Cost-Effectiveness of Surgical Decompression for Space-Occupying Hemispheric Infarction

Background and Purpose—Surgical decompression reduces mortality and increases the probability of a favorable functional outcome after space-occupying hemispheric infarction. Its cost-effectiveness is uncertain. Methods—We assessed clinical outcomes, costs, and cost-effectiveness for the first 3 years in patients who were randomized to surgical decompression or best medical treatment within 48 hours after symptom onset in the Hemicraniectomy After Middle Cerebral Artery Infarction With Life-Threatening Edema Trial (HAMLET). Data on medical consumption were derived from case record files, hospital charts, and general practitioners. We calculated costs per quality-adjusted life year (QALY). Uncertainty was assessed with bootstrapping. A Markov model was constructed to estimate costs and health outcomes after 3 years. Results—Of 39 patients enrolled within 48 hours, 21 were randomized to surgical decompression. After 3 years, 5 surgical (24%) and 14 medical patients (78%) had died. In the first 3 years after enrollment, operated patients had more QALYs than medically treated patients (mean difference, 1.0 QALY [95% confidence interval, 0.6–1.4]), but at higher costs (mean difference, €127 000 [95% confidence interval, 73 100–181 000]), indicating incremental costs of €127 000 per QALY gained. Ninety-eight percent of incremental cost-effectiveness ratios replicated by bootstrapping were >€80 000 per QALY gained. Markov modeling suggested costs of ≈€60 000 per QALY gained for a patient’s lifetime. Conclusions—Surgical decompression for space-occupying infarction results in an increase in QALYs, but at very high costs