title: Cost-effectiveness of revascularization for limb preservation in patients with marginal functional status.
abstract: BACKGROUND
  Revascularization and limb salvage attempts are often offered to patients with foot wounds and chronic limb ischemia who are thought to be good-risk candidates, but some skepticism remains about the utility of these efforts for elderly patients with marginal functional status. We sought to determine whether limb preservation efforts in this population could be justified from a patient-centered, cost-effectiveness perspective.
  
  
  METHODS
  A probabilistic Markov model was used to simulate the clinical outcomes, health utilities, and costs over a 10-year period with various management strategies. Clinical parameter estimates were obtained from previous clinical trials and large observational series. Cost estimates were obtained from cost literature and also a single-center study that reviewed total costs accumulated (including secondary amputations, wound care, outpatient nursing care, and nursing home costs). Cost (in 2011 U.S. dollars) per year of ambulation (with limb preservation or with a prosthesis after amputation) was the primary measure of cost-effectiveness.
  
  
  RESULTS
  The total 10-year costs of revascularization--either endovascular or surgical--were lower than the costs of either local wound care alone or primary amputation. Revascularization strategies also produced more health benefits as measured in terms of years of ambulatory ability, years of limb salvage, or quality-adjusted life-years. In none of the scenarios modeled in deterministic sensitivity analyses did primary amputation prove to be cost-effective.
  
  
  CONCLUSIONS
  Revascularization and limb preservation attempts appear less costly and provide more health benefits than wound care alone or primary amputation, even among patients with marginal functional status at baseline.
authors: Division of Vascular Surgery and Endovascular Therapy, Michael E. Debakey Department of Surgery, Baylor College of Medicine/Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX. Electronic address: nbarshes@bcm.edu.
authors: Neal R
authors: NR
authors: Barshes
authors: Division of Vascular Surgery and Endovascular Therapy, Michael E. Debakey Department of Surgery, Baylor College of Medicine/Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX.
authors: Panos
authors: P
authors: Kougias
authors: Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA.
authors: C Keith
authors: CK
authors: Ozaki
authors: Division of Vascular Surgery and Endovascular Therapy, Michael E. Debakey Department of Surgery, Baylor College of Medicine/Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX.
authors: George
authors: G
authors: Pisimisis
authors: Division of Vascular Surgery and Endovascular Therapy, Michael E. Debakey Department of Surgery, Baylor College of Medicine/Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX.
authors: Carlos F
authors: CF
authors: Bechara
authors: Division of Physical Medicine and Rehabilitation, Baylor College of Medicine/Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX.
authors: Helene K
authors: HK
authors: Henson
authors: Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA.
authors: Michael
authors: M
authors: Belkin
mesh_terms: D000367:Age Factors; D000671:Amputation, Surgical / Q000191:economics; D019917:Blood Vessel Prosthesis Implantation / Q000191:economics; D002908:Chronic Disease; D015897:Comorbidity; D003198:Computer Simulation; D003362:Cost-Benefit Analysis; D057510:Endovascular Procedures / Q000191:economics; D016523:Foot Ulcer / Q000175:diagnosis / Q000191:economics* / Q000503:physiopathology / Q000628:therapy*; D017048:Health Care Costs; D006304:Health Status; D006801:Humans; D007511:Ischemia / Q000175:diagnosis / Q000191:economics* / Q000503:physiopathology / Q000628:therapy*; D023821:Limb Salvage / Q000191:economics*; D035002:Lower Extremity / Q000098:blood supply*; D008390:Markov Chains; D018803:Models, Economic; D018579:Patient Selection; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014654:Vascular Patency; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000191:economics*; D014945:Wound Healing