Medicina Basica

From the New England Society for Vascular Surgery

Cost-effectiveness in the contemporary management of critical limb ischemia with tissue loss
Neal R. Barshes, MD, MPH,a James D. Chambers, PhD, MPharm, MSc,b Joshua Cohen, PhD,b and Michael Belkin, MD,c on behalf of the Model To Optimize Healthcare Value in Ischemic Extremities 1 (MOVIE) Study Collaborators,* Houston, Tex; and Boston, MassBackground: The care of patients with critical limb ischemia (CLI) and tissue loss is notoriously challenging and expensive. We evaluated the cost-effectiveness of various management strategies to identify those that would optimize value to patients. Methods: A probabilistic Markov model was used to create a detailed simulation of patient-oriented outcomes, including clinical events, wound healing,functional outcomes, and quality-adjusted life-years (QALYs) after various management strategies in a CLI patient cohort during a 10-year period. Direct and indirect cost estimates for these strategies were obtained using transition cost-accounting methodology. Incremental cost-effectiveness ratios (ICERs), in 2009 U.S. dollars per QALYs, were calculated compared with the most conservativemanagement strategy of local wound care with amputation as needed. Results: With an ICER of $47,735/QALY, an initial surgical bypass with subsequent endovascular revision(s) as needed was the most cost-effective alternative to local wound care alone. Endovascular-first management strategies achieved comparable clinical outcomes but at higher cost (ICERs >$101,702/QALY); however, endovascular managementdid become cost-effective when the initial foot wound closure rate was >37% or when procedural costs were decreased by >42%. Primary amputation was dominated (less effectiveness and more costly than wound care alone). Conclusions: Contemporary clinical effectiveness and cost estimates show an initial surgical bypass is the most costeffective alternative to local wound care alone for CLI with tissueloss and can be supported even in a cost-averse health care environment. ( J Vasc Surg 2012;56:1015-24.)

Given the unsustainable rate of growth of U.S. health care costs and the increasingly important effect it is having on the overall U.S. economy,1 ensuring the provision of cost-effective care stands among the foremost priorities for U.S. clinicians.2,3 This priority should be especiallypoignant for vascular surgeons who care for patients with critical limb ischemia (CLI) and tissue loss, for several reasons. First, care for these patients is costly, laborious, and will not infrequently result in limb loss despite intensive efforts to avoid it.4 Second, the U.S. population is increasingly elderly and/or diabetic, two characteristics that are strongly associated with CLI.5 Finally,management of the ischemic limb is done in the context of systemic comorbidiFrom the Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houstona; the Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Bostonb; and the Division of Vascular andEndovascular Surgery, Department of Surgery, Brigham and Women’s Hospital, Boston.c *A list of the MOVIE collaborators can be found in Appendix A. Author conflict of interest: none. Presented at the Thirty-eighth Annual Meeting of the New England Society for Vascular Surgery, Providence, RI, September 16-18, 2011. Additional material for this article may be found online at www.jvascsurg.org.Correspondence: Michael Belkin, MD, Professor and Chief, Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02215 (e-mail: mbelkin@partners.or). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which...