Brain aneurysm coiling proves better but more expensive than surgical clipping

The new era of comparative effectiveness research may test the wits of all involved in healthcare reform. It is a point underscored by a recent study from University of Minnesota researchers, which shows the latest technological advancement in the treatment of ruptured brain aneurysms has proved less invasive and more effective -- but also far more expensive -- than conventional surgical clipping.

"The study demonstrates that endovascular treatment delivers better patient outcomes but at a higher cost than surgery in patients who can be treated with either treatment," said senior investigator Dr. Adnan I. Qureshi, a professor of neurology, neurosurgery, and radiology at the University of Minnesota Medical Center, in an interview with Diagnostic Imaging.

Surgical clipping has been the standard of care for brain aneurysms for more than 70 years. In the early 1990s, neurovascular specialists added endovascular coiling as a less invasive alternative, or even as their first line of treatment. The procedure entails the insertion of tiny platinum coils into an aneurysm through the brain arteries via a catheter inserted in the groin. For either procedure to be effective, it must be performed shortly after a brain aneurysm bursts.

Ten years' worth of data collected by the International Subarachnoid Aneurysm Trial (ISAT), published in The Lancet in 2005, suggested that endovascular coiling was just as safe and effective as surgical clipping in patients with ruptured aneurysms. According to trial results, coiling led to lower rates of death and disability compared with clipping, particularly for patients with small aneurysms. ISAT, however, did not compare the two techniques' merits based on their cost-effectiveness.

Qureshi and colleagues at the University of Minnesota Medical Center and Mayo Clinic in Rochester, MN, reviewed outcomes and economic data from more than 2000 patients in the ISAT. They calculated costs incurred by treatment with either procedure, including disability, hospitalization, recurrence, and retreatment.

The investigators confirmed that coiling provided better patient outcomes than clipping. However, they also found that the minimally invasive procedure cost, on average, about $70,000 more than surgery for each survival year gained, mostly due to multiple follow-up scans and treatment of recurrence within one year of intervention. Results appeared in the May issue of the Journal of Neurosurgery (2009;110[5]:880-886).

A new generation of devices could make the benefits of coiling more permanent, said principal investigator Dr. Alberto Maud. Despite the additional treatments postcoiling, patient death and disability rates were still lower than those observed in surgically treated patients. Additional outcomes data could improve coiling's cost-effectiveness over time; it may eventually surpass surgery's, Maud said.

According to Qureshi, the findings reflect the evolution of any new procedure. Researchers first questioned if endovascular coiling could deliver better, or at least equal, patient outcomes. Physicians, on the other hand, have focused decision-making precisely on patient outcomes and not necessarily on cost-effectiveness. The next logical question, involving the whole healthcare system, will have to address the issue of coiling's cost-effectiveness and its broader applicability, Qureshi said.

"The challenge for healthcare is to make the new procedure more cost-effective" he said.