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 We constructed a decision tree and Markov analysis model using published and institutional data to estimate the cost-effectiveness of an echocardiographic risk-stratification strategy for infective endocarditis. Our 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&rdquo").
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 to 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 is a cost-attractive treatment strategy for IE, as it improves outcome for an incremental cost < $50,000/QALY. Key words: endocarditis, stroke, decision analysis
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