Cost-utility framework to evaluate therapeutic interventions targeting reduction in cerebral infarction among aneurysmal subarachnoid hemorrhage patients

We developed a framework to assess cost-utility of potential therapeutic interventions targeting reduction in cerebral infarction in aneurysmal subarachnoid hemorrhage (aSAH) patients prior to investing in high cost randomized controlled trials. We estimated the cost and Quality-Adjusted Life Years (QALYs) for 100 hypothetical aSAH patients varying the proportion of patients who develop cerebral infarction (35%, 30%, 25%, and 20%) during initial hospitalization. We estimated both cost and QALYs at 1, 5, and 30-year time. We compared the net costs of therapeutic interventions that cost $5,000, $10,000, $15,000, and $20,000 per patient to simulate costs of existing and potential therapeutic interventions. In the base case in which 35% of the 100 aSAH patients develop cerebral infarction, the total cost was $13,777,940, with total QALYs of 56.9 at 1 year. The total cost was lowest for 100 aSAH patients in the scenario where only 20% of them developed cerebral infarction with total cost estimated at $13,012,653 and QALYs of 60.8 at 1 year. A therapeutic intervention that costs $5,000 per patient (for example: enteral nimodipine, cilostazol or IV 25% humanized albumin alone or in various combinations) was cost effective at 1 year with 10% and 15% reduction in cerebral infarction (compared to the base case) and at 5 years with 5%, 10%, and 15% reduction in cerebral infarction based on a health system expense threshold (willingness to pay) of <$50,000 per QALY gained. A therapeutic intervention that costs $15,000 per patient (for example: IV clazosentan) was cost effective at 5 years only with 15% reduction in cerebral infarction under willingness to pay <$100,000 per QALY. We present a cost-utility framework which allows pre-trial assessment based on the cost of a therapeutic intervention and the expected magnitude of reduction in occurrence of cerebral infarction in aSAH patients.