Transcarotid artery revascularization (TCAR) produces similar outcomes to the gold standard treatment for carotid stenosis—carotid endarterectomy (CEA)—but comes at a greater cost. This was among the conclusions presented by Sheila M. Coogan, MD, at the Vascular Annual Meeting (VAM) in San Diego on Friday (Aug. 20), drawn from analysis of the cost-effectiveness of treatment modalities for non-emergent significant carotid artery stenosis. The analysis also showed that TCAR was incrementally more cost effective than carotid artery stenting (CAS).
“I think as a specialty we recognize that carotid stenosis is a significant problem,” Coogan commented in the opening to her presentation, noting that a total of 34% of ischemic strokes result from carotid artery disease. Globally, she added, more than $11,621 million is projected to be spent on treatment of carotid artery disease in 2023, of which 37.8% will be within the United States.
Working within the Houston-based Memorial Hermann Health Care System (MMHS)—a 13-hospital network including community and academic facilities—Coogan and colleagues sought to determine which was the most cost-effective carotid revascularization treatment, using Vascular Quality Initiative (VQI) data to assess each of the three modalities. A hospital cost program, EPSI (Enterprise Performance Systems Inc.), was also used to track the use of resources and assign estimates of cost based upon payroll and general ledger expenses. “These are real dollars, and this is a real-time metric that hospitals are using,” commented Coogan, professor of surgery at McGovern Medical School, the University of Texas, in Houston.
Data were analyzed using descriptive statistics, analysis of variance (ANOVA), linear and logistic regression, while incremental cost-effective ratio (ICER) was computed where more effective treatments were more expensive, and cost savings where more effective treatments were less expensive, the VAM audience heard.
Between July 2017 to June 2020, MHSS performed a total of 1,143 non-emergent carotid revascularization procedures, the majority of which were treated via CEA (798, 69.8%), followed by TCAR (177, 15.5%) and CAS (168, 14.7%).
Researchers recorded rates of stroke and transient ischemic attack (TIA) for patients treated using each of the three modalities, with events recoded in 1.1% of CEA patients, 1.7% of TCAR patients and 4.2% of CAS patients. Substantial differences were also observed in relation to the cost of treatment in each of the three groups, Coogan reported, the most costly of which was TCAR. “CEA was significantly less expensive for overall adjusted procedure time and length of stay,” she added.
Breaking down the cost by category, Coogan told VAM attendees that the biggest cost differential related to device costs. Comparing the treatment modalities on a cost-by-cost basis, the analysis showed that CEA vs. CAS saved roughly $5,000 per case, while CEA vs. TCAR was a $6,000 cost saving per case. ICER, which is based upon the outcomes and the cost effectiveness of the procedure, determined that TCAR was incrementally more cost effective than CAS, at a rate of $640 saved per event prevented.
The study was limited by the fact that there was a low event rate among patients studied, and the fact that it was a single-center analysis, Coogan said.
Concluding her presentation, Coogan pointed to the finding that though CEA remains the gold standard for the treatment of carotid artery stenosis, TCAR produced similar outcomes, albeit at a higher cost. “In the future I hope there will be a multicenter study using VQI data which is readily available, and using real cost data from your institutions, and if we could find a way to collaborate with multiple institutions we could probably have enough outcome events that we would power this for the most cost-effective treatment for carotid stenosis,” she remarked.
Coogan also commented that further cost-effectiveness analysis could provide greater insight to guide treatment choices. She said: “One of the reasons we proposed this was that our institution was very reluctant to pay for TCAR because it was so much more expensive than other procedures, but we have demonstrated that even though they did not have any pushback for CAS procedures, TCAR was more cost-effective. It highlights the fact that VQI is a really powerful way, both for contract negotiations with device companies, and also for analysis of what your institution might be willing to support financially.”