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Effectiveness and Cost-Effectiveness of Echocardiography and Carotid Imaging in the Management of Stroke
Evidence Reports/Technology Assessments, No. 49
Investigators: Richard T Meenan, PhD, MPH, Principal Investigator, Somnath Saha, MD, MPH, Co-Principal Investigator, Roger Chou, MD, Karleen Swarztrauber, MD, MPH, Kathryn Pyle Krages, AMLS, MA, Maureen O'Keefee-Rosetti, MS, Marian McDonagh, PharmD, Benjamin KS Chan, MS, Mark C Hornbrook, PhD, and Mark Helfand, MD, MPH, EPC Director.
Structured Abstract
Objectives:
Considerable controversy exists over the appropriate use of imaging procedures to target stroke treatments, such as carotid endarterectomy (CEA) and anticoagulant therapy, to those most likely to benefit. This report discusses the effectiveness and cost-effectiveness of various imaging strategies for evaluating and managing new stroke patients: transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), carotid ultrasound (CUS), magnetic resonance imaging (MRA), and cerebral angiography.
Search Strategy:
Literature databases searched included MEDLINE, HealthSTAR, the Cochrane Controlled Trials Register, the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effectiveness, and Health Technology Assessment.
Selection Criteria:
Two investigators independently reviewed the retrieved abstracts for each key question using predetermined inclusion/exclusion criteria, then compared results. Differences were resolved through discussions between the reviewers. Specific exclusion criteria were applied to individual key questions.
Data Collection and Analysis:
A review of 4,159 potentially relevant citations yielded 210 articles meeting eligibility criteria. Evidence tables summarize study quality and abstracted data, and where appropriate, results are synthesized by meta-analysis. Cost-effectiveness analyses are in the form of decision analyses.
Echocardiography Results and Conclusions:
Available evidence is insufficient to allow conclusions regarding whether and to what degree most echocardiographically identifiable lesions are associated with increased risk of future stroke. Moreover, insufficient data exist regarding the efficacy of treatment for reducing the risk of future stroke associated with intracardiac thrombus or other lesions identifiable with echocardiography. Under current estimates of echocardiographic accuracy and the prevalence of intracardiac thrombus, testing all stroke patients with echocardiography likely results in false positives at least as often as true positives. Assuming that anticoagulation reduces the risk of recurrent stroke from intracardiac thrombus by 33 percent over one year, both TEE and TTE cost over $290,000 per quality-adjusted life year (QALY) saved at thrombus prevalences of 5 percent or below. Cost-effectiveness ratios dropped below $50,000 per QALY if the relative risk reduction with anticoagulation was 86 percent and the prevalence of thrombus at least 6 percent. More information is needed on the risk of recurrent stroke among those with potential sources of cardioembolism, and the efficacy of anticoagulation in reducing that risk.
Carotid Imaging Results and Conclusions:
The accuracy of CUS appears to vary substantially across centers. MRA may be more accurate than CUS, but few high-quality studies have addressed its accuracy. The combination of CUS and MRA has high reported sensitivity, but all relevant studies to date have been affected by verification bias and were of fair to poor methodological quality. In cost-effectiveness analyses varying sensitivities and specificities of noninvasive tests over a wide range, all testing strategies cost at least $250,000 per QALY when the prevalence of severe (70-99 percent) stenosis was assumed to be 15 percent. However, two testing strategies -- initial CUS with angiographic confirmation and CEA for those with severe stenosis, and MRA with direct referral to CEA for those with severe stenosis -- had cost-effectiveness ratios below $75,000 per QALY when the prevalence of severe stenosis increased above 20 percent, and below $50,000 per QALY as the prevalence exceeded 25-30 percent. High-quality assessments of CUS, MRA, and cerebral angiography are needed to better inform clinical decisionmaking about the appropriate use of these imaging strategies.
Contents
- Preface
- Summary
- 1. Introduction
- 2. Methods
- 3. Results -- Echocardiography
- 1. Which clinically inapparent abnormalities identified by echocardiography among patients presenting with new ischemic brain syndrome represent risk factors for recurrent stroke?
- 2. What is the yield of echocardiography in detecting potential sources of cardioembolism among patients with a new ischemic brain syndrome?
- 3. What are the operating characteristics (sensitivities, specificities, and likelihood ratios) of transthoracic and transesophageal echocardiography in detecting potential sources of cardioembolic stroke?
