions, abdominal aortic aneurysm (AAA) repair, and carotid endarterectomy (CEA) were included. All included studies were quality assessed to determine the overall strength of UK economic evidence for each intervention. Results: Four superficial venous, six AAA, and two CEA studies met the inclusion criteria. After quality assessment, the UK evidence supporting the cost-effectiveness of superficial venous intervention was graded strong. The economic evidence for asymptomatic and symptomatic CEA was graded limited and insufficient, respectively, owing to a paucity of UK literature in this field. There was strong UK economic evidence affirming that endovascular aneurysm repair (EVAR) is unlikely to be a cost-effective alternative to open repair. Conclusions: There is strong economic evidence for symptomatic superficial venous intervention. However, funding for varicose vein treatments remains controversial. Future economic analyses are required for symptomatic and asymptomatic CEA to better advise national policy. Despite strong economic evidence, current UK guidance is for EVAR over open repair in the elective setting, with the majority of elective AAA repairs being EVAR. (J Vasc Surg 2015;61:1331-9.)
Existing cost-effective analyses do not appear to be a major factor when decisions are made on vascular surgical services in the United Kingdom (UK). This may be analogous to other health care systems outside the UK, necessitating further research in this field and questioning the purpose of health economic analyses if recommendations are not implemented. Health care costs are soaring globally. In 2012 alone, £121 billion and $1.81 trillion were spent on domestic health care by the UK and United States, respectively, From the Academic Section of Vascular Surgery, Division of Surgery, Imperial College London, Charing Cross Hospital. This study was supported by funding from the National Institute of Health Research (NIHR) Imperial Biomedical Research Centre (BRC) grant. Author conflict of interest: none. Reprint requests: Rishi Mandavia, BSc, Academic Section of Vascular Surgery, 4 North, Charing Cross Hospital, Fulham Palace Rd, London W6 8RF, UK (e-mail: [email protected]). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. 0741-5214 Copyright Ó 2015 by the Society for Vascular Surgery. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jvs.2015.01.034
making up >8% of the gross domestic product in both countries.1,2 Similar levels of expenditure are echoed across Europe.3 With the recent global economic crisis, there is increasing financial pressure to make health care savings and to increase efficiency.4 In the UK, as part of the drive to promote national health care savings and efficiency, local health care budgets for medical specialties have come under considerable scrutiny; and with the increasing trend toward centralization of care, rationing is a major element, resulting in limited financial resources.5,6 This sentiment is echoed in America, with the Affordable Care Act aiming to expand access to affordable health care and to reduce rising health care costs. Owing to this financial pressure, health economics has played an increasingly important role in identifying costeffective interventions. Cost-effectiveness and cost-utility studies are regarded as the most relevant types of health economic evaluation to health care professionals. Cost-utility studies measure outcome in terms of cost per quality-adjusted life-year (QALY) or incremental cost-effectiveness ratio (ICER). QALYs measure health as a combination of duration of life and health-related quality of life (HRQoL), whereby 1 QALY represents 1 year spent in perfect health. The ICER is the ratio of additional cost 1331
1332 Mandavia et al
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Fig. Summary of search strategy following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance.7
to additional health benefit (eg, QALY) in comparison to the next best alternative. Cost-effectiveness studies express costs as cost per unit of health effect, whereby the outcome is common to the treatment options assessed (such as life-years gained). In the UK, a treatment strategy is typically considered cost-effective if the ICER is less than £20,000 per QALY.4 Similarly in the United States, a figure of $50,000 per QALY is often suggested as a threshold for costeffectiveness. The National Institute for Health and Care
Excellence (NICE) highlights the importance of using cost-effectiveness analyses to determine resource allocation in the UK National Health Service (NHS). However, it is unclear whether cost-effective analyses actually influence national guidance and service provision. This study summarizes and quality assesses the UK evidence for the cost-effectiveness and cost-utility of three common vascular surgery interventions, namely, superficial venous interventions, abdominal aortic aneurysm (AAA) repair, and symptomatic and asymptomatic carotid
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Table I. Inclusion and exclusion criteria Inclusion criteria UK-based studies Cost-effectiveness or cost-utility economic evaluation Standardized treatment (indication and execution) Surgical treatments including superficial venous interventions, AAA repair, or CEA Exclusion criteria Review articles Commentaries Letters Non-English language studies
Mandavia et al 1333
evidence required at least one study of medium- or highquality evidence. If limited evidence was not present, this was regarded as insufficient evidence. A total of four superficial venous, six AAA, and two CEA studies were included for analysis. A summary of included studies and their quality assessment is displayed in Table II. A conference abstract9 met our inclusion criteria but contained no published results. Attempts were made to contact the authors for further information, but this was unsuccessful. The abstract was therefore excluded from analysis.
AAA, Abdominal aortic aneurysm; CEA, carotid endarterectomy.
