Selective preoperative cardiac screening improves five-year survival in patients undergoing major vascular surgery: A cost-effectiveness analysis

Abstract

Objective: To evaluate the long-term outcomes (5-year survival) and cost-effectiveness of selective coronary revascularization before major vascular surgery. Design: A decision-tree model was constructed to compare the cost-effectiveness of four preoperative screening strategies from the perspective of the health care system. Setting: Based on patient mortality, morbidity, and cost data from a literature review. Participants: Hypothetical cohort of patients scheduled for elective abdominal aortic aneurysm repair followed up over a 5-year period. Interventions: Patients either proceeded directly to surgery or were screened using one of three possible preoperative screening strategies. In the first strategy, all patients were screened with a dipyridamole-thallium test. In the second strategy, all patients underwent coronary angiography. The third strategy, selective screening, first divided patients into high-, intermediate-, and low-risk groups using clinical criteria. High-risk patients underwent preoperative angiography. Intermediate-risk patients were screened noninvasively, and low-risk patients proceeded directly to surgery without further testing. Measurement and Main Results: Proceeding directly to vascular surgery resulted in the poorest 5-year survival rate (77.4%) compared with preoperative risk stratification followed by selective coronary revascularization, routine noninvasive testing (86.1%), selective testing (86.0%), and routine angiography (87.9%; p = 0.00). The incremental cost-effectiveness ratio for selective testing was significantly lower than for routine angiography ($44,800/years of life saved (YLS) v $93,300/YLS; p < 0.02). Routine noninvasive testing was not cost-effective. Thirty-day mortality was the same for all four strategies ( p = 0.84). Conclusion: Selective screening before vascular surgery may improve 5-year survival and be cost-effective. Neither routine noninvasive testing nor routine angiography appears to be cost-effective compared with currently accepted medical therapies.