COST-EFFICACY ISSUES IN THE TREATMENT OF PERIPHERAL VASCULAR-DISEASE - PRIMARY AMPUTATION OR REVASCULARIZATION FOR LIMB-THREATENING ISCHEMIA

Controlling rising health care: costs represents a major challenge to our society, Due to the aging of the population and the increasing num ber of patients with vascular disease, vascular specialists will be un der mounting pressure by the managed care industry to provide the most cost-effective case for these patients, One particular controversy is whether to attempt revascularization in the patient with limb-threate ning ischemia or to proceed directly with primary amputation, Although it has been assumed that the operative risk. for revascularization pr ocedures is high in elderly patients with a severely ischemic limb, mo rtality rates in the sickest patients are actually higher for amputati on, It is also incorrect to assume that the duration of hospitalizatio n is shorter for patients undergoing amputation than for patients unde rgoing revascularization, For both types of procedures, it is complica tions that prolong the length of hospital stay, and the rate of second ary amputation following a revascularization attempt is low (8.5%), co mpared with the rate of operative revision in patients following prima ry below-knee amputation (23%), The costs for revascularization and pr imary amputation are similar when the costs of a prosthesis and rehabi litative therapy are included in the calculations for amputation, The rationale for primary amputation assumes that patients will ambulate s uccessfully with a prosthesis; however, many do not, and thus costs fo r institutionalization must be included in the equation, Long-term cos ts following revascularization were $28,374 in patients with a viable limb, compared with $56,809 in those undergoing secondary revasculariz ation, The key to minimizing health care costs in this population is c areful patient selection for initial revascularization, with aggressiv e long-term surveillance to ensure graft patency and limb viability.