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Cardiovascular surgery
Echocardiographic risk stratification for early surgery with endocarditis: a cost-effectiveness analysis
  1. L Liao1,
  2. D F Kong1,
  3. Z Samad1,
  4. P A Pappas1,
  5. J G Jollis1,
  6. S S Lin2,
  7. A Wang1,
  8. V G Fowler Jr1,
  9. V H Chu1,
  10. D J Sexton1,
  11. G R Corey1,
  12. C H Cabell1
  1. 1
    Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
  2. 2
    Department of Surgery, Duke University Medical Center, Durham, NC, USA
  1. Lawrence Liao, MD, Box 3850, Duke University Medical Center, Durham, NC 27710, USA; liao0002{at}mc.duke.edu

Abstract

Background: Despite widespread acceptance of echocardiography for diagnosis of infective endocarditis, few investigators have evaluated its utility as a risk-stratification tool to aid therapeutic decision-making.

Methods: A decision tree and Markov analysis model were constructed using published and institutional data to estimate the cost-effectiveness of an echocardiographic risk-stratification strategy for infective endocarditis. The models compared surgery for high-risk patients based on clinical factors (“standard care”) and surgery for high-risk patients based on echocardiographic findings (“echocardiography-guided”).

Results: The cost per patient for standard care and echocardiography-guided strategies was $47 766 and $53 669, respectively. The expected quality-adjusted life years (QALY) for standard care and echocardiography-guided strategies were 5.86 years and 6.10 years, respectively. Compared with standard care, the echocardiography-guided strategy cost an additional $23 867 per QALY saved. In one-way sensitivity analyses, the incremental cost of this strategy remained <$50 000/QALY across a broad range of scenarios. Baseline stroke risk had the greatest effect on cost-effectiveness. For populations with stroke risk less than 3.65%, the echocardiography-guided strategy was not cost-attractive (ICER >$50 000/QALY). At stroke risk between 3.65% and 14%, the ICER for the echocardiography-guided strategy was attractive (<$50 000/QALY). The echocardiography-guided strategy became economically dominant at any baseline stroke risk greater than 18.3%.

Conclusion: Echo-guided risk stratification for early surgery in patients with large vegetations is a cost-attractive treatment strategy for IE, as it improves outcome for an incremental cost <$50 000/QALY.

  • endocarditis
  • stroke
  • decision analysis

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Footnotes

  • Competing interests: None declared.

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