- 4. What are the incidence and nature of complications associated with transesophageal echocardiography?
- 5. Are there clinically identifiable groups of patients with new ischemic brain syndrome who benefit from anticoagulation?
- 6. Are there echocardiographically identifiable groups of patients with new ischemic brain syndrome who benefit from anticoagulation?
- Cost Effectiveness of Echocardiography
- Results
- 4. Results - Carotid Imaging
- 1. What are the operating characteristics of available tests for measuring carotid artery stenosis?
- 2. What is the incidence of complications associated with cerebral angiography?
- 3. What is the efficacy of carotid endarterectomy in reducing the rate of recurrent stroke among symptomatic patients with carotid artery stenosis?
- 4. What is the incidence of complications associated with carotid endarterectomy?
- 5. Does timing affect the safety of carotid endarterectomy?
- Cost Effectiveness of Carotid Imaging
- 5. Conclusions
- 6. Recommendations for Future Research
- Evidence Tables
- Appendixes
- Appendix A. Abbreviations
- Appendix B. Research Team, Technical Expert Advisory Group, and Peer Reviewers
- Appendix C. Search Strategies
- Appendix D. Search results
- Appendix E. Criteria for Grading Individual Studies Developed by the Third US Preventive Services Task Force, 1999
- Appendix F. Statistical analysis report for effectiveness and cost-effectiveness of echocardiography and carotid imaging in the management of stroke
- References
- Bibliography
Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services.1 Contract No. 290-97-0018. Prepared by: Oregon Health & Science University Evidence-based Practice Center.
Suggested citation:
Meenan RT, Saha S, Chou R, et al. Effectiveness and Cost-Effectiveness of Echocardiography and Carotid Imaging in the Management of Stroke. Evidence Report/Technology Assessment Number 49. (Prepared by Oregon Health & Science University Evidence-based Practice Center under Contract No. 290-97-0018.) AHRQ Publication No. 02-EO22 Rockville, MD: Agency for Healthcare Research and Quality. July 2002.
This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. Endorsement by the Agency for Healthcare Research and Quality (AHRQ) or the U.S. Department of Health and Human Services (DHHS) of such derivative products may not be stated or implied.
AHRQ is the lead Federal agency charged with supporting research designed to improve the quality of health care, reduce its cost, address patient safety and medical errors, and broaden access to essential services. AHRQ sponsors and conducts research that provides evidence-based information on health care outcomes; quality; and cost, use, and access. The information helps heath care decisionmakers -- patients and clinicians, health system leaders, and policymakers -- make more informed decisions and improve the quality of health care services.
The authors of this report are responsible for its content. Statements in the report should not be construed as endorsement by the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services of a particular drug, device, test, treatment, or other clinical service.
- 1
2101 East Jefferson Street, Rockville, MD 20852. www
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- Costs and cost-effectiveness of carotid stenting versus endarterectomy for patients at increased surgical risk: results from the SAPPHIRE trial.[Catheter Cardiovasc Interv. 2011]Costs and cost-effectiveness of carotid stenting versus endarterectomy for patients at increased surgical risk: results from the SAPPHIRE trial.Mahoney EM, Greenberg D, Lavelle TA, Natarajan A, Berezin R, Ishak KJ, Caro JJ, Yadav JS, Gray WA, Wholey MH, et al. Catheter Cardiovasc Interv. 2011 Mar 1; 77(4):463-72.
- Cost-effectiveness analysis of protected carotid artery stent placement versus endarterectomy in high-risk patients.[J Endovasc Ther. 2010]Cost-effectiveness analysis of protected carotid artery stent placement versus endarterectomy in high-risk patients.Maud A, Vázquez G, Nyman JA, Lakshminarayan K, Anderson DC, Qureshi AI. J Endovasc Ther. 2010 Apr; 17(2):224-9.
- Review Carotid endarterectomy: still the standard of care for carotid bifurcation disease.[Semin Vasc Surg. 2011]Review Carotid endarterectomy: still the standard of care for carotid bifurcation disease.Rockman C, Loh S. Semin Vasc Surg. 2011 Mar; 24(1):10-20.
- Review [Carotid endarterectomy: recent controversies].[No Shinkei Geka. 1998]Review [Carotid endarterectomy: recent controversies].Yamada K. No Shinkei Geka. 1998 Mar; 26(3):207-15.
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