SUMMARY OF EVIDENCE endarterectomy (CEA). Furthermore, we discuss the international literature and use the specialty of vascular surgery in the UK as an example to assess whether costeffectiveness analyses are used to determine and to guide service provision. METHODS A systematic search adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was performed.7 MEDLINE and Embase databases were searched using the Ovid portal. The databases were searched on September 3, 2013, for articles published between 1947 and 2013. The following search string was used: [(cost-effectiveness or cost-utility or cost-benefit or qaly) and (carotid and endarterectomy)] or [(cost-effectiveness or cost-utility or cost-benefit or qaly) and (varicose veins or chronic venous disease or [venous and [reflux or insufficiency])] or [(cost-effectiveness or cost-utility or cost-benefit or qaly) and (abdominal aortic aneurysm)]. Two authors (R.M., M.I.Q) searched independently and compared results at each stage. A third author (A.H.D) arbitrated inconsistencies. After duplications were removed, 978 articles were screened, of which 12 studies were included for qualitative analysis (Fig). Inclusion and exclusion criteria. Studies were considered for qualitative analysis according to the criteria given in Table I. Quality assessment. All studies were assessed according to Evers’ checklist,8 and papers were scored as high, medium, or low evidence. A high-quality ranking required (1) clinical evidence of the main health effect to be based on one or more randomized controlled trials (RCTs) or a meta-analysis of RCTs, (2) at least 50% of Evers’ criteria to be fulfilled, and (3) an appropriate health outcome. A low-quality study was one in which 80% of CEAs performed in the United States are asymptomatic.38,44 However, with only one UK study to date, the UK health economic evidence for asymptomatic CEA is limited. Future UK economic analyses of symptomatic and asymptomatic CEA are required to better advise national policy. Whereas some UK studies support the costeffectiveness of EVAR over open repair, there is strong-level UK economic evidence affirming that EVAR is unlikely to be a cost-effective alternative to open repair and is also unlikely to be a cost-effective treatment policy for patients considered unfit for open repair. This is supported by Canadian45 and European studies.46,47 A recent analysis of four RCTs found that EVAR was not costeffective compared with open repair in the long term in European centers.48 Conversely, studies from the United States lend support to the cost-effectiveness of EVAR over open repair49,50; however, these studies have short follow-up periods, likely omitting the long-term costs associated with EVAR, including surveillance and stent graft complications. Despite the strong UK cost-effectiveness
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evidence, NICE currently recommends EVAR for all patients who are suitable for both EVAR and open repair.20 Indeed, the majority of elective AAA repairs in the UK are EVARs, with data from the Vascular Society of Great Britain and Ireland identifying 4796 EVARs and 3583 open repairs during the period October 1, 2008, to September 30, 2010.51 Therefore, UK health economic analyses for AAA repair do not appear to have had a significant influence on either national guidance or service provision. The current NICE guidance for AAA repair was reviewed in March 2013, with outcomes yet to be published. It would be prudent to consider the UK economic evidence in the review process. The UK cost-effectiveness of EVAR vs open repair in the emergency setting is unclear, with only low-quality studies present for analysis. However, this should be assisted following the completion of the IMPROVE (Immediate Management of the Patient with Rupture: Open Versus Endovascular repair aneurysm trial) RCT.52 CONCLUSIONS With the global drive to reduce rising health care costs and to increase efficiency, health economics has played an increasingly important role in identifying cost-effective interventions. For further consistency among costeffectiveness analyses, we recommend referring to tools such as Evers’ checklist8 when constructing methodologies. Whereas health economic analyses evaluate both cost and health effect to determine cost-effectiveness, societal pressures may be conflicting, preferentially prioritizing treatments for conditions with greater morbidity and treatments with lower perceived costs. UK cost-effective analyses do not appear to be a major factor in determining vascular surgery service provision in the UK, particularly in the management of patients with superficial venous disease and those requiring elective AAA repair, despite the strong-level economic evidence available. Similarly, cost-effectiveness analyses in other countries may not play a determining role in the allocation of their health care resources. Further research is required in this field to question the purpose of health economic analyses if recommendations are not implemented. It also raises numerous issues with respect to what should be included in societal costs rather than just straightforward cost-effectiveness. AUTHOR CONTRIBUTIONS Conception and design: RM, BD, MQ, AD Analysis and interpretation: RM, BD, MQ, AD Data collection: RM, BD, MQ, AD Writing the article: RM, BD, MQ, AD Critical revision of the article: RM, BD, MQ, AD Final approval of the article: RM, BD, MQ, AD Statistical analysis: RM, BD, MQ, AD Obtained funding: RM Overall responsibility: RM
