Cost-effectiveness of supervised exercise, stenting, and optimal medical care for claudication: results from the Claudication: Exercise Versus Endoluminal Revascularization (CLEVER) trial.
BACKGROUND
Both supervised exercise (SE) and stenting (ST) improve functional status, symptoms, and quality of life compared with optimal medical care (OMC) in patients with claudication. The relative cost-effectiveness of these strategies is not well defined.


RESULTS
The Claudication: Exercise Versus Endoluminal Revascularization (CLEVER) study randomized patients with claudication due to aortoiliac stenosis to a 6-month SE program, to ST, or to OMC. Participants who completed 6-month follow-up (n=98) were included in a health economic analysis through 18 months. Costs were assessed using resource-based methods and hospital billing data. Quality-adjusted life-years were estimated using the EQ-5D. Markov modeling based on the in-trial results was used to explore the impact of assumptions about the longer term durability of observed differences in quality of life. Through 18 months, mean healthcare costs were $5178, $9804, and $14 590 per patient for OMC, SE, and ST, respectively. Measured quality-adjusted life-years through 18 months were 1.04, 1.16, and 1.20. In our base case analysis, which assumed that observed differences in quality of life would dissipate after 5 years, the incremental cost-effectiveness ratios were $24 070 per quality-adjusted life-year gained for SE versus OMC, $41 376 for ST versus OMC, and $122 600 for ST versus SE. If the treatment effect of ST was assumed to be more durable than that of SE, the incremental cost-effectiveness ratio for ST versus SE became more favorable.


CONCLUSIONS
Both SE and ST are economically attractive by US standards relative to OMC for the treatment of claudication in patients with aortoiliac disease. ST is more expensive than SE, with uncertain incremental benefit.


BACKGROUND
www.clinicaltrials.gov, Unique identifier: NCT00132743.
Harvard Clinical Research Institute, Boston, MA (M.R.R., P.A.).
Matthew R
MR
Reynolds
Harvard Clinical Research Institute, Boston, MA (M.R.R., P.A.).
Patricia
P
Apruzzese
Brigham & Women's Hospital, Boston, MA (B.Z.G.).
Benjamin Z
BZ
Galper
Rhode Island Hospital, Providence, RI (T.P.M.).
Timothy P
TP
Murphy
University of Minnesota, Minneapolis, MN (A.T.H.).
Alan T
AT
Hirsch
Beth Israel Deaconess Medical Center, Boston, MA (D.E.C.).
Donald E
DE
Cutlip
Division of Cardiovascular Disease, Section of Vascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA (E.R.M.).
Emile R
ER
Mohler
University of Colorado School of Medicine, Aurora, CO (J.G.R.).
Judith G
JG
Regensteiner
Saint-Luke's Mid America Heart Institute, University of Missouri-Kansas City School of Medicine, Kansas City, MO (D.J.C.).
David J
DJ
Cohen
D000553:Ambulatory Care / Q000191:economics; D001018:Aortic Diseases / Q000175:diagnosis / Q000191:economics* / Q000503:physiopathology / Q000628:therapy*; D002317:Cardiovascular Agents / Q000191:economics* / Q000627:therapeutic use*; D003251:Constriction, Pathologic; D003362:Cost-Benefit Analysis; D016527:Drug Costs; D057510:Endovascular Procedures / Q000009:adverse effects / Q000191:economics* / Q000295:instrumentation*; D005081:Exercise Therapy / Q000009:adverse effects / Q000191:economics*; D017048:Health Care Costs; D017721:Hospital Costs; D006801:Humans; D007083:Iliac Artery / Q000503:physiopathology; D007383:Intermittent Claudication / Q000175:diagnosis / Q000191:economics* / Q000503:physiopathology / Q000628:therapy*; D008017:Life Expectancy; D018803:Models, Economic; D058729:Peripheral Arterial Disease / Q000175:diagnosis / Q000191:economics* / Q000503:physiopathology / Q000628:therapy*; D011788:Quality of Life; D019057:Quality-Adjusted Life Years; D015607:Stents / Q000191:economics*; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States; D014654:Vascular Patency
D002317:Cardiovascular Agents
claudication; cost–benefit analysis; exercise; peripheral vascular disease; stents