Health economics analysis of minimally invasive surgery for hypertensive intracerebral hemorrhage based on a multicenter randomized controlled trial

Objective To evaluate the health economics differences of 3 minimally invasive surgical techniques about neuroendoscopic surgery, frameless stereotactic catheter drainage guided by imaging navigation (puncture drainage), and small bone window craniotomy over a 6-month follow-up period. Methods Total 651 patients with hypertensive intracerebral hemorrhage treated between July 2016 and June 2022 at 16 medical centers in China were included: neuroendoscopic surgery (n=219), puncture drainage (n=220), and small bone window craniotomy (n=212). Neurological outcomes at 6 months were assessed using the modified Rankin Scale (mRS), which was then mapped to health utility values to calculate quality adjusted life year (QALY). Cost-effectiveness analysis (CEA) and cost-utility analysis (CUA) models were constructed to calculate the incremental cost-effectiveness ratio (ICER) and incremental cost-utility ratio (ICUR), with one-way and probabilistic sensitivity analyses (PSA) performed to assess result robustness. Results Puncture drainage achieved the lowest hospitalization cost (77351 CNY) and favorable health utility (QALY=0.204 years), resulting in the most favorable CUA (379110 CNY/QALY), making the optimal surgical approach with the greatest health economics advantage. Although neuroendoscopic surgery yielded slightly higher QALY (0.218 years), its high consumable and equipment costs led to an ICUR of approximately 1059630 CNY/QALY, far exceeding China's willingness-to-pay threshold, limiting its broad application. Small bone window craniotomy showed the lowest benefit, with the lowest QALY (0.189 years) and the highest cost (100947 CNY), and was therefore deemed an economically inferior strategy. One-way and PSA showed that puncture drainage had the greatest health economics advantage and was the only surgical procedure that maintained its economics advantage across different parameter assumptions and willingness-to-pay thresholds. Conclusions Under the current healthcare cost structure and willingness-to-pay context, puncture drainage demonstrates the best performance in terms of cost, clinical effectiveness and health economics advantage, making it the preferred minimally invasive surgical approach for the treatment of hypertensive intracerebral hemorrhage. Neuroendoscopic surgery, despite higher health utility value, is better suited for individualized use in specific patient populations due to cost constraints. Small bone window craniotomy, with high cost and low benefit, is not recommended as a routine surgery option. This study provides systematic and quantitative evidence to support clinical decision, making regarding surgical pathway selection and the optimization of health insurance reimbursement policies.