{
  "abstract": "Background A clinical prediction model (IMPROVE) for ipsilateral ischaemic stroke risk in symptomatic patients with carotid disease was recently developed with good performance. We aim to evaluate the model-based cost-effectiveness of IMPROVE-based triage versus triage in care-as-usual (CAU) for optimal medical treatment (OMT) alone or carotid endarterectomy plus OMT.Methods A dataset of 678 patients with carotid disease and a recent ipsilateral ischaemic stroke, transient ischaemic attack or amaurosis fugax from four cohort studies informed a decision-analytic model. Stratification of patients for carotid endarterectomy was based on ≥50% carotid stenosis (CAU arm) or a range of 3-year ipsilateral ischaemic stroke risk thresholds (IMPROVE arm). The threshold resulting in the lowest number of ipsilateral strokes and perioperative strokes and deaths was selected as the optimal threshold. Patients with <50% stenosis (CAU) or an IMPROVE risk score below the threshold (IMPROVE) were modelled to receive OMT only. Parameter uncertainty was incorporated in probabilistic analyses using Monte Carlo simulations for a 3-year and lifetime horizon. Subgroup analyses for <50%, 50–69% and 70–99% carotid stenosis were performed.Results IMPROVE-based triage reduced ipsilateral ischaemic strokes and perioperative strokes and deaths by 34.5% (CAU: 4.3%, IMPROVE: 2.8%) over 3 years. Revascularisations decreased by 20% with IMPROVE, while Quality-Adjusted Life Years slightly increased. Procedural stroke occurred in 1.8% of patients in CAU versus 1.4% of patients for IMPROVE. Societal costs decreased on average by €1441/patient for IMPROVE versus CAU for a 3-year time horizon (lifetime cost reduction: €6101/patient). Subgroup analyses identified IMPROVE as the superior strategy for 50–69% and 70–99% stenosis (3-year and lifetime horizon) and <50% stenosis (lifetime horizon).Conclusions In this modelling analysis, triage of symptomatic patients with carotid disease with the IMPROVE model can lead to the prevention of one-third of ipsilateral ischaemic strokes and perioperative strokes and deaths, while also reducing societal costs. These findings should be validated in a clinical trial.",
  "authors": [
    {
      "affiliations": [
        "Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, Maastricht, LI, Netherlands",
        "CARIM Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, LI, Netherlands"
      ],
      "name": "Kelly P H Nies"
    },
    {
      "affiliations": [
        "Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University, Maastricht, LI, Netherlands"
      ],
      "name": "Bram Ramaekers"
    },
    {
      "affiliations": [
        "Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, Maastricht, LI, Netherlands",
        "CARIM Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, LI, Netherlands"
      ],
      "name": "Juul Bierens"
    },
    {
      "affiliations": [
        "Sir Peter Mansfield Imaging Centre and Mental Health & Clinical Neuroscience Unit, School of Medicine, University of Nottingham, Nottingham, Nottinghamshire, UK",
        "NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, England, UK"
      ],
      "name": "Dorothee P Auer"
    },
    {
      "affiliations": [
        "Institute of Neuroradiology, University Hospital, LMU Munich, Munich, BY, Germany"
      ],
      "name": "Andreas Schindler"
    },
    {
      "affiliations": [
        "Die Radiologie, Radiologie Rosenheim, Rosenheim, BY, Germany"
      ],
      "name": "Tobias Saam"
    },
    {
      "affiliations": [
        "Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, ZH, Netherlands",
        "Department of Epidemiology, Erasmus MC University Medical Center Rotterdam, Rotterdam, ZH, Netherlands"
      ],
      "name": "Daniel Bos"
    },
    {
      "affiliations": [
        "Department of Radiology and Nuclear Medicine, University Medical Centre Utrecht, Utrecht, GE, Netherlands"
      ],
      "name": "Pim A de Jong"
    },
    {
      "affiliations": [
        "Department of Neurology, Amsterdam University Medical Centres, Duivendrecht, Noord-Holland, Netherlands"
      ],
      "name": "Paul J Nederkoorn"
    },
    {
      "affiliations": [
        "Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, Netherlands",
        "Reinier de Graaf Gasthuis, Delft, Netherlands"
      ],
      "name": "Gert J de Borst"
    },
    {
      "affiliations": [
        "CARIM Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, LI, Netherlands",
        "Department of Neurology, Maastricht University Medical Centre+, Maastricht, LI, Netherlands"
      ],
      "name": "Robert J van Oostenbrugge"
    },
    {
      "affiliations": [
        "Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University, Maastricht, LI, Netherlands"
      ],
      "name": "Manuela A Joore"
    },
    {
      "affiliations": [
        "Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, Maastricht, LI, Netherlands",
        "CARIM Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, LI, Netherlands"
      ],
      "name": "M Eline Kooi"
    },
    {
      "affiliations": [
        "Department of Epidemiology, Maastricht University, Maastricht, Limburg, Netherlands"
      ],
      "name": "Luc J M Smits"
    }
  ],
  "title": "Risk-based selection for carotid revascularisation using the IMPROVE score versus standard care in symptomatic carotid artery disease: a model-based cost-effectiveness analysis using pooled-data",
  "uid": "aa1d167f-d92a-5dd4-90cd-005089ab8b22"
}