Critical leg ischaemia in New Zealand: economic cost of amputation versus intravenous iloprost

The purpose of this study was to establish the incidence of surgical amputation for critical leg ischaemia in New Zealand, and estimate the hospital, prostheses and indirect costs of this intervention. The cost of amputations was then compared with the cost of treating such patients with iloprost. The study was retrospective. Individual patient records relating to 1991 for both public and private hospitals were analysed. Unit costs relevant to 1991 were applied to the volume data of patients and procedures to derive total costs. Costs were estimated on an incremental basis taking a societal perspective. Conservative estimates were obtained for hospital costs, prostheses and for production loss (loss of output or productivity). Total cost was $NZ15.9 million (hospital and prosthesis cost $NZ13.1 million, production loss $NZ2.8 million). The total quantified cost per amputation was $NZ23 038 (hospital and prosthesis cost $NZ19 020, production loss $NZ4017). 32% of patients requiring amputations were in the working age group. The theoretical avoidance of amputation by treatment with iloprost resulted in net savings of hospital and prosthetic costs of between $NZ6660 and $NZ8720 per patient. Amputation for critical leg ischaemia is costly and has a high mortality, but for iloprost treatment to be cost effective in a New Zealand hospital setting, patients must be targeted and a success rate of at least 55% achieved in avoidance of amputation and reduction of pain while at rest.

Long-term cost comparison of major limb salvage using the Ilizarov method versus amputation

Hospital costs and professional fees of Ilizarov limb reconstruction patients were compared with hospital costs, professional fees, and prosthetic costs of lower-extremity amputation patients. Ten patients with tibial nonunions, osteomyelitis, infected nonunions, and/or bone defects underwent Ilizarov limb reconstruction while six patients with similar traumatic injuries underwent amputation (three acute and three delayed). The average age was 41 years for the Ilizarov group and 40 years for the amputation group. Both the Ilizarov and the amputation groups required an average of four surgical procedures. The average hospital length of stay was 16 days for the Ilizarov group and 25 days for the amputation group. The total average treatment time was 322 days for the Ilizarov group and 175 days for the amputation group. The total cost of the Ilizarov limb reconstruction averaged $59,213.71. The hospital costs and professional fees for the amputation group averaged $30,148.02 without prosthetic costs, but with the projected lifetime prosthetic costs included, averaged $403,199.18. This study suggests that Ilizarov limb reconstruction is cost-effective when compared with amputation when prosthetic costs are also considered.

Amputations in the surgical budget

AIM

To describe the extent and distribution of in patient costs of nontraumatic lower limb amputations and to identify areas of high cost as a basis for cost saving strategic planning.

METHODS

Retrospective review of 134 consecutive admissions resulting in lower limb amputations for reasons other than trauma over a 33 month period. General surgical and orthopaedic costs were compared. More detailed cost distribution analysis was then conducted for a group of general surgical amputees corroborating data from the resource utilisation system, Otago surgical audit and patient records.

RESULTS

The mean cost of admission for nontraumatic lower limb amputations performed by general surgeons was $11,342 (median $21,439 range $144-$43,022) and was significantly more expensive than orthopaedic amputations, mean $2318 (median $6277 range $307-$13,907) p < 0.001. Of general surgical patients, 38.7% had diabetes and these accounted for 36.1% of total costs. Most amputations (73.9%) in diabetics were of the minor type compared with 29.0% in the nondiabetic group (p < 0.001). Ward costs accounted for the largest proportion of total cost 55.6% (95% CI 45.1, 66.0). For major amputees 40% (95% CI 31.4, 48.1) of in-hospital time was used for rehabilitation.

CONCLUSION

Nontraumatic amputations are costly. Diabetics, having mainly minor amputations, account for a disproportionate amount of the cost. Length of hospital stay is the most important determinant of cost, much of which is spent on rehabilitation. A case is made for early definitive surgery and a greater use of community based services and low cost centres in rehabilitation.

