Cost-Effectiveness of Adjunctive Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: Secondary Analysis of EMBOLISE.

BACKGROUND AND PURPOSE: Chronic subdural hematoma (cSDH) has high recurrence rates after evacuation surgery (ES). Middle meningeal artery embolization (MMAE) adjunctive to ES reduces recurrence but increases hospital costs. This study evaluated the cost-effectiveness of adjunctive MMAE (ES/MMAE) versus ES alone as a secondary post hoc analysis of the Embolization of the Middle Meningeal Artery With ONYX Liquid Embolic System for Subacute and Chronic Subdural Hematoma (EMBOLISE) randomized trial of ES/MMAE versus ES alone.

MATERIALS AND

METHODS

A cost-effectiveness analysis using 2024 US dollars was conducted averaging hospital costing data from 2 EMBOLISE trial sites for 42 patients with cSDH (21 ES/MMAE, 21 ES alone) from a US hospital (health facility) perspective, with clinical data (eg, cSDH recurrence rates) derived from the EMBOLISE trial. Quality-adjusted life years (QALYs) were derived from EuroQol 5-dimension 5-level assessment data with a 180-day horizon. Incremental cost-effectiveness ratio (ICER) was calculated. One- and 2-way sensitivity analyses and probabilistic sensitivity analysis (PSA) with 5000 Monte Carlo iterations (gamma distributions for costs and beta for utilities/probabilities) were performed.

RESULTS

Mean expected costs were $23,809 for ES/MMAE (4.1% recurrence rate), $17,197 for ES alone (11.3% recurrence rate), and $10,376 for rescue surgery for either treatment. ES/MMAE provided a 0.02 QALY gain over ES alone, at an incremental cost of $6612. The resultant ICER was approximately $382,267.50/QALY, exceeding the commonly cited $100,000/QALY cost-effectiveness criterion. One-way sensitivity analyses indicated QALY gain was the most impactful economic driver. PSA indicated a 31.8% probability of ES/MMAE being cost-effective at $100,000/QALY (68.2% for ES alone).

CONCLUSIONS

At 2024 pricing, and from a US hospital perspective, ES/MMAE for cSDH may not be cost-effective within a 180-day horizon, but PSA suggests a greater favorability toward ES/MMAE at higher willingness-to-pay thresholds. The positive net QALY benefit with adjunctive MMAE for cSDH suggests a small but meaningful quality-of-life improvement, preventing complete ES dominance. Cost-reduction strategies, longer time frames, and validated cSDH-specific patient-reported outcome measures could enhance ES/MMAE cost-effectiveness. These findings could guide future optimization efforts for ES/MMAE for cSDH management.