Perler B A
Department of Surgery-Blalock 685, Johns Hopkins Hospital, Baltimore, MD 21287-4685, USA.
J Vasc Interv Radiol. 1995 Nov-Dec;6(6 Pt 2 Suppl):111S-115S. doi: 10.1016/s1051-0443(95)71259-3.
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.
控制不断上涨的医疗费用是我们社会面临的一项重大挑战。由于人口老龄化以及血管疾病患者数量的增加，血管专科医生将面临管理式医疗行业越来越大的压力，需要为这些患者提供最具成本效益的治疗。一个特别有争议的问题是，对于有肢体威胁性缺血的患者，是尝试进行血管重建，还是直接进行一期截肢。尽管人们一直认为，对于患有严重缺血肢体的老年患者，血管重建手术的手术风险很高，但实际上，病情最严重的患者截肢后的死亡率更高。认为截肢患者的住院时间比血管重建患者短也是不正确的。对于这两种手术类型，都是并发症延长了住院时间，而且与一期膝下截肢患者的手术翻修率（23%）相比，血管重建尝试后的二次截肢率较低（8.5%）。当将假肢和康复治疗费用纳入截肢计算时，血管重建和一期截肢的费用相似。一期截肢的理由是假设患者使用假肢能够成功行走；然而，许多患者做不到，因此必须将机构护理费用纳入考量。血管重建后，有存活肢体的患者的长期费用为28374美元，而接受二次血管重建的患者为56809美元。在这一人群中，将医疗费用降至最低的关键是谨慎选择初次血管重建的患者，并进行积极的长期监测，以确保移植物通畅和肢体存活。
