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Cost-efficacy issues in the treatment of peripheral vascular disease: primary amputation or revascularization for
1Department of Surgery-Blalock 685, Johns Hopkins Hospital, Baltimore, MD 21287-4685, USA.
Insights
For limb-threatening ischemia, revascularization is often more cost-effective than primary amputation. Careful patient selection and follow-up are key to minimizing long-term health care costs for vascular disease patients.
Area of Science:
- Vascular Surgery
- Health Economics
- Geriatric Medicine
Background:
- Rising healthcare costs and an aging population increase pressure on vascular specialists to provide cost-effective limb salvage care.
- A key controversy involves choosing between revascularization and primary amputation for limb-threatening ischemia.
- Assumptions about higher operative risks and shorter hospital stays for revascularization in elderly patients are challenged.
Purpose of the Study:
- To compare the costs and outcomes of revascularization versus primary amputation for limb-threatening ischemia.
- To evaluate the long-term economic implications of both treatment strategies.
- To identify optimal patient selection and management for cost-effective limb salvage.
Main Methods:
- Comparative analysis of mortality rates, hospitalization duration, complication rates, and long-term costs for revascularization and amputation.
- Inclusion of costs for prostheses, rehabilitation, and institutionalization in amputation calculations.
- Assessment of secondary amputation rates after revascularization and revision rates after primary amputation.
Main Results:
- Mortality rates are higher for primary amputation than for revascularization in the sickest patients.
- Hospitalization duration is not necessarily shorter for amputation; complications prolong stays for both procedures.
- Secondary amputation rates after revascularization (8.5%) are lower than operative revision rates after primary below-knee amputation (23%).
Conclusions:
- Revascularization can be more cost-effective than primary amputation when considering long-term outcomes and associated costs.
- Careful patient selection for initial revascularization is crucial for minimizing healthcare expenditures.
- Aggressive long-term surveillance is essential to ensure graft patency and limb viability, thereby reducing long-term costs.
Abstract:
Controlling rising health care costs represents a major challenge to our society. Due to the aging of the population and the increasing number of patients with vascular disease, vascular specialists will be under mounting pressure by the managed care industry to provide the most cost-effective care for these patients. One particular controversy is whether to attempt revascularization in the patient with limb-threatening ischemia or to proceed directly with primary amputation. Although it has been assumed that the operative risk for revascularization procedures is high in elderly patients with a severely ischemic limb, mortality rates in the sickest patients are actually higher for amputation. It is also incorrect to assume that the duration of hospitalization is shorter for patients undergoing amputation than for patients undergoing revascularization. For both types of procedures, it is complications that prolong the length of hospital stay, and the rate of secondary amputation following a revascularization attempt is low (8.5%), compared with the rate of operative revision in patients following primary below-knee amputation (23%). The costs for revascularization and primary amputation are similar when the costs of a prosthesis and rehabilitative therapy are included in the calculations for amputation. The rationale for primary amputation assumes that patients will ambulate successfully with a prosthesis; however, many do not, and thus costs for institutionalization must be included in the equation. Long-term costs following revascularization were $28,374 in patients with a viable limb, compared with $56,809 in those undergoing secondary revascularization. The key to minimizing health care costs in this population is careful patient selection for initial revascularization, with aggressive long-term surveillance to ensure graft patency and limb viability.