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Incorporating Patient-Centered Outcomes in the Analysis of Cost-Effectiveness: Imaging Strategies for Renovascular Hypertension

¹ Department of Radiology, University of Michigan, 1500 E Medical Center Dr., Ann Arbor, MI 48109-0030.
² Department of Surgery, University of Michigan, Ann Arbor, MI 48109-0030.
³ Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109-0030.

View larger version (12K): [in a new window]   Fig. 1. —Diagram shows decision tree comparing natural history of medication-resistant hypertension (MRH) with other evaluation and treatment strategies and events occurring within the first year after presentation. Treatment response ranges from improvement (diastolic blood pressure, [DBP], 90 mm Hg), to some improvement (DBP, 90–110 mm Hg), to no improvement (DBP > 110 mm Hg). hx = history, tx = therapy, CTA = CT angiography, MRA = MR angiography, CA = conventional angiography, NRD = contrast nephropathy requiring dialysis, Senscta = sensitivity of CT angiography, sensangio = sensitivity of conventional angiography, angio = angiography.

View larger version (18K): [in a new window]   Fig. 2. —Diagram shows decision tree comparing natural history of medication-resistant hypertension with other evaluation and treatment strategies and events occurring after treatment (stent placement for either renal artery stenosis or enhanced medical therapy). Individuals can remain status quo, acquire one or more adverse sequelae of hypertension, or die (either from hypertension, its complications, or unrelated cause). Probability of death or other complications resulting from hypertension (e.g., chronic renal failure [crf], myocardial infarction [mi], stroke, or any combination of these three) depends on diastolic blood pressure (DBP). One-time costs accrue from diagnostic tests or stent placement. Yearly costs accrue from enhanced medical therapy, dialysis, or management of myocardial infarction or stroke.

View larger version (9K): [in a new window]   Fig. 3. —Graph shows cost–utility trade-off of evaluation and treatment strategies in medication-resistant hypertension. Natural history of medication-resistant hypertension represents base case (BC) and results in least costly strategy with shortest quality-adjusted life expectancy. All alternative strategies increase quality-adjusted life expectancy at increased expense. Slope of line drawn between BC and each of other strategies estimates relative cost-effectiveness of alternatives. Steeper slope corresponds to less cost-effective strategy, relative to other alternative strategies. Thus, enhanced medical therapy without imaging (Med) is less cost-effective than any of other strategies incorporating preliminary imaging. MR angiography (MRA) is most cost-effective strategy compared with BC and dominates medical therapy and CT angiography (CTA) strategies. Conventional angiography (CA) is cost-effective alternative to MRA.

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