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Cost‐effectiveness Analysis of Follow‐up Strategies for Thunderclap Headache Patients With Negative Noncontrast CT
Author(s) -
Malhotra Ajay,
Wu Xiao,
Kalra Vivek B.,
Schindler Joseph,
Forman Howard P.
Publication year - 2016
Publication title -
academic emergency medicine
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.221
H-Index - 124
eISSN - 1553-2712
pISSN - 1069-6563
DOI - 10.1111/acem.12891
Subject(s) - medicine , radiology , emergency medicine
Objectives Accurate diagnosis of acute subarachnoid hemorrhage ( SAH ) is critical in thunderclap headache patients due to high morbidity and mortality associated with missed aneurysmal bleeds. The objective of this study was to determine the utility of computed tomography angiography ( CTA ) in managing patients with acute, severe headaches and negative noncontrast CT and assess the cost‐effectiveness of three different screening strategies—no follow up, CTA , and lumbar puncture ( LP ). Methods A modeling‐based economic evaluation was performed with a time horizon of 1 year for thunderclap headache patients in the emergency department with negative noncontrast CT for SAH . Sensitivity analyses were performed to determine the effect of sensitivity of CT and the prevalence of SAH on cost‐effectiveness. Results Lumbar puncture follow‐up has the lowest cost and the highest utility in the mathematical model. The Monte Carlo simulation shows noncontrast CT with LP follow‐up to be the most cost‐effective strategy in 85.3% of all cases even at a $1 million/quality‐adjusted life‐years willingness‐to‐pay. Sensitivity analyses demonstrate that LP follow‐up should be performed, except for when CT sensitivity exceeds 99.2% and the SAH prevalence is below 3.2%, where no follow‐up may be considered. Conclusions Although CTA is frequently used for evaluation of thunderclap headache patients, its utility is not clearly defined. LP follow‐up is shown to be the most cost‐effective strategy for evaluation of thunderclap headache patients in most clinical settings.