title: Cost-effectiveness of revascularization for limb preservation in patients with end-stage renal disease.
abstract: BACKGROUND
  Limb revascularization in patients with end-stage renal disease (ESRD) has been criticized because of the low rates of limb preservation and overall survival that characterize this patient population. We undertook a formal cost-utility analysis to evaluate the role of revascularization in the ESRD population.
  
  
  METHODS
  A probabilistic Markov model was used to simulate the clinical outcomes and long-term outcomes after six different strategies for the management of nonhealing foot wounds in patients with critical limb ischemia and ESRD. All scenarios considered all-cause mortality and major amputation for failure of limb salvage. Parameter estimates of the costs, clinical events, and functional outcomes used in the model were derived from primary data or published literature. Costs are reported in 2011 U.S. dollars.
  
  
  RESULTS
  Local wound care alone had the lowest long-term total cost of the management strategies evaluated; primary amputation had the highest. Purely endovascular intervention yielded the highest limb salvage rates. Endovascular intervention had a cost of $15,403 per additional year of ambulation beyond that by local wound care alone. Endovascular intervention had the potential for cost-savings (ie, better health benefits at lower cost) only with very high 1-year wound healing rates. The 5-year survival rates ranged from 17% to 34% in all management strategies.
  
  
  CONCLUSIONS
  Endovascular intervention may be a cost-effective alternative to local wound care alone for patients with ESRD and ischemic foot wounds, but with small marginal health benefits at considerable cost. Local wound care alone may be preferable to primary amputation.
authors.affiliation: 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, Tex. Electronic address: nbarshes@bcm.edu.
authors.forename: Neal R
authors.initials: NR
authors.lastname: Barshes
authors.affiliation: 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, Tex.
authors.forename: Panos
authors.initials: P
authors.lastname: Kougias
authors.affiliation: Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Mass.
authors.forename: C Keith
authors.initials: CK
authors.lastname: Ozaki
authors.affiliation: Section of Vascular Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
authors.forename: Philip P
authors.initials: PP
authors.lastname: Goodney
authors.affiliation: Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Mass.
authors.forename: Michael
authors.initials: M
authors.lastname: Belkin
mesh_terms: D000671:Amputation, Surgical / Q000191:economics; D003362:Cost-Benefit Analysis; D016638:Critical Illness; D057510:Endovascular Procedures / Q000009:adverse effects / Q000191:economics* / Q000401:mortality; D005528:Foot / Q000098:blood supply*; D017721:Hospital Costs; D006801:Humans; D007511:Ischemia / Q000150:complications / Q000175:diagnosis / Q000191:economics* / Q000401:mortality / Q000628:therapy*; D007676:Kidney Failure, Chronic / Q000150:complications / Q000191:economics* / Q000401:mortality / Q000628:therapy; D023821:Limb Salvage / Q000191:economics*; D008390:Markov Chains; D018803:Models, Economic; D010043:Outcome and Process Assessment, Health Care / Q000191:economics*; D058729:Peripheral Arterial Disease / Q000150:complications / Q000175:diagnosis / Q000191:economics* / Q000401:mortality / Q000628:therapy*; D013997:Time Factors; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000191:economics* / Q000401:mortality; D014945:Wound Healing