Department of Surgery, Amphia Hospital, Breda, The Netherlands.
Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands; Department of Medical Psychology, Elisabeth Two Cities, Tilburg, The Netherlands.
J Vasc Surg. 2019 Aug;70(2):530-538.e1. doi: 10.1016/j.jvs.2018.11.042. Epub 2019 Mar 25.
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.
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).
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).
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.
治疗严重肢体缺血（CLI）的目的是预防肢体丧失，这通常是一种密集且昂贵的治疗方法。本研究的目的是检验不适合手术的老年 CLI 患者的腔内治疗和保守治疗的成本效益。
本前瞻性观察队列研究在荷兰的两家外周医院进行数据收集。CLI 患者年龄 70 岁或以上，纳入门诊。排除标准为恶性疾病、语言能力缺失和认知障碍；共纳入 195 例患者，排除 192 例患者。在多学科血管会议后，患者被分为三组（腔内血管重建、手术血管重建或保守治疗）。进行了基于年龄的亚分析（70-79 岁和≥80 岁）。随访期为 2 年。使用增量成本效益比（ICER）以欧元/质量调整生命年（QALY）衡量腔内治疗和保守治疗的成本效益。
基线时，接受手术血管重建的患者健康状况更好，但腔内血管重建和保守治疗患者的健康状况相当。腔内血管重建的 ICER 为 38,247.41 欧元/QALY（约 50,869 美元/QALY），与保守治疗相比具有成本效益。与荷兰适用的 80,000 欧元/QALY（约 106,400 美元/QALY）阈值相比，这是有利的。亚分析还表明，腔内血管重建在 70 至 79 岁患者（ICER 为 29,898.36 欧元/QALY；约 39,765 美元/QALY）和 80 岁以上患者（ICER 为 56,810.14 欧元/QALY；约 75,557 美元/QALY）中，也是保守治疗的一种具有成本效益的替代方案。
我们的研究表明，腔内血管重建与 70 岁以上 CLI 患者的保守治疗相比具有成本效益，在 80 岁以上患者中也是如此。鉴于成本和效果的微小绝对差异，医生还应考虑可能改变干预结果的个体情况。成本效益仍然是做出临床决策时需要考虑的因素之一。