REFERENCES 1. United Kingdom Central Government Spending 2012. Available at: http://www.ukpublicspending.co.uk/year_spending_2013UKbn_13 bc1n_10#ukgs302. Accessed October 15, 2013. 2. United States Government Spending 2012. Available at: http://www. usgovernmentspending.com/. Accessed October 15, 2013. 3. Przywara B. Projecting future health-care expenditure at European level: drivers, methodology and main results. Eur Comission Econ Papers 2010;417:1-85. 4. Gohel M. Which treatments are cost-effective in the management of varicose veins? Phlebology 2013;28:153-7. 5. NHS England. Available at: http://www.nhs.uk/NHSEngland/ thenhs/about/Pages/ccg-outcomes.aspx. Accessed October 20, 2013. 6. Gaynor M, Laudicella M, Propper C. Can governments do it better? Merger mania and hospital outcomes in the English NHS. J Health Econ 2012;31:528-43. 7. Moher D, Liberati A, Tetzlaff J, Altman DG. PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Int J Surg 2010;8:336-41. 8. Evers S, Goossens M, de Vet H, van Tulder M, Ament A. Criteria list for assessment of methodological quality of economic evaluations: Consensus on Health Economic Criteria. Int J Technol Assess Health Care 2005;21:240-5. 9. Samuel N, Mazari F, Wallace T, Carradice D, Chetter I. Economic analysis of EVLA and surgery in the treatment of small saphenous incompetence. Results from an RCT. Abstracts from the 48th Congress of the European Society for Surgical Research, Istanbul, Turkey, May 29-June 1, 2013. Eur Surg Res 2013;50:25. 10. Michaels JA, Campbell WB, Brazier JE, Macintyre JB, Ratcliffe J, Rigby K. Randomised clinical trial, observational study and assessment of cost-effectiveness of the treatment of varicose veins (REACTIV trial). Health Technol Assess 2006;10:1-196. 11. Gohel MS, Epstein DM, Davies AH. Cost-effectiveness of traditional and endovenous treatments for varicose veins. Br J Surg 2010;97: 1815-23. 12. Ratcliffe J, Brazier JE, Campbell WB, Palfreyman S, MacIntyre JB, Michaels JA. Cost-effectiveness analysis of surgery versus conservative treatment for uncomplicated varicose veins in a randomized clinical trial. Br J Surg 2006;93:182-6. 13. CG168 Varicose veins in the legs. NICE guidance 2013. Available at: http://guidance.nice.org.uk/CG168/NICEGuidance/pdf/. Accessed October 20, 2013. 14. Thapar A, Garcia Mochon L, Epstein D, Shalhoub J, Davies AH. Modelling the cost-effectiveness of carotid endarterectomy for asymptomatic stenosis. Br J Surg 2013;100:231-9. 15. Endarterectomy for asymptomatic carotid artery stenosis. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. JAMA 1995;10:1421-8. 16. Haacke C, Althaus A, Spottke A, Siebert U, Back T, Dodel R. Longterm outcome after stroke: evaluating health-related quality of life using utility measurements. Stroke 2006;37:193-8. 17. Duncan PW, Lai SM, Keighley J. Defining post-stroke recovery: implications for design and interpretation of drug trials. Neuropharmacology 2000;39:835-41. 18. Lewis SC, Warlow CP, Bodenham AR, Colam B, Rothwell PM, Torgerson D, et al. General anesthesia versus local anesthesia for carotid surgery (GALA): a multicentre, randomised controlled trial. Lancet 2008;20:2132-42. 19. Gomes M, Soares MO, Dumville JC, Lewis SC, Torgerson DJ, Bodenham AR, et al. Cost-effectiveness analysis of general anesthesia versus local anesthesia for carotid surgery (GALA Trial). Br J Surg 2010;97:1218-25. 20. TA167 Abdominal aortic aneurysm-endovascular stent-grafts . NICE guidance 2009. Available at: http://www.nice.org.uk/nicemedia/ live/12129/43289/43289.pdf. Accessed September 26, 2013. 21. Brown LC, Powell JT, Thompson SG, Epstein DM, Sculpher MJ, Greenhalgh RM. The UK EndoVascular Aneurysm Repair (EVAR) trials: randomised trials of EVAR versus standard therapy. Health Technol Assess 2012;16:1-218.
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22. Killeen SD, Andrews EJ, Redmond HP, Fulton GJ. Provider volume and outcomes for abdominal aortic aneurysm repair, carotid endarterectomy, and lower extremity revascularization procedures. J Vasc Surg 2007;45:615-26. 23. Epstein DM, Sculpher MJ, Manca A, Michaels J, Thompson SG, Brown LC, et al. Modelling the long-term cost-effectiveness of endovascular or open repair for abdominal aortic aneurysm. Br J Surg 2008;95:183-90. 24. Michaels JA, Drury D, Thomas SM. Cost-effectiveness of endovascular abdominal aortic aneurysm repair. Br J Surg 2005;92:960-7. 25. Hayes PD, Sadat U, Walsh SR, Noorani A, Tang TY, Bowden DJ, et al. Cost-effectiveness analysis of endovascular versus open surgical repair of acute abdominal aortic aneurysms based on worldwide experience. J Endovasc Ther 2010;17:174-82. 26. Sadat U, Boyle JR, Walsh SR, Tang T, Varty K, Hayes PD. Endovascular vs open repair of acute abdominal aortic aneurysmsda systematic review and meta-analysis. J Vasc Surg 2008;48:227-36. 27. Cota AM, Omer AA, Jaipersad AS, Wilson NV. Elective versus ruptured abdominal aortic aneurysm repair: a 1-year cost-effectiveness analysis. Ann Vasc Surg 2005;19:858-61. 28. Eskelinen E, Räsänen P, Albäck A, Lepantalo M, Eskelinen A, Peltonen M, et al. Effectiveness of superficial venous surgery in terms of quality-adjusted life years and costs. Scand J Surg 2009;98: 229-33. 29. Disselhoff BC, Buskens E, Kelder JC, der Kinderen DJ, Moll FL. Randomised comparison of costs and cost-effectiveness of cryostripping and endovenous laser ablation for varicose veins: 2-year results. Eur J Vasc Endovasc Surg 2009;37:357-63. 30. Kelleher D, Lane TR, Franklin IJ, Davies AH. Socio-economic impact of endovenous thermal ablation techniques. Lasers Med Sci 2014;29: 493-9. 31. Lane TR, Dharmarajah B, Kelleher D, Franklin IJ, Davies AH. Shortterm gain for long-term pain? Which patients should be treated and should we ration? Phlebology 2013;28:148-52. 32. Moore HM, Lane TR, Thapar A, Franklin IJ, Davies AH. The European burden of primary varicose veins. Phlebology 2013;28: 141-7. 33. Costing report. Varicose veins in the legs: the diagnosis and management of varicose veins. NICE guideline 2013. Available at: http://www.nice. org.uk/nicemedia/live/14226/64582/64582.pdf. Accessed October 20, 2013. 34. Royal College of Physicians. National clinical guidelines for stroked fourth edition. Available at, www.rcplondon.ac.uk/resources/strokeguidelines. Accessed October 4, 2013. 35. CG68 Stroke. NICE guideline 2008. Available at: http://guidance. nice.org.uk/CG68/NICEGuidance/pdf/English. Accessed October 4, 2013. 36. Rothwell PM, Eliasziw M, Gutnikov SA, Fox AJ, Taylor DW, Mayberg MR, et al. Analysis of pooled data from the randomised controlled trials of endarterectomy for symptomatic carotid stenosis. Lancet 2003;361:107-16. 37. Patel ST, Haser PB, Korn P, Bush HL Jr, Deitch JS, Kent KC. Is carotid endarterectomy cost-effective in symptomatic patients with moderate (50% to 69%) stenosis? J Vasc Surg 1999;30:1024-33. 38. Kuntz KM, Kent KC. Is carotid endarterectomy cost-effective? An analysis of symptomatic and asymptomatic patients. Circulation 1996;1:194-8.
