Renal artery stenosis: Cost-effectiveness of diagnosis and treatment
Purpose: To use a decision analytic model to determine the cost-effectiveness of performing diagnostic digital subtraction angiography (DSA), computed tomographic (CT) angiography, or magnetic resonance (MR) angiography or proceeding immediately to tentative percutaneous revascularization in patients suspected of having renovascular hypertension. Materials and Methods: With use of a Markov-Monte Carlo decision model, cost-effectiveness analysis was performed from a societal perspective. Data were derived from the Renal Artery Diagnostic Imaging Study in Hypertension and from published literature. The base-case analyses were used to evaluate a 50-year-old patient with a diastolic blood pressure higher than 95 mm Hg and one or more clinical clues suggestive of renovascular hypertension. Outcome measures were quality-adjusted life-year (QALY), lifetime costs, and incremental cost-effectiveness. Results: For a 50-year-old male patient, immediate tentative revascularization was the least costly (€54 415) and most effective (12.265 QALYs) strategy. For the other strategies, costs and QALYs, respectively, were €55 570 and 12.195 for DSA, €55 191 and 12.163 for CT angiography, and €56 890 and 12.088 for MR angiography. For a 50-year-old female patient, costs and QALYs, respectively, were €66 731 and 13.731 for MR angiography, €63 970 and 13.749 for CT angiography, and €63 079 and 13.902 for DSA. Immediate tentative revascularization yielded more QALYs (13.937) and was more costly (€63 329) than DSA. The incremental cost-effectiveness ratio was €7143 per QALY. As the prior probability increased, use of a more invasive diagnostic imaging strategy became justified. Also, the sensitivities of CT angiography and MR angiography and the costs of DSA influenced the results. Conclusion: Given currently accepted incremental cost-effectiveness ratios, immediate tentative percutaneous revascularization is a cost-effective strategy for the diagnosis of renal artery stenosis. Management decisions should be conditional on the prior probability.