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Intermittent Claudication: Cost-effectiveness of Revascularization versus Exercise Therapy¹

¹ From the Department of Health Sciences, University of Groningen, the Netherlands (S.O.d.V., J.A.d.V., M.G.M.H.); Department of Medicine, New England Medical Center, Tufts University School of Medicine, Boston, Mass (J.B.W.); Division of Vascular Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass (M.C.D.); Departments of Epidemiology and Biostatistics and Radiology, Erasmus Medical Center Rotterdam, Rm EE2140, Dr Molewaterplein 50, 3015 GE Rotterdam, the Netherlands (K.V., M.G.M.H.); and Department of Health Policy and Management, Harvard School of Public Health, Boston, Mass (M.G. M.H.). Received October 31, 2000; revision requested January 8, 2001; final revision received July 6; accepted August 3. Supported by a PIONIER award from the Netherlands Organization for Scientific Research. Address correspondence to M.G.M.H. (e-mail: hunink@epib.fgg.eur.nl).

PURPOSE: To compare the costs, effectiveness, and cost-effectiveness of alternative treatment strategies for intermittent claudication.

MATERIALS AND METHODS: By combining data from the literature and original patient data, a Markov decision model was developed to evaluate the societal cost-effectiveness. Patients presented with previously untreated intermittent claudication, and treatment options were exercise, percutaneous transluminal angioplasty (with stent placement, if necessary), and/or bypass surgery. Treatment strategies were defined as the initial therapy in combination with secondary treatment options should the initial therapy fail. The main outcome measures were quality-adjusted life days, expected lifetime costs (in 1995 U.S. dollars), and incremental cost-effectiveness ratios.

RESULTS: Compared with an exercise program, revascularization (either angioplasty or bypass surgery) improved effectiveness by 33–61 quality-adjusted life days among patients with no history of coronary artery disease. The incremental cost-effectiveness ratio was $38,000 per quality-adjusted life year gained when angioplasty was performed whenever feasible, as compared with exercise alone, and $311,000 with additional bypass surgery. The incremental cost-effectiveness ratios were sensitive to age, history of coronary artery disease, estimated health values for no or mild claudication versus severe claudication, and revascularization costs.

CONCLUSION: The results suggest that, on average, the expected gain in effectiveness achieved with bypass surgery for intermittent claudication is small compared with the costs. Angioplasty performed whenever feasible was more effective than was exercise alone, and the cost-effectiveness ratio was within the generally accepted range.

Index terms: Arteries, interventional procedures, 92.1268, 92.1269, 92.128 • Arteries, transluminal angioplasty, 92.1268, 92.128 • Cost-effectiveness • Extremities, abnormalities, 92.721, 92.76

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