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39. Young KC, Holloway RG, Burgin WS, Benesch CG. A cost-effectiveness analysis of carotid artery stenting compared with endarterectomy. J Stroke Cerebrovasc Dis 2010;19:404-9. 40. Nussbaum ES, Heros RC, Erickson DL. Cost-effectiveness of carotid endarterectomy. Neurosurgery 1996;38:237-44. 41. Spence JD. Is there a role for revascularisation in asymptomatic carotid stenosis? No. BMJ 2010;341:4900. 42. Royal College of Physicians. UK carotid endarterectomy audit round 4 public report. Includes operations performed between 1 October 2010 and 30 September 2011. Available at: http://www.vascularsociety.org.uk/ vascular/wp-content/uploads/2012/11/UK-Carotid-Endarterectomy -Audit-Round-4-Public-Report.pdf. Accessed September 27, 2013. 43. Henriksson M, Lundgren F, Carlsson P. Cost-effectiveness of endarterectomy in patients with asymptomatic carotid artery stenosis. Br J Surg 2008;95:714-20. 44. Cronenwett JL, Birkmeyer JD, Nackman GB, Fillinger MF, Bech FR, Zwolak RM, et al. Cost-effectiveness of carotid endarterectomy in asymptomatic patients. J Vasc Surg 1997;25:298-309. 45. Blackhouse G, Hopkins R, Bowen JM, De Rose G, Novick T, Tarride JE, et al. A cost-effectiveness model comparing endovascular repair to open surgical repair of abdominal aortic aneurysms in Canada. Value Health 2009;12:245-52. 46. Kapma MR, Groen H, Oranen BI, van der Hilst CS, Tielliu IF, Zeebregts CJ, et al. Emergency abdominal aortic aneurysm repair with a preferential endovascular strategy: mortality and cost-effectiveness analysis. J Endovasc Ther 2007;14:777-84. 47. Hynes N, Sultan S. A prospective clinical, economic, and quality-of-life analysis comparing endovascular aneurysm repair (EVAR), open repair, and best medical treatment in high-risk patients with abdominal aortic aneurysms suitable for EVAR: the Irish patient trial. J Endovasc Ther 2007;14:763-76. 48. Epstein D, Sculpher MJ, Powell JT, Thompson SG, Brown LC, Greenhalgh RM. Long-term cost-effectiveness analysis of endovascular versus open repair for abdominal aortic aneurysm based on four randomized clinical trials. Br J Surg 2014;101:623-31. 49. Stroupe KT, Lederle FA, Matsumura JS, Kyriakides TC, Jonk YC, Freischlag JA, et al. Cost-effectiveness of open versus endovascular repair of abdominal aortic aneurysm in the OVER trial. J Vasc Surg 2012;56:901-9. 50. Lederle FA, Stroupe KT; Open Versus Endovascular Repair (OVER) Veterans Affairs Cooperative Study Group. Cost-effectiveness at two years in the VA Open Endovascular Repair Trial. Eur J Vasc Endovasc Surg 2012;44:543-8. 51. Outcomes after elective repair of infra-renal abdominal aortic aneurysm. A report from The Vascular Society, March 2012. Available at: http:// www.vascularsociety.org.uk/vascular/wp-content/uploads/2012/11/ VSGBI-Mortality-Report.pdf. Accessed September 27, 2013. 52. IMPROVE Trial, Powell JT, Thompson SG, Thompson MM, Grieve R, Nicholson AA, Ashleigh R, et al. The Immediate Management of the Patient with Rupture: Open Versus Endovascular repair (IMPROVE) aneurysm trialdISRCTN 48334791 IMPROVE trialists. Acta Chir Belg 2009;109:678-80.
Submitted Sep 26, 2014; accepted Jan 19, 2015.
