Clinical outcomes and cost-effectiveness analysis for the treatment of basilar tip aneurysms

Background Endovascular treatment of basilar tip aneurysms is less invasive than microsurgical clipping, but requires closer follow-up. Objective To characterize the additional costs associated with endovascular treatment of basilar tip aneurysms rather than microsurgical clipping. Materials and methods We obtained clinical records and billing information for 141 basilar tip aneurysms treated with clip ligation (n=48) or endovascular embolization (n=93). Costs included direct and indirect costs associated with index hospitalization, as well as re-treatments, follow-up visits, imaging studies, rehabilitation, and disability. Effectiveness of treatment was quantified by converting functional outcomes (modified Rankin Scale (mRS) score) into quality-adjusted life-years (QALYs). Cost-effectiveness was performed using cost/QALY ratios. Results Average index hospitalization costs were significantly higher for patients with unruptured aneurysms treated with clip ligation ($71 400 +/- $47 100) compared with coil embolization ($33 500 +/- $22 600), balloon-assisted coiling ($26 200 +/- $11 600), and stent-assisted coiling ($38 500 +/- $20 900). Multivariate predictors for higher index hospitalization cost included vasospasm requiring endovascular intervention, placement of a ventriculoperitoneal shunt, longer length of stay, larger aneurysm neck and width, higher Hunt-Hess grade, and treatment-associated complications. At 1 year, endovascular treatment was associated with lower cost/QALY than clip ligation in unruptured aneurysms ($52 000/QALY vs $137 000/QALY, respectively, p=0.006), but comparable rates in ruptured aneurysms ($193 000/QALY vs $233 000/QALY, p=0.277). Multivariate predictors for higher cost/QALY included worse mRS score at discharge, procedural complications, and larger aneurysm width. Conclusions Coil embolization of basilar tip aneurysms is associated with a lower cost/QALY. This effect is sustained during follow-up. Clinical condition at discharge is the most significant predictor of overall cost/QALY at 1 year.