The cost-effectiveness of exclusion arteriography in extremity trauma.

The purpose of this study was to apply decision analysis to an established practice in vascular trauma diagnosis. While exclusion arteriography has resulted in an increase in positive surgical explorations, no formal analysis that determined either the cost-effectiveness of exclusion arteriography or the cost-effectiveness ratio has been reported in the literature. We created a decision model that compared exclusion arteriography and surgical exploration, the standard used prior to the development of extremity arteriography. The decision model used predominantly literature derived estimates for the prevalence of arterial injuries and the accuracy, complications, outcomes and costs of both arteriography and exploration. Exclusion arteriography is cost-effective. This finding is robust to changes in the major model variables. Compared to surgical exploration, exclusion arteriography is a superior strategy by dominance (more effective and costs less). Therefore, a cost-effectiveness ratio cannot be calculated. Under the base case assumption of 28% prevalence of arterial injury requiring operation, exclusion arteriography saves about $2000 and adds 0.3 quality adjusted life years (QALY) for each patient. Decision analysis can be successfully applied to problems in vascular trauma diagnosis.

Proximity arteriography: cost-effectiveness in asymptomatic penetrating extremity trauma.

PURPOSE: Many urban trauma centers have abandoned proximity arteriography, which is defined as exclusion arteriography used to evaluate the asymptomatic patient with penetrating extremity trauma near major arteries. However, decision analysis has not been applied to study proximity arteriography. MATERIALS AND METHODS: The cost-effectiveness of proximity arteriography was examined by creating a decision model that compared arteriography with observation after patient examination in the trauma unit. The model used predominantly literature-derived estimates for input variables and outcomes. The authors retrospectively reviewed arteriograms for 1 year to identify major occult injuries (requiring intervention) at their institution. After a resource-based cost analysis from the taxpayers' perspective, the cost-effectiveness ratio was calculated (incremental cost per quality-adjusted life year [QALY] gained) for proximity arteriography. RESULTS: For proximity trauma, arteriography is a dominant strategy (more effective and costs less) at a prevalence of major occult injury of 5.5% or more. Observation is a dominant strategy if the prevalence is from 0% to 0.5% or 2.0%, depending on arteriography complication assumptions. In between, arteriography is cost-effective, with a ratio of $12,100 per QALY at 2.5% prevalence (base case). Besides prevalence of occult injury, the model is sensitive to outcome assumptions for occult injuries. CONCLUSION: Proximity arteriography is a cost-effective procedure if major occult injuries equal or exceed 1.0%.