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Original research
Cost-effectiveness analysis of endovascular coiling and neurosurgical clipping for aneurysmal subarachnoid hemorrhage in Thailand
  1. Pichayen Duangthongphon1,
  2. Amnat Kitkhuandee1,
  3. Waranon Munkong2,
  4. Phumtham Limwattananon1,
  5. Onanong Waleekhachonloet3,
  6. Thananan Rattanachotphanit3,
  7. Supon Limwattananon4
  1. 1 Department of Surgery, Khon Kaen University Faculty of Medicine, Khon Kaen, Thailand
  2. 2 Department of Radiology, Khon Kaen University Faculty of Medicine, Khon Kaen, Thailand
  3. 3 Faculty of Pharmacy, Mahasarakham University, Mahasarakham, Thailand
  4. 4 Division of Social and Administrative Pharmacy, Khon Kaen University Faculty of Pharmaceutical Sciences, Khon Kaen, Thailand
  1. Correspondence to Dr Amnat Kitkhuandee, Department of Surgery, Khon Kaen University Faculty of Medicine, Khon Kaen 40002, Thailand; amnat811{at}


Background For patients with aneurysmal subarachnoid hemorrhage (aSAH), the Universal Coverage Scheme in Thailand covers the full costs of surgical and endovascular procedures except for those of embolization coils and assisting devices. Costs and effectiveness were compared between endovascular coiling and neurosurgical clipping to inform reimbursement policy decisions.

Methods Costs and quality-adjusted life years (QALYs) were compared between coiling and clipping using the decision tree and Markov models. Mortality and functional outcomes of clipping were derived from national and hospital databases, and relative efficacies of coiling were obtained from meta-analyses of randomized controlled trials. Risks of rebleeding were abstracted from the International Subarachnoid Aneurysm Trial. Costs of the primary treatments, retreatments and follow-up care as well as utilities were obtained from hospital-based data. Non-health and indirect costs were abstracted from standard cost lists.

Results Coiling and clipping contributed 10.59 and 9.28 QALYs to patients aged in their 50s. Under the societal and healthcare perspectives, the incremental costs incurred by coiling compared with clipping were US$1923 and $4343, respectively, which were equal to the incremental cost-effectiveness ratio of US$1470 and $3321 per QALY gained, respectively. Coiling became a cost-saving option when the costs of coil devices were reduced by 65.7%. At the country’s cost-effectiveness threshold of US$5156, the probability of coiling being cost-effective was 71.3% and 65.6%, under the societal and healthcare perspectives, respectively.

Conclusion Endovascular treatment for aSAH is cost-effective and this evidence supports coverage by national insurance.

  • aneurysm
  • coil
  • economics
  • subarachnoid

Data availability statement

Data may be obtained from a third party and are not publicly available.

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Data availability statement

Data may be obtained from a third party and are not publicly available.

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  • Contributors All authors approve the final manuscript version, have full access to the data and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: PD, AK. Acquisition of data: PD, WM. Analysis and interpretation of data: all authors. Drafting of the manuscript: PD, AK, PL. Critical revision of the manuscript for important intellectual content: all authors. Statistical analysis: OW, TR, SL. Obtained funding: PD.

  • Funding The present study was funded by a national research granting agency in Thailand.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.