11.56 vermassen site cost effectiveness endovascular def2
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Transcript of 11.56 vermassen site cost effectiveness endovascular def2
Is endovascular revascularisation of lower limb a cost-effective treatment ?
Frank VermassenGhent University Hospital
Ghent - Belgium
Cost-effectiveness analysis: why? In a restricted health care budget choices have to be made
on what the money can best be spent. Comparison
Different procedures for the same pathology Treatment for different pathologies Small improvement for large numbers of patients vs.
very expensive treatment for small numbers of patients Therapeutic interventions vs screening programs or care for
the elderly In the absence of cost-consideration, it is inevitable that
health care resources will be inefficiently allocated, which results in reduced health benefits for the total population
Cost Cost of procedure Indirect costs Costs of complications
Effectiveness Prevented costs Life years gained Quality adjustment = QALY (Cost-utility)
Cost-effectiveness studies
Cost of Cost of proceduprocedurere
Indirect costsIndirect costsCost of Cost of complicaticomplicationsons
CE-Ratio: Cost per QALY gained
CE parameters in CLI
Direct costsInterventionComplicationsFollow-upReinterventions or
amputations Indirect costs
Nursing careInstitutional care
Life yearsMortality of procedureSurvival
Quality adjustmentQOL with CLIQOL after CLIQOL after amputationComorbidity
Is revascularisation cost-effective in CLI ? Critical limb ischemia
• QOL with active ulcer: 0,42QOL with amputation: 0,54
• Cost of amputation : 2x cost of surgical revascularisationCost of prosthetic and institutional care (only 52% ambulatory after amputation)
->Loss of utility: 0,3
CE of revascularisation for CLI Finnish vascular registry (Laurilla, Int J Angiol 2000)
118 patients with CLI: PTA or bypassSurgery was better for
Hemodynamic result Reoperation free years Limb-salvage
PTA was less expensive: 8855 $ vs 16470 $Cost per year of leg saved
PTA: 3877 $ Surgery: 6055 $
• 452 patients in 27 UK hospitals
• Severe limb ischemia• Suitable for randomisation
between PTA and bypass• Conclusion:
SLI patients that are likely to survive > 2 yrs are probably better served by bypass surgery first
SLI patients that are unlikely to live > 2 yrs are probably better served by angioplasty
BASIL-trial
Amputation-free survivalBradbury JVS 2010
CE analysis of Basil results
• Costs SurvivalAFS: + 12 d. for PTAOS: +32 d for PTA
QOL
QALY: + 11 d for Surgery
0
10000
20000
30000
40000
50000
1 yr 3 yr
Bypass Angioplasty
Difference at 3 yr: 5521 $
ICER at 3 yrs: 184492 $/QALY
Angioplasty is cost-effective
over surgery in CLI at 3 yrs
Forbes JVS 2010
Is treatment cost-effective in claudicants ?Intermittent claudication
Moriarty (JVS 2011)Systematic review of 19 studies of different design, including economical analysisConclusions:All approaches (exercise, endovascular, bypass) are cost-effective with the baseline comparator approach of no treatmentExisting lower extremity arterial revascularisation literature is inadequate for drawing cost-efficacy conclusions and cannot inform guidelines for open vs endovascular treatment
Nordanstig (Circulation 2014)
RCT 158 patients
Non-invasive treatmentInvasive treatment
HRQOL evaluation after 1 yearResults
Invasive treatment improves ICDInvasive treatment improves quality
of life @ 1 year
Invasive treatment vs exercise treatment
Murphy et al. (Circulation 2012)
111 patientsOptimal Medical Control (OMC)OMC + Supervised exerciseOMC + Stenting
ResultsGreatest improvement in walking
distance with supervised exerciseBest improvement of quality of life
with stenting
Endovascular vs Exercise
Greenhalgh (EJVES 2008)
RCT: Mimic trial 144 patients (out of 1401)
Supervised exerciseSupervised exercise + angioplasty
Separate femoro-popliteal and aorto-iliac analysis
ResultsAngioplasty adds to walking
distance in patients under exercise treatment
Non-significant improvement in QOL
PTA on top of exercise treatment
Invasive treatment vs exercise treatment
Meta-analysis 9 trials (873 participants).• Endovascular (EVT) superior to medical therapy
for ABI, MWD and ICD• No significant difference in MWD between
endovascular and supervised exercise (SVE)• EVT + SVE significant better than SVE alone for
ABI, MWD and ICD
Which endovascular technique?
BJS 2013
Conclusions Revascularisation in CLI patients is cost-effective,
regardless of the technique that is used In claudicants invasive treatment can best be added to a
background of optimal medical treatment including exercise
Endovascular techniques seem in general more cost-effective than surgical techniques but efforts should be made to further decrease the number of reinterventions
Prevention is probably most cost-effective of all