Cost-effectiveness analysis of surgical repair versus observation of complex abdominal aortic aneurysms in elderly patients.

Abstract

The operative risks and financial costs associated with fenestrated endovascular aneurysm repair (FEVAR) and open surgical repair (OSR) of complex abdominal aortic aneurysms may not be justified in elderly patients because of limited expected survival. We performed a cost-effectiveness analysis to determine whether FEVAR or OSR was preferable to observation in elderly patients with complex abdominal aortic aneurysms. We constructed a probabilistic Markov model comparing lifetime costs and survival (in quality-adjusted life years or QALYs) among patients undergoing FEVAR vs OSR vs observation. Cohorts undergoing aneurysm repair were exposed to risk of complications, reintervention, or death, whereas those undergoing observation were exposed to risk of rupture. Baseline mortality was modeled from a national life table. Outcomes were costs in U.S. dollars, QALYs, and incremental cost-effectiveness ratios. Sensitivity analyses were performed for various combinations of age at the time of repair (range: 50-90 years), sex, and aneurysm size (range: 5.5-8.5 cm/5.0-8.5 cm in men/women, respectively). FEVAR tended to have better survival than OSR for 70-year-old men with 5.5-cm aneurysms (6.5 vs 5.7 QALYs, respectively) and 70-year-old women with 5.0-cm aneurysms (8.0 vs 7.2 QALYs, respectively). However, FEVAR and OSR led to comparable costs in these cohorts. As such, FEVAR was preferred over OSR in these cohorts. Incremental cost-effectiveness ratios of FEVAR vs observation were $27,621 and $21,653 per QALY gained in men and women, respectively. Both FEVAR and OSR were cost-effective compared with observation for most scenarios, except for age >80 to 85 years with smaller aneurysms (≤7.0 cm in men and ≤6.0 cm in women). FEVAR and OSR are cost-effective compared with observation for most patients, even among elderly.