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Abstract - Original Article

J Cerebrovasc Endovasc Neurosurg. 2021 23(1): 6-15
The Journal of Cerebrovascular and Endovascular Neurosurgery
Surgical revascularization for Moyamoya disease in the United States: A cost-effectiveness analysis
David. R. Santiago-Dieppa1, Shanmukha Srinivas1, Michael G. Brandel1, Jeffrey A. Steinberg1, Robert C Rennert1, Ross Mandeville2, James D. Murphy3, Scott Olson1, J. Scott Pannell1, Alexander A. Khalessi1
1Department of Neurological Surgery, University of California, San Diego, CA, USA 2Department of Neurology, University of California, San Diego, CA, USA 3Department of Radiation Medicine and Applied Sciences, University of California, San Diego, CA, USA

Objective: Moyamoya disease (MMD) is a vasculopathy of the internal carotid arteries with ischemic and hemorrhagic sequelae. Surgical revascularization confers upfront peri-procedural risk and costs in exchange for long-term protective benefit against hemorrhagic disease. The authors present a cost-effectiveness analysis (CEA) of surgical versus non-surgical management of MMD. Methods: A Markov Model was used to simulate a 41-year-old suffering a transient ischemic attack (TIA) secondary to MMD and now faced with operative versus non-operative treatment options. Health utilities, costs, and outcome probabilities were obtained from the CEA registry and the published literature. The primary outcome was incremental cost-effectiveness ratio which compared the quality adjusted life years (QALYs) and costs of surgical and nonsurgical treatments. Base-case, one-way sensitivity, two-way sensitivity, and probabilistic sensitivity analyses were performed with a willingness to pay threshold of $50,000. Results: The base case model yielded 3.81 QALYs with a cost of $99,500 for surgery, and 3.76 QALYs with a cost of $106,500 for nonsurgical management. One-way sensitivity analysis demonstrated the greatest sensitivity in assumptions to cost of surgery and cost of admission for hemorrhagic stroke, and probabilities of stroke with no surgery, stroke after surgery, poor surgical outcome, and death after surgery. Probabilistic sensitivity analyses demonstrated that surgical revascularization was the cost-effective strategy in over 87.4% of simulations. Conclusions: Considering both direct and indirect costs and the postoperative QALY, surgery is considerably more cost-effective than non-surgical management for adults with MMD.
Key words : Cost-effectiveness, Moyamoya disease, Cerebrovascular neurosurgery, Surgical revascularization, Stroke

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