Cost-effectiveness of screening for carotid stenosis in asymptomatic persons

Ann Intern Med. 1997 Mar 1;126(5):337-46. doi: 10.7326/0003-4819-126-5-199703010-00001.


Background: The Asymptomatic Carotid Atherosclerosis Study (ACAS) showed that carotid endarterectomy was beneficial for symptom-free patients with carotid stenosis of 60% or more. This finding raises the question of whether widespread screening to identify cases of asymptomatic carotid stenosis should be implemented.

Objective: To determine whether a screening program to identify cases of asymptomatic carotid stenosis would be a cost-effective strategy for stroke prevention.

Design: Cost-effectiveness analysis using published data from clinical trials.

Setting: General population of asymptomatic 65-year-old men.

Intervention: Patients who were screened for carotid disease with duplex Doppler ultrasonography were compared with patients who were not screened. If ultrasonography found significant carotid stenosis (> or = 60%), disease was confirmed by angiography before carotid endarterectomy was done.

Measurements: Quality-adjusted life-years, costs, and marginal cost-effectiveness ratios.

Results: When the conditions and results of ACAS were modeled and it was assumed that the survival advantage produced by endarterectomy would last for 30 years, the lifetime marginal cost-effectiveness of screening relative to no screening was $120,000 per quality-adjusted life-year. Sensitivity analysis showed that marginal cost-effectiveness decreased to $50,000 or less per quality-adjusted life-year only under implausible conditions (for example, if a free screening instrument with perfect test characteristics was used or an asymptomatic population with a 40% prevalence of carotid stenosis was found).

Conclusions: Surgery offers a real but modest absolute reduction in the rate of stroke at a substantial cost. A program to identify candidates for endarterectomy by screening asymptomatic populations for carotid stenosis costs more per quality-adjusted life-year than is usually considered acceptable.

Publication types

  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, Non-P.H.S.
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Aged
  • Carotid Stenosis / diagnostic imaging*
  • Carotid Stenosis / surgery
  • Cerebrovascular Disorders / prevention & control*
  • Cost-Benefit Analysis
  • Decision Support Techniques
  • Endarterectomy, Carotid
  • Health Care Costs
  • Humans
  • Male
  • Mass Screening / economics*
  • Quality-Adjusted Life Years
  • Sensitivity and Specificity
  • Ultrasonography, Doppler, Duplex / economics