Cost-effectiveness of percutaneous patent foramen ovale closure as secondary stroke prevention

J Med Econ. 2018 Jul;21(7):656-665. doi: 10.1080/13696998.2018.1456445. Epub 2018 Apr 13.

Abstract

Objective: Compared to medical therapy alone, percutaneous closure of patent foramen ovale (PFO) further reduces risk of recurrent ischemic strokes in carefully selected young to middle-aged patients with a recent cryptogenic ischemic stroke. The objective of this study was to evaluate the cost-effectiveness of this therapy in the context of the United Kingdom (UK) healthcare system.

Methods: A Markov cohort model consisting of four health states (Stable after index stroke, Post-Minor Recurrent Stroke, Post-Moderate Recurrent Stroke, and Death) was developed to simulate the economic outcomes of device-based PFO closure compared to medical therapy. Recurrent stroke event rates were extracted from a randomized clinical trial (RESPECT) with a median of 5.9-year follow-up. Health utilities and costs were obtained from published sources. One-way and probabilistic sensitivity analyses (PSA) were performed to assess robustness. The model was discounted at 3.5% and reported in 2016 Pounds Sterling.

Results: Compared with medical therapy alone and using a willingness-to-pay (WTP) threshold of £20,000, PFO closure reached cost-effectiveness at 4.2 years. Cost-effectiveness ratios (ICERs) at 4, 10, and 20 years were ₤20,951, ₤6,887, and ₤2,158, respectively. PFO closure was cost-effective for 89% of PSA iterations at year 10. Sensitivity analyses showed that the model was robust.

Conclusions: Considering the UK healthcare system perspective, percutaneous PFO closure in cryptogenic ischemic stroke patients is a cost-effective stroke prevention strategy compared to medical therapy alone. Its cost-effectiveness was driven by substantial reduction in recurrent strokes and patients' improved health-related quality-of-life.

Keywords: Cost-effectiveness; D61, I13; Markov model; cryptogenic stroke; ischemic stroke; patent foramen ovale; percutaneous device closure; recurrent stroke.

Publication types

  • Multicenter Study
  • Randomized Controlled Trial

MeSH terms

  • Adolescent
  • Adult
  • Cost-Benefit Analysis
  • Female
  • Fibrinolytic Agents / administration & dosage
  • Foramen Ovale, Patent / complications
  • Foramen Ovale, Patent / surgery*
  • Health Resources / economics
  • Health Resources / statistics & numerical data
  • Humans
  • Male
  • Markov Chains
  • Middle Aged
  • Models, Econometric
  • Quality of Life
  • Recurrence
  • Secondary Prevention / economics*
  • Secondary Prevention / methods*
  • Severity of Illness Index
  • Stroke / economics*
  • Stroke / etiology
  • Stroke / prevention & control*
  • United Kingdom
  • Young Adult

Substances

  • Fibrinolytic Agents