The role of cost-effectiveness for vascular surgery service provision in the United Kingdom Rishi Mandavia, BSc, Brahman Dharmarajah, MA, Mahim I. Qureshi, MA, and Alun H. Davies, DM, London, United Kingdom Objective: The cost of health care is increasingly becoming an international issue, with many health care systems requiring evaluation of cost when agreeing to fund health care. In the United Kingdom (UK), for example, the National Institute for Health and Care Excellence highlights the importance of using cost-effectiveness analyses to facilitate the effective use of resources. This study evaluates the use of cost-effectiveness analyses and the provision of vascular surgery. Methods: A systematic review of published literature was performed. UK-based studies assessing cost-effectiveness or costutility of superficial venous interventions, abdominal aortic aneurysm (AAA) repair, and carotid endarterectomy (CEA) were included. All included studies were quality assessed to determine the overall strength of UK economic evidence for each intervention. Results: Four superficial venous, six AAA, and two CEA studies met the inclusion criteria. After quality assessment, the UK evidence supporting the cost-effectiveness of superficial venous intervention was graded strong. The economic evidence for asymptomatic and symptomatic CEA was graded limited and insufficient, respectively, owing to a paucity of UK literature in this field. There was strong UK economic evidence affirming that endovascular aneurysm repair (EVAR) is unlikely to be a cost-effective alternative to open repair. Conclusions: There is strong economic evidence for symptomatic superficial venous intervention. However, funding for varicose vein treatments remains controversial. Future economic analyses are required for symptomatic and asymptomatic CEA to better advise national policy. Despite strong economic evidence, current UK guidance is for EVAR over open repair in the elective setting, with the majority of elective AAA repairs being EVAR. (J Vasc Surg 2015;61:1331-9.)
Existing cost-effective analyses do not appear to be a major factor when decisions are made on vascular surgical services in the United Kingdom (UK). This may be analogous to other health care systems outside the UK, necessitating further research in this field and questioning the purpose of health economic analyses if recommendations are not implemented. Health care costs are soaring globally. In 2012 alone, £121 billion and $1.81 trillion were spent on domestic health care by the UK and United States, respectively, From the Academic Section of Vascular Surgery, Division of Surgery, Imperial College London, Charing Cross Hospital. This study was supported by funding from the National Institute of Health Research (NIHR) Imperial Biomedical Research Centre (BRC) grant. Author conflict of interest: none. Reprint requests: Rishi Mandavia, BSc, Academic Section of Vascular Surgery, 4 North, Charing Cross Hospital, Fulham Palace Rd, London W6 8RF, UK (e-mail: [email protected]). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. 0741-5214 Copyright Ó 2015 by the Society for Vascular Surgery. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jvs.2015.01.034
making up >8% of the gross domestic product in both countries.1,2 Similar levels of expenditure are echoed across Europe.3 With the recent global economic crisis, there is increasing financial pressure to make health care savings and to increase efficiency.4 In the UK, as part of the drive to promote national health care savings and efficiency, local health care budgets for medical specialties have come under considerable scrutiny; and with the increasing trend toward centralization of care, rationing is a major element, resulting in limited financial resources.5,6 This sentiment is echoed in America, with the Affordable Care Act aiming to expand access to affordable health care and to reduce rising health care costs. Owing to this financial pressure, health economics has played an increasingly important role in identifying costeffective interventions. Cost-effectiveness and cost-utility studies are regarded as the most relevant types of health economic evaluation to health care professionals. Cost-utility studies measure outcome in terms of cost per quality-adjusted life-year (QALY) or incremental cost-effectiveness ratio (ICER). QALYs measure health as a combination of duration of life and health-related quality of life (HRQoL), whereby 1 QALY represents 1 year spent in perfect health. The ICER is the ratio of additional cost 1331
1332 Mandavia et al
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Fig. Summary of search strategy following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance.7
to additional health benefit (eg, QALY) in comparison to the next best alternative. Cost-effectiveness studies express costs as cost per unit of health effect, whereby the outcome is common to the treatment options assessed (such as life-years gained). In the UK, a treatment strategy is typically considered cost-effective if the ICER is less than £20,000 per QALY.4 Similarly in the United States, a figure of $50,000 per QALY is often suggested as a threshold for costeffectiveness. The National Institute for Health and Care
Excellence (NICE) highlights the importance of using cost-effectiveness analyses to determine resource allocation in the UK National Health Service (NHS). However, it is unclear whether cost-effective analyses actually influence national guidance and service provision. This study summarizes and quality assesses the UK evidence for the cost-effectiveness and cost-utility of three common vascular surgery interventions, namely, superficial venous interventions, abdominal aortic aneurysm (AAA) repair, and symptomatic and asymptomatic carotid
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Table I. Inclusion and exclusion criteria Inclusion criteria UK-based studies Cost-effectiveness or cost-utility economic evaluation Standardized treatment (indication and execution) Surgical treatments including superficial venous interventions, AAA repair, or CEA Exclusion criteria Review articles Commentaries Letters Non-English language studies
Mandavia et al 1333
evidence required at least one study of medium- or highquality evidence. If limited evidence was not present, this was regarded as insufficient evidence. A total of four superficial venous, six AAA, and two CEA studies were included for analysis. A summary of included studies and their quality assessment is displayed in Table II. A conference abstract9 met our inclusion criteria but contained no published results. Attempts were made to contact the authors for further information, but this was unsuccessful. The abstract was therefore excluded from analysis.
AAA, Abdominal aortic aneurysm; CEA, carotid endarterectomy.
