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Echocardiographic risk stratification for early surgery with endocarditis: a cost-effectiveness analysis
  1. Lawrence Liao (liao0002{at}mc.duke.edu)
  1. Duke University, United States
    1. David F Kong
    1. Duke University, United States
      1. Zainab Samad
      1. Duke University, United States
        1. Paul A Pappas
        1. Duke University, United States
          1. James G Jollis
          1. Duke University, United States
            1. Shu S Lin
            1. Duke University, United States
              1. Andrew Wang
              1. Duke University, United States
                1. Vance Fowler
                1. Duke University, United States
                  1. Vivian Chu
                  1. Duke University, United States
                    1. Daniel Sexton
                    1. Duke University, United States
                      1. G Ralph Corey
                      1. Duke University, United States
                        1. Christopher H Cabell (chris.cabell{at}duke.edu)
                        1. Duke University, United States

                          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 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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