Surgical decompression's gains carry steep price

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Surgical decompression offers mortality benefits for patients with space-occupying hemispheric infarction but at a high cost, according to an analysis published online Aug. 13 in Stroke.

Results from HAMLET (Hemicraniectomy After Middle Cerebral Artery Infarction with Life-threatening Edema Trial) found that surgical decompression within 48 hours of stroke onset improved mortality for patients with space-occupying hemispheric infarction. Survivors had an increased likelihood of moderate to severe disability and cognitive impairment, though, which may require care in a rehabilitation center or nursing home.

Using HAMLET data, Jeannette Hofmeijer, MD, PhD, of Rijnstate Hospital in Arnhem, The Netherlands, and colleagues compared the costs of surgical decompression and the best medical treatment to assess cost-effectiveness. They used modified Rankin Scale scores to measure functional outcomes and based their cost analyses on 2009 prices.

Within the HAMLET cohort, 39 patients were enrolled within 48 hours and 21 of them were randomized to surgical decompression. At one year, 76 percent of surgical patients and 78 percent of medical treatment patients had a poor outcome. After three years, 24 percent of surgical patients died vs. 78 percent of medical treatment patients.   

Hofmeijer et al calculated that surgical patients had one more quality-adjusted life year (QALY) than medically treated patients after three years but with a mean difference in costs of approximately $170,000 (€127,000). In a sensitivity analysis, 98 percent of estimates topped $107,000, (€80,000).

When they explored long-term costs in Markov modeling, the estimated lifetime incremental cost-effectiveness ratio was $82,000 (€60 000) per QALY gained.

They noted that from a societal perspective, this cost for QALY gained was considered high.

“Our sensitivity analyses showed that with this threshold it is unlikely that surgical decompression can be considered cost effective,” they wrote. “Admissions in rehabilitation centers and chronic nursing homes are the most important cost drivers. These are unlikely to be modifiable.”

The cost-effectiveness analysis for the first three years used data from the trial but the lifetime cost analysis relied on assumptions and “should be interpreted with caution,” they added.