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