David Epstein informed the 2009 CX Symposium audience of his role in the NICE (The National Institute for Clinical Excellence) appraisal of EVAR cost-effectiveness. In his presentation, he concluded, “previous cost-effectiveness analysis concluded that that EVAR was not cost-effective given the survival, cost, and long-term risk of complications.” He referred to the publication from himself, Professor Mark Sculpher, and others, modelling the long-term cost-effectiveness of endovascular and open repair for abdominal aortic aneurysm which appeared in the British Journal of Surgery in 2008.
The first model presented to NICE was based to a large extent on the EVAR 1 trial results. As can be seen in Table 1, the incremental cost-effectiveness ratio was £121,725 pounds per quality life year gained (QALY). He explained to delegates that NICE regards £20,000 pounds per QALY as the threshold of cost-effectiveness.
Epstein assumed that the excess hazard of late aneurysm mortality would be lowered, taking the initial cost down to £48,990.
And with an assumption that less surveillance will be needed in future, it fell further, to £43,988.
And with an assumption that fewer reinterventions will be needed, it fell further, to £24,227.
The final assumption which did the trick, lower procedure costs, brought the figure to £12,305 per QALY.
NICE seems to have accepted all of these assumptions and declared EVAR cost-effective based upon them.
The workings and these findings came as a surprise to the audience of 2,000 vascular specialists from 71 countries attending CX2009 in Imperial College in April. The EVAR enthusiasts were, of course, delighted. There were understandable groans from conservative surgeons. And a focus on the methodology used by NICE created the biggest uproar.
It was commented that the method used was similar to that of a management consultant in which a desired result is sometimes delivered against the odds. CX delegates expected merely an interim statement in 2008, and a more definitive statement when more data are available. But it seems that NICE are happy to announce on these assumptions.
Endovascular enthusiasts are delighted. There are concerns, however. These decisions are based upon the above assumptions and in the next three years it will become plain whether the assumptions become reality. It is not all over yet.