SUMMARY OF EVIDENCE endarterectomy (CEA). Furthermore, we discuss the international literature and use the specialty of vascular surgery in the UK as an example to assess whether costeffectiveness analyses are used to determine and to guide service provision. METHODS A systematic search adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was performed.7 MEDLINE and Embase databases were searched using the Ovid portal. The databases were searched on September 3, 2013, for articles published between 1947 and 2013. The following search string was used: [(cost-effectiveness or cost-utility or cost-benefit or qaly) and (carotid and endarterectomy)] or [(cost-effectiveness or cost-utility or cost-benefit or qaly) and (varicose veins or chronic venous disease or [venous and [reflux or insufficiency])] or [(cost-effectiveness or cost-utility or cost-benefit or qaly) and (abdominal aortic aneurysm)]. Two authors (R.M., M.I.Q) searched independently and compared results at each stage. A third author (A.H.D) arbitrated inconsistencies. After duplications were removed, 978 articles were screened, of which 12 studies were included for qualitative analysis (Fig). Inclusion and exclusion criteria. Studies were considered for qualitative analysis according to the criteria given in Table I. Quality assessment. All studies were assessed according to Evers’ checklist,8 and papers were scored as high, medium, or low evidence. A high-quality ranking required (1) clinical evidence of the main health effect to be based on one or more randomized controlled trials (RCTs) or a meta-analysis of RCTs, (2) at least 50% of Evers’ criteria to be fulfilled, and (3) an appropriate health outcome. A low-quality study was one in which 80% of CEAs performed in the United States are asymptomatic.38,44 However, with only one UK study to date, the UK health economic evidence for asymptomatic CEA is limited. Future UK economic analyses of symptomatic and asymptomatic CEA are required to better advise national policy. Whereas some UK studies support the costeffectiveness of EVAR over open repair, there is strong-level UK economic evidence affirming that EVAR is unlikely to be a cost-effective alternative to open repair and is also unlikely to be a cost-effective treatment policy for patients considered unfit for open repair. This is supported by Canadian45 and European studies.46,47 A recent analysis of four RCTs found that EVAR was not costeffective compared with open repair in the long term in European centers.48 Conversely, studies from the United States lend support to the cost-effectiveness of EVAR over open repair49,50; however, these studies have short follow-up periods, likely omitting the long-term costs associated with EVAR, including surveillance and stent graft complications. Despite the strong UK cost-effectiveness
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evidence, NICE currently recommends EVAR for all patients who are suitable for both EVAR and open repair.20 Indeed, the majority of elective AAA repairs in the UK are EVARs, with data from the Vascular Society of Great Britain and Ireland identifying 4796 EVARs and 3583 open repairs during the period October 1, 2008, to September 30, 2010.51 Therefore, UK health economic analyses for AAA repair do not appear to have had a significant influence on either national guidance or service provision. The current NICE guidance for AAA repair was reviewed in March 2013, with outcomes yet to be published. It would be prudent to consider the UK economic evidence in the review process. The UK cost-effectiveness of EVAR vs open repair in the emergency setting is unclear, with only low-quality studies present for analysis. However, this should be assisted following the completion of the IMPROVE (Immediate Management of the Patient with Rupture: Open Versus Endovascular repair aneurysm trial) RCT.52 CONCLUSIONS With the global drive to reduce rising health care costs and to increase efficiency, health economics has played an increasingly important role in identifying cost-effective interventions. For further consistency among costeffectiveness analyses, we recommend referring to tools such as Evers’ checklist8 when constructing methodologies. Whereas health economic analyses evaluate both cost and health effect to determine cost-effectiveness, societal pressures may be conflicting, preferentially prioritizing treatments for conditions with greater morbidity and treatments with lower perceived costs. UK cost-effective analyses do not appear to be a major factor in determining vascular surgery service provision in the UK, particularly in the management of patients with superficial venous disease and those requiring elective AAA repair, despite the strong-level economic evidence available. Similarly, cost-effectiveness analyses in other countries may not play a determining role in the allocation of their health care resources. Further research is required in this field to question the purpose of health economic analyses if recommendations are not implemented. It also raises numerous issues with respect to what should be included in societal costs rather than just straightforward cost-effectiveness. AUTHOR CONTRIBUTIONS Conception and design: RM, BD, MQ, AD Analysis and interpretation: RM, BD, MQ, AD Data collection: RM, BD, MQ, AD Writing the article: RM, BD, MQ, AD Critical revision of the article: RM, BD, MQ, AD Final approval of the article: RM, BD, MQ, AD Statistical analysis: RM, BD, MQ, AD Obtained funding: RM Overall responsibility: RM
