Cost-Effectiveness Analysis of Early Minimally Invasive Removal of Intracerebral Hemorrhage

Abstract

Background: Supratentorial intracerebral hemorrhage (ICH) is common and often devastating. In a randomized controlled trial, ICH evacuation with minimally invasive trans-sulcal parafascicular surgery (MIPS) improved functional outcomes at 180 days compared with medical management (MM), primarily in patients with lobar hemorrhages. The cost-effectiveness of MIPS compared with MM is explored.

Methods: A Markov model compared costs and outcomes using ENRICH trial (Early Minimally Invasive Removal of Intracerebral Hemorrhage) data for MIPS versus MM over the 6-month trial duration. Costs were 2020 US$ and effectiveness was quality-adjusted life years. Monthly model transitions between modified Rankin Scale score health states were estimated from trial data. Costs were obtained from US databases and literature. MIPS device costs were $5705/patient. Primary outcomes were total hospital costs from the hospital perspective and the incremental cost-effectiveness ratio between MIPS and MM (ie, the 6-month cost difference between strategies divided by quality-adjusted life year difference) from the healthcare perspective for patients with lobar ICH. Sensitivity analyses were performed.

Results: From the hospital perspective, MIPS costs were $2782 less per patient than MM ($74 252 versus $77 034), with MIPS having decreased the intensive care unit hospital length of stay, non-MIPS neurosurgery, mortality, and rehospitalization. From the healthcare perspective, including hospital and nonhospital costs, MIPS in lobar ICH cost $8850 less and gained 0.068 quality-adjusted life year per patient compared with MM; thus MIPS was dominant (less costly and more effective). Results were robust to individual parameter variation over plausible ranges and, with all parameters varied simultaneously in a probabilistic sensitivity analysis, MIPS was dominant in >93% of 10 000 model iterations and favored in >99% at $100 000/quality-adjusted life year gained (a common US benchmark).

Conclusions: In the ENRICH randomized controlled trial, MIPS cost less and was more effective compared with MM from both hospital and healthcare perspectives for patients with lobar ICH.

Registration: URL: https://clinicaltrials.gov/; Unique identifier: NCT02880878.

Keywords: cost-benefit analysis; cost-effectiveness analysis; minimally invasive surgical procedures; quality-adjusted life years; stroke.