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Published on: September 22, 2020
Cost-effectiveness of the treatments for critical limb ischemia in the elderly population
Chloé M L Peters1, Jolanda de Vries2, Steef Redeker3
1Department of Surgery, Amphia Hospital, Breda, The Netherlands.
Insights
Endovascular revascularization is a cost-effective treatment for critical limb ischemia (CLI) in patients over 70, including octogenarians. This approach offers a favorable alternative to conservative therapy, improving quality-adjusted life-years (QALYs).
Area of Science:
- Vascular Surgery
- Health Economics
- Geriatric Medicine
Background:
- Critical limb ischemia (CLI) treatment is intensive and costly, aiming to prevent limb loss.
- Elderly patients often present complex cases for CLI management.
- Surgical interventions for CLI carry significant risks in older populations.
Purpose of the Study:
- To evaluate the cost-effectiveness of endovascular revascularization versus conservative therapy for elderly CLI patients unsuitable for surgery.
- To compare treatment outcomes in different age subgroups (70-79 and ≥80 years).
Main Methods:
- Prospective observational cohort study in two Dutch hospitals.
- Inclusion of 195 CLI patients aged 70+ years; exclusion of those with malignancy, language barriers, or cognitive impairment.
- Cost-effectiveness analysis using incremental cost-effectiveness ratios (ICERs) per quality-adjusted life-year (QALY) over a 2-year follow-up.
Main Results:
- Endovascular revascularization yielded an ICER of €38,247.41/QALY, below the Dutch threshold of €80,000/QALY, indicating cost-effectiveness compared to conservative therapy.
- Cost-effectiveness was confirmed in patients aged 70-79 (€29,898.36/QALY) and octogenarians (€56,810.14/QALY).
- Baseline health states were comparable between endovascular and conservative groups, but better in the surgical group.
Conclusions:
- Endovascular revascularization is a cost-effective strategy for treating critical limb ischemia in elderly patients, including octogenarians.
- Clinical decisions should also incorporate individual patient circumstances beyond cost-effectiveness.
- This analysis provides valuable economic insights for managing CLI in older adults.
Objective:
The treatment of critical limb ischemia (CLI), with the intention to prevent limb loss, is often an intensive and expensive therapy. The aim of this study was to examine the cost-effectiveness of endovascular and conservative treatment of elderly CLI patients unsuitable for surgery.
Methods:
In this prospective observational cohort study, data were gathered in two Dutch peripheral hospitals. CLI patients aged 70 years or older were included in the outpatient clinic. Exclusion criteria were malignant disease, lack of language skills, and cognitive impairment; 195 patients were included and 192 patients were excluded. After a multidisciplinary vascular conference, patients were divided into three treatment groups (endovascular revascularization, surgical revascularization, or conservative therapy). Subanalyses based on age were made (70-79 years and ≥80 years). The follow-up period was 2 years. Cost-effectiveness of endovascular and conservative treatment was quantified using incremental cost-effectiveness ratios (ICERs) in euros per quality-adjusted life-years (QALYs).
Results:
At baseline, patients allocated to surgical revascularization had better health states, but the health states of endovascular revascularization and conservative therapy patients were comparable. With an ICER of €38,247.41/QALY (∼$50,869/QALY), endovascular revascularization was cost-effective compared with conservative therapy. This is favorable compared with the Dutch applicable threshold of €80,000/QALY (∼$106,400/QALY). The subanalyses also established that endovascular revascularization is a cost-effective alternative for conservative treatment both in patients aged 70 to 79 years (ICER €29,898.36/QALY; ∼$39,765/QALY) and in octogenarians (ICER €56,810.14/QALY; ∼$75,557/QALY).
Conclusions:
Our study has shown that endovascular revascularization is cost-effective compared with conservative treatment of CLI patients older than 70 years and also in octogenarians. Given the small absolute differences in costs and effects, physicians should also consider individual circumstances that can alter the outcome of the intervention. Cost-effectiveness remains one of the aspects to take into consideration in making a clinical decision.
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