REFERENCES 1. United Kingdom Central Government Spending 2012. Available at: http://www.ukpublicspending.co.uk/year_spending_2013UKbn_13 bc1n_10#ukgs302. Accessed October 15, 2013. 2. United States Government Spending 2012. Available at: http://www. usgovernmentspending.com/. Accessed October 15, 2013. 3. Przywara B. Projecting future health-care expenditure at European level: drivers, methodology and main results. Eur Comission Econ Papers 2010;417:1-85. 4. Gohel M. Which treatments are cost-effective in the management of varicose veins? Phlebology 2013;28:153-7. 5. NHS England. Available at: http://www.nhs.uk/NHSEngland/ thenhs/about/Pages/ccg-outcomes.aspx. Accessed October 20, 2013. 6. Gaynor M, Laudicella M, Propper C. Can governments do it better? Merger mania and hospital outcomes in the English NHS. J Health Econ 2012;31:528-43. 7. Moher D, Liberati A, Tetzlaff J, Altman DG. PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Int J Surg 2010;8:336-41. 8. Evers S, Goossens M, de Vet H, van Tulder M, Ament A. Criteria list for assessment of methodological quality of economic evaluations: Consensus on Health Economic Criteria. Int J Technol Assess Health Care 2005;21:240-5. 9. Samuel N, Mazari F, Wallace T, Carradice D, Chetter I. Economic analysis of EVLA and surgery in the treatment of small saphenous incompetence. Results from an RCT. Abstracts from the 48th Congress of the European Society for Surgical Research, Istanbul, Turkey, May 29-June 1, 2013. Eur Surg Res 2013;50:25. 10. Michaels JA, Campbell WB, Brazier JE, Macintyre JB, Ratcliffe J, Rigby K. Randomised clinical trial, observational study and assessment of cost-effectiveness of the treatment of varicose veins (REACTIV trial). Health Technol Assess 2006;10:1-196. 11. Gohel MS, Epstein DM, Davies AH. Cost-effectiveness of traditional and endovenous treatments for varicose veins. Br J Surg 2010;97: 1815-23. 12. Ratcliffe J, Brazier JE, Campbell WB, Palfreyman S, MacIntyre JB, Michaels JA. Cost-effectiveness analysis of surgery versus conservative treatment for uncomplicated varicose veins in a randomized clinical trial. Br J Surg 2006;93:182-6. 13. CG168 Varicose veins in the legs. NICE guidance 2013. Available at: http://guidance.nice.org.uk/CG168/NICEGuidance/pdf/. Accessed October 20, 2013. 14. Thapar A, Garcia Mochon L, Epstein D, Shalhoub J, Davies AH. Modelling the cost-effectiveness of carotid endarterectomy for asymptomatic stenosis. Br J Surg 2013;100:231-9. 15. Endarterectomy for asymptomatic carotid artery stenosis. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. JAMA 1995;10:1421-8. 16. Haacke C, Althaus A, Spottke A, Siebert U, Back T, Dodel R. Longterm outcome after stroke: evaluating health-related quality of life using utility measurements. Stroke 2006;37:193-8. 17. Duncan PW, Lai SM, Keighley J. Defining post-stroke recovery: implications for design and interpretation of drug trials. Neuropharmacology 2000;39:835-41. 18. Lewis SC, Warlow CP, Bodenham AR, Colam B, Rothwell PM, Torgerson D, et al. General anesthesia versus local anesthesia for carotid surgery (GALA): a multicentre, randomised controlled trial. Lancet 2008;20:2132-42. 19. Gomes M, Soares MO, Dumville JC, Lewis SC, Torgerson DJ, Bodenham AR, et al. Cost-effectiveness analysis of general anesthesia versus local anesthesia for carotid surgery (GALA Trial). Br J Surg 2010;97:1218-25. 20. TA167 Abdominal aortic aneurysm-endovascular stent-grafts . NICE guidance 2009. Available at: http://www.nice.org.uk/nicemedia/ live/12129/43289/43289.pdf. Accessed September 26, 2013. 21. Brown LC, Powell JT, Thompson SG, Epstein DM, Sculpher MJ, Greenhalgh RM. The UK EndoVascular Aneurysm Repair (EVAR) trials: randomised trials of EVAR versus standard therapy. Health Technol Assess 2012;16:1-218.
JOURNAL OF VASCULAR SURGERY Volume 61, Number 5
22. Killeen SD, Andrews EJ, Redmond HP, Fulton GJ. Provider volume and outcomes for abdominal aortic aneurysm repair, carotid endarterectomy, and lower extremity revascularization procedures. J Vasc Surg 2007;45:615-26. 23. Epstein DM, Sculpher MJ, Manca A, Michaels J, Thompson SG, Brown LC, et al. Modelling the long-term cost-effectiveness of endovascular or open repair for abdominal aortic aneurysm. Br J Surg 2008;95:183-90. 24. Michaels JA, Drury D, Thomas SM. Cost-effectiveness of endovascular abdominal aortic aneurysm repair. Br J Surg 2005;92:960-7. 25. Hayes PD, Sadat U, Walsh SR, Noorani A, Tang TY, Bowden DJ, et al. Cost-effectiveness analysis of endovascular versus open surgical repair of acute abdominal aortic aneurysms based on worldwide experience. J Endovasc Ther 2010;17:174-82. 26. Sadat U, Boyle JR, Walsh SR, Tang T, Varty K, Hayes PD. Endovascular vs open repair of acute abdominal aortic aneurysmsda systematic review and meta-analysis. J Vasc Surg 2008;48:227-36. 27. Cota AM, Omer AA, Jaipersad AS, Wilson NV. Elective versus ruptured abdominal aortic aneurysm repair: a 1-year cost-effectiveness analysis. Ann Vasc Surg 2005;19:858-61. 