Cost Evaluation of Endovascular Coiling and Surgical Clipping of Intracranial Aneurysm : A Systemic Review : راشتنا لحم

:هلاقم هصلاخ Introduction: Cost-effectiveness of medical intervention is becoming increasingly important in healthcare delivery. Treatment in neurosurgery is extremely expensive and there have been very few publications on neurosurgical health economics and comparative effectiveness analysis of neurosurgical procedures. Previous studies which had compared the costs of clipping and coiling were held out in European centers with data specifically from the ISAT study conducted in Europe. No significant differences were seen in the total cost of coiling when compared to clipping in a time period of one year. Methods: A systematic literature search was conducted using electronic databases including MEDLINE and EMBASE. The inclusion criteria included the literature search limited to the last ۱۰ years (۲۰۰۶-۲۰۱۶), studies on adult human patients, and papers published in English. All editorials, comments and correspondences were excluded from this study. Results: Systematic literature search yielded ۵۷۸۴ studies. After removing duplicates and non-relevant studies, finally five studies had specifically analyzed cost economics of coiling and clipping of intracranial aneurysm. Overall, coiling was more expensive than clipping in three studies. The study which was conducted by Wolsteholme et al. showed no significant differences between the two procedures in terms of their costs. Conclusion: Cost evaluations of intracranial aneurysm showed that surgical clipping results to reduced re-operation rate when compared to endovascular coiling, associated with increased complications, longer hospital stays and ultimately greater hospital costs.


Introduction
The standard treatment of intracranial aneurysms has been neurosurgical clipping.2][3] The major advantage of endovascular coiling is the avoidance of craniotomy and early recovery following the procedure.The major disadvantage is in the event of coil impaction of the failed endovascular coiling.Actually, patients will have to undergo craniotomy. 4Endovascular coiling of intracranial aneurysm was firstly introduced in 1991 as an alternative to microsurgical clipping.The proportion of patients undergoing endovascular coiling increased from 34% to 54% in the UK after this publication. 5ost-effectiveness of medical interventions is becoming increasingly important in healthcare delivery.7][8][9] Previous studies which had compared the cost of clipping and coiling were from European centers with data specifically from the ISAT study conducted in Europe.No significant differences were observed in the total cost of coiling when compared to clipping during a one year period. 10,11 e aim of this review is to evaluate and analyses the cost-effectiveness of endovascular coiling (in comparison to neurosurgical clipping) in the treatment of intracranial aneurysm.

Methods
Systematic literature search was conducted using electronic databases including Medline, EMBASE and Google Scholar following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA).The search keywords were used individually and /or in combination to identify relevant papers.The used keywords included, Intracranial Aneurysm, Endovascular Coiling, Cost/ Cost-effectiveness.The inclusion criteria included the literature searches limited to the last 10 years (2006-2016), studies on adult human patients, and papers published in English.In addition, editorials, comments and correspondences were excluded.Finally, only five studies were used for this systematic review (Figure 1).

