Department of Cardiovascular Sciences, National Institute for Health and Care Research (NIHR) Biomedical Research Centre (BRC), Leicester, UK.
School of Cardiovascular Medicine and Metabolic Sciences, King's College London, London, UK.
BJS Open. 2024 Sep 3;8(5). doi: 10.1093/bjsopen/zrae099.
Missed opportunities to reduce numbers of primary major lower-limb amputation and increase limb-salvage procedures when treating chronic limb-threatening ischaemia have previously been identified in the literature. However, the potential economic savings for healthcare providers when salvaging a chronic limb-threatening ischaemia-affected limb have not been well documented.
A model using National Health Service healthcare usage and cost data for 1.6 million individuals and averaged numbers of primary surgical procedures for chronic limb-threatening ischaemia from England and Wales in 2019-2021 was created to perform a budget impact analysis. Two scenarios were tested: the averaged national rates of major lower-limb amputation (above the ankle joint), angioplasty, open bypass surgery or arterial endarterectomy in the National Vascular Registry (current scenario); and revascularization rates adjusted based on the lowest amputation rate reported by the National Vascular Registry at the time of the study (hypothetical scenario). The primary outcome was the net impact on costs to the National Health Service over 12 months after the index procedure.
In the current scenario, the proportions of different index procedures were 10% for lower-limb major amputation, 55% for angioplasty, 25% for open bypass surgery and 10% for arterial endarterectomy. In the hypothetical scenario, the procedure rates were 3% for major lower-limb amputation, 59% for angioplasty, 27% for open bypass surgery and 11% for arterial endarterectomy. For 16 025 index chronic limb-threatening ischaemia procedures, the total care cost in the current scenario was €243 924 927. In the hypothetical scenario, costs would be reduced for index procedures (-€10 013 814), community care (-€633 943) and major cardiovascular events (-€383 407), and increased for primary care (€59 827), outpatient appointments (€120 050) and subsequent chronic limb-threatening ischaemia-related surgery (€1 179 107). The net saving to the National Health Service would be €9 645 259.
A shift away from primary major lower-limb amputation towards revascularization could lead to substantial savings for the National Health Service without major cost increases later in the care pathway, indicating that care decisions taken in hospitals have wider benefits.
在治疗慢性肢体威胁性缺血时，以前的文献已经确定了在减少主要下肢截肢和增加肢体保肢手术数量方面的错失机会。然而，当保存受慢性肢体威胁性缺血影响的肢体时，医疗机构的潜在经济节省尚未得到很好的记录。
我们使用了英国国民保健服务的医疗保健使用情况和 160 万人的成本数据，并使用了英格兰和威尔士 2019-2021 年慢性肢体威胁性缺血的主要手术次数的平均值，创建了一个预算影响分析模型。测试了两种情况：国家血管登记处报告的当前平均下肢主要截肢（踝关节以上）、血管成形术、开放旁路手术或动脉内膜切除术的全国比率（当前情况）；以及根据研究时国家血管登记处报告的最低截肢率调整的再血管化率（假设情况）。主要结果是在索引手术后 12 个月内对国民保健服务的成本净影响。
在当前情况下，不同索引程序的比例分别为 10%为下肢主要截肢，55%为血管成形术，25%为开放旁路手术，10%为动脉内膜切除术。在假设情况下，手术率分别为 3%为下肢主要截肢，59%为血管成形术，27%为开放旁路手术，11%为动脉内膜切除术。对于 16025 例慢性肢体威胁性缺血指数手术，当前情况下的总护理费用为 243924927 欧元。在假设情况下，索引手术（-10013814 欧元）、社区护理（-633943 欧元）和主要心血管事件（-383407 欧元）的成本将降低，而初级保健（59827 欧元）、门诊预约（120050 欧元）和随后的慢性肢体威胁性缺血相关手术（1179107 欧元）的成本将增加。国民保健服务的净节省将为 9645259 欧元。
从主要下肢截肢向再血管化的转变可能会为国民保健服务带来大量节省，而不会在护理途径的后期增加重大成本，这表明医院做出的护理决策具有更广泛的好处。