28. Eskelinen E, Räsänen P, Albäck A, Lepantalo M, Eskelinen A, Peltonen M, et al. Effectiveness of superficial venous surgery in terms of quality-adjusted life years and costs. Scand J Surg 2009;98: 229-33. 29. Disselhoff BC, Buskens E, Kelder JC, der Kinderen DJ, Moll FL. Randomised comparison of costs and cost-effectiveness of cryostripping and endovenous laser ablation for varicose veins: 2-year results. Eur J Vasc Endovasc Surg 2009;37:357-63. 30. Kelleher D, Lane TR, Franklin IJ, Davies AH. Socio-economic impact of endovenous thermal ablation techniques. Lasers Med Sci 2014;29: 493-9. 31. Lane TR, Dharmarajah B, Kelleher D, Franklin IJ, Davies AH. Shortterm gain for long-term pain? Which patients should be treated and should we ration? Phlebology 2013;28:148-52. 32. Moore HM, Lane TR, Thapar A, Franklin IJ, Davies AH. The European burden of primary varicose veins. Phlebology 2013;28: 141-7. 33. Costing report. Varicose veins in the legs: the diagnosis and management of varicose veins. NICE guideline 2013. Available at: http://www.nice. org.uk/nicemedia/live/14226/64582/64582.pdf. Accessed October 20, 2013. 34. Royal College of Physicians. National clinical guidelines for stroked fourth edition. Available at, www.rcplondon.ac.uk/resources/strokeguidelines. Accessed October 4, 2013. 35. CG68 Stroke. NICE guideline 2008. Available at: http://guidance. nice.org.uk/CG68/NICEGuidance/pdf/English. Accessed October 4, 2013. 36. Rothwell PM, Eliasziw M, Gutnikov SA, Fox AJ, Taylor DW, Mayberg MR, et al. Analysis of pooled data from the randomised controlled trials of endarterectomy for symptomatic carotid stenosis. Lancet 2003;361:107-16. 37. Patel ST, Haser PB, Korn P, Bush HL Jr, Deitch JS, Kent KC. Is carotid endarterectomy cost-effective in symptomatic patients with moderate (50% to 69%) stenosis? J Vasc Surg 1999;30:1024-33. 38. Kuntz KM, Kent KC. Is carotid endarterectomy cost-effective? An analysis of symptomatic and asymptomatic patients. Circulation 1996;1:194-8.
Mandavia et al 1339
39. Young KC, Holloway RG, Burgin WS, Benesch CG. A cost-effectiveness analysis of carotid artery stenting compared with endarterectomy. J Stroke Cerebrovasc Dis 2010;19:404-9. 40. Nussbaum ES, Heros RC, Erickson DL. Cost-effectiveness of carotid endarterectomy. Neurosurgery 1996;38:237-44. 41. Spence JD. Is there a role for revascularisation in asymptomatic carotid stenosis? No. BMJ 2010;341:4900. 42. Royal College of Physicians. UK carotid endarterectomy audit round 4 public report. Includes operations performed between 1 October 2010 and 30 September 2011. Available at: http://www.vascularsociety.org.uk/ vascular/wp-content/uploads/2012/11/UK-Carotid-Endarterectomy -Audit-Round-4-Public-Report.pdf. Accessed September 27, 2013. 43. Henriksson M, Lundgren F, Carlsson P. Cost-effectiveness of endarterectomy in patients with asymptomatic carotid artery stenosis. Br J Surg 2008;95:714-20. 44. Cronenwett JL, Birkmeyer JD, Nackman GB, Fillinger MF, Bech FR, Zwolak RM, et al. Cost-effectiveness of carotid endarterectomy in asymptomatic patients. J Vasc Surg 1997;25:298-309. 45. Blackhouse G, Hopkins R, Bowen JM, De Rose G, Novick T, Tarride JE, et al. A cost-effectiveness model comparing endovascular repair to open surgical repair of abdominal aortic aneurysms in Canada. Value Health 2009;12:245-52. 46. Kapma MR, Groen H, Oranen BI, van der Hilst CS, Tielliu IF, Zeebregts CJ, et al. Emergency abdominal aortic aneurysm repair with a preferential endovascular strategy: mortality and cost-effectiveness analysis. J Endovasc Ther 2007;14:777-84. 47. Hynes N, Sultan S. A prospective clinical, economic, and quality-of-life analysis comparing endovascular aneurysm repair (EVAR), open repair, and best medical treatment in high-risk patients with abdominal aortic aneurysms suitable for EVAR: the Irish patient trial. J Endovasc Ther 2007;14:763-76. 48. Epstein D, Sculpher MJ, Powell JT, Thompson SG, Brown LC, Greenhalgh RM. Long-term cost-effectiveness analysis of endovascular versus open repair for abdominal aortic aneurysm based on four randomized clinical trials. Br J Surg 2014;101:623-31. 49. Stroupe KT, Lederle FA, Matsumura JS, Kyriakides TC, Jonk YC, Freischlag JA, et al. Cost-effectiveness of open versus endovascular repair of abdominal aortic aneurysm in the OVER trial. J Vasc Surg 2012;56:901-9. 50. Lederle FA, Stroupe KT; Open Versus Endovascular Repair (OVER) Veterans Affairs Cooperative Study Group. Cost-effectiveness at two years in the VA Open Endovascular Repair Trial. Eur J Vasc Endovasc Surg 2012;44:543-8. 51. Outcomes after elective repair of infra-renal abdominal aortic aneurysm. A report from The Vascular Society, March 2012. Available at: http:// www.vascularsociety.org.uk/vascular/wp-content/uploads/2012/11/ VSGBI-Mortality-Report.pdf. Accessed September 27, 2013. 52. IMPROVE Trial, Powell JT, Thompson SG, Thompson MM, Grieve R, Nicholson AA, Ashleigh R, et al. The Immediate Management of the Patient with Rupture: Open Versus Endovascular repair (IMPROVE) aneurysm trialdISRCTN 48334791 IMPROVE trialists. Acta Chir Belg 2009;109:678-80.
Submitted Sep 26, 2014; accepted Jan 19, 2015.