Results
Systematic literature search yielded 5784 studies.After removing duplicates and non-relevant studies, finally five studies that specifically analysed cost economics of coiling and clipping of intracranial aneurysm were used in this study (Figure 1).3][14] The study conducted by Wolstenholme 15 showed that clipping is much more expensive than coiling (Table 1).Treatment effectiveness was measured in QALY.Cost-effectiveness analysis includes additional consumed resources and associated health intervention measured in ICER (measure of the additional cost per health gain unit).Cost analysis for endovascular coiling and surgical clipping may not reflect the exact cost for hospitalisation and services because these were collected retrospectively and this may be influenced by ascertainment and documentation biases.In addition, the endovascular treatment is evolving at a rapid rate with significant and remarkable changes and adjustment.Hence, this will go a long way to influence the cost effectiveness unlike surgical clipping technique with little or no changes.This study reveals that in the United States, endovascular coiling results with higher costs in a one year period.It also associates with better outcomes compared to surgical clipping among patients with ruptured intracranial aneurysm suitable for either endovascular or neurosurgical treatment pathways.Wolstenholme et al. 15 carried out a cost analysis on the treatment pathways, used resources and the cost of endovascular coiling and surgical clipping after aneurysmal subarachnoid haemorrhage.This study was a post-randomisation analysis of ISAT.A total number of 2143 patients were recruited to the ISAT trial by 42 neurological centres.This is while this study focused on the UK patients only comprising 1644 patients with a randomised endovascular group of 809 patients and a neurosurgical group of 835 patients.These patients were followed up for two years.
It was obviously seen that during the first episode of care, the staff costs associated with interventions were remarkably lower in the endovascular group (£1450 per patient) as compared to the neurosurgical group (£2108), a difference of £658.As the consumable costs were higher in the endovascular group (£ 2627) than the neurosurgical group (£901), this significant difference was due to the cost of coils.The costs of post-operative length of stay in the first episode of care were much lower in the endovascular group (£11 547) compared to the neurosurgical group (£15 311).These results reveal that neurosurgical groups spent more days in the inpatient wards, ITU and rehabilitation clinics compared to the endovascular.The mean and standard deviation of the overall total cost per patients after 12-months follow up was estimated to be £18 436 and £15 849 respectively for the endovascular group.This is while, the mean value of £20 176 with a standard deviation of £21 984 for the neurosurgical group with insignificant difference of £1740 was in favour of the endovascular patients.Furthermore, subsequent care costs from 12 to 24 months follow up showed a mean cost of £613 in the endovascular group as against £131 in the neurosurgical group.This actually shows a remarkable difference of £482 in favour of the neurosurgical group.
There is no significant difference in the treatment costs for aneurysmal subarachnoid haemorrhage, though in favour of endovascular group in the first 12 months, endovascular patients had higher cost of treatment during the first intervention that was latter minimized by length of stay.In addition, in the 12 to 24 months follow up period, costs were greater in the endovascular group due to subsequent procedures including angiograms, complications and adverse effects.There is no information regarding the costs for long-term nursing and informal care hence this study is not a reflection of accurate and exact cost effectiveness.However, it provides a significant glimpse into the cost economics of aneurysmal subarachnoid treatment pathway.Tahir et al. 14 performed a study on the cost-effectiveness of clipping compared to coiling of intracranial aneurysm after subarachnoid haemorrhage in a developing country.This research was a prospective study with a population of 55 patients with aneurysmal subarachnoid haemorrhage and was actively treated and followed up for ruptured aneurysm at Aga Khan University Hospital (Pakistan) between January 2004 and June 2007.All costs were in Pakistani Rupees (Rs) which got converted to US dollars, 60Rs = $1).Costs included treatment costs (clipping or coiling), inpatient stay (initial stay, regular bed, ICU bed occupancy), and radiologic follow up (angiograms).Total costs were manually calculated.Clinical outcomes were measured at the time of discharged and six months follow up visit using the modified Rankin scale.Statistical analysis were performed using SPSS 13.0 (SPSS, Chicago, and III).The average total cost for coiling and clipping was $5080 (Rs.304 800) and $3127 (Rs.187 620) respectively.The cost of coiling was found to be 62% more expensive compared to the cost of clipping without providing additional benefit of decrease morbidity.There was a decrease in the cost of hospital stay in the endovascular group due to the short length of stay as compared to the surgical group.
As this study was conducted in a developing country, only 7% of them were medically insured.This issue put huge financial pressure on both patients and their relatives.In terms of the clinical outcome, this study showed no significant difference between coiling and clipping.Hol et al. 18

Conclusions
Cost economics of intracranial aneurysm showed that surgical clipping reduced the re-operation rate when compared to endovascular coiling and also associated with increased complication, longer hospital stay and ultimately greater hospital cost.However, clipping is costlier than coiling for the initial procedure but in terms of the overall cost for one, two and five years post procedure period did not reveal any statistically significant differences.In addition, Wolstenholme 15 found no significant difference in regards to the cost between coiling and clipping 2-years post aneurysm treatment.However, an Australian study1 showed that clipping was associated with higher total costs.

Ethical Approval
None.

Table 1 . Study Characteristics Study/ Year Design Clipping (cost) Coiling (cost) Egger 13 2009 Retrospective study $41769 $45493 Wolstenholme 15 2007 Post randomisation analysis £20176 £18436 Tahir 14 2009
additional resources consumed and associated with health intervention measured in ICER (measure of the additional cost per health gain unit).The average cost was estimated by multiplying each cost by the rate of clinical outcomes from the findings of ISAT.

5784 Articles identified through databases search 3415 Articles after removal of duplicates 560 full text articles screened 15 Relevant articles excluded 5 Studies for systematic Review 545 full text articles excluded 10 Non-relevant studies International
This research was a retrospective study based on the foremost database in the United States from 2005-2006 using the ISAT trial to extract data and for comparisons.ISAT is the best evidence for the treatment of intracranial aneurysm.About 1000 patients were randomized in each group with the majority in good clinical conditions (WFNS Grades I-III).
Journal of Medical Reviews.2017;4(1):32-36 13ear overall total healthcare cost of $75 784 for surgical clipping compared to $73 673 for endovascular coiling (P = 0.51).Patients who underwent surgical clipping accumulated more haemorrhage related costs at 5 years ($3352 vs $731, P = 0.63).Though clipping is associated with increased complications but results in less reoperation rates hence, the cost of clipping and coiling are comparable at 5-yrears.This is while those in the coiling group accumulate more costs due to longer follow up as a result of high reoperation rates and angiogram rates.The study conducted by Maud et al. was the only research which recorded QUALY and ICER values13.