[Cost of the diabetic foot]

Among the long term complications of diabetes, leg and foot problems frequently associated with chronic nonhealing wounds constitute a heavy economic cost previously evaluated in some countries. This specific cost has not yet been calculated in France. This study represents the first "estimation" of the frequency and cost of these complications in our country. Methodological obstacles must be considered related to a large variety of clinical situations all covered by the word "diabetic foot", neurotrophic or ischemic origin, and the heterogeneity of the therapeutical approach more or less expensive. We have estimated the incidence of leg and foot problems about 50,000 to 60,000 per years, 20,000 to 25,000 requiring an inpatient treatment for a neurotrophic complication and 10,000 to 15,000 for an ischemic problem (frequently followed by a limited or a large amputation). The annual total cost, direct plus indirect, calculated on this basis should be: 3,750 millions of francs/year (about 700 millions of US $). This value must be compared to the total cost of diabetes in France 12,000 to 18,000 millions of francs/year when considering 1 to 1.5 million diabetic patients. Thus leg and foot problems appear to constitute a prominent part of the economical cost of diabetes in our country as in others developed countries. Multidisciplinary and specialized structures for the care and prevention of such complications of diabetes must be developed as new therapeutical approaches to reduce this incidence, the duration of healing and the risk of relapse.

The social and economic outcome after upper limb amputation

This paper reports a study of 66 upper limb amputees in County Funen, Denmark who were visited in their homes by the author. The purpose of this study was to evaluate for the same period of time the social and economic outcome for a population of upper limb amputees compared with the normal population. The number of amputees investigated corresponds to the annual number of persons becoming upper limb amputees in Denmark. The aetiology of registered amputees also corresponds to the Danish Amputation Register. The amputees had become "better placed" in the social system after amputation independent of prosthetic use. The mean age of the amputees corresponded with the age where people reach their best social grouping. Their social migration quotient was higher than the background population and reflected the amputees better income and housing conditions. The reasons for these surprising results must be the high grade social system in a sophisticated industrial county. None of the amputees were required to pay for rehabilitation or prosthetic supply. A lower divorce rate for the amputees was explained by a symbiosis between the amputees and their partners to protect their future existence. Only 14% lived alone. Those who had their sexual debut after amputation were 3 years later in sexual experience than the rest of the amputees because of difficulties during the maturing process.

The economics of femorocrural reconstruction for critical leg ischemia with and without autologous vein

It is well established that primary arterial reconstruction, even to crural vessels, is cheaper than amputation. Reintervention increases expenditure and may produce mean costs exceeding those of primary amputation. Furthermore, secondary amputation may eventually become necessary. Femorocrural grafts have the highest average "reconstruction policy" cost (i.e., primary procedure and all further operations necessary during follow-up). We must therefore seek support for this potentially expensive form of treatment. In conjunction with health economists we have compared the average policy cost of 130 reconstructions with grafts exceeding 70 cm in length (89 vein grafts, 41 polytetrafluoroethylene grafts with a distal vein collar) with 67 vascular amputations, at mean follow-up of 3 years. One-month mortality rate after reconstruction was less than 1% but was 10% after amputation. At 3 years, however, 20% of both groups were dead. Overall 3-year patency is 65% (72% for vein grafts, 48% for polytetrafluoroethylene grafts). Ninety-seven percent of irreversible graft occlusions resulted in amputation in these patients. After autologous vein grafting reintervention, our follow-up showed increased mean costs from $6898 to $15,024 per patient. After prosthetic grafting, the higher reintervention rate increased from $6898 to $20,416. These mean costs remained less than amputation, reintervention, and additional mobility costs, which amounted to a mean of $21,726 per patient. Important differences in outcome were observed: 70% of patients undergoing amputation were confined to the home compared with only 9% of patients undergoing reconstruction; 30% of patients undergoing amputation were confined to bed or had to use a wheelchair compared with 1% of patients undergoing reconstruction.

Amputation in the diabetic population: incidence, causes, cost, treatment, and prevention

Amputation is a complex problem for a patient, the health care system, and the country. Every endeavor should be made to try to reduce the incidence of amputation. The only way this can be done is by identifying the causative problems and designing interventions to solve those problems. The new era of amputation prevention for the patient with diabetes includes the development of comprehensive wound or foot care programs that use state-of-the-art noninvasive vascular testing, quality angiography, distal vascular reconstruction procedures, aggressive infection control, total contact casting as appropriate, use of growth factors to enhance wound healing, use of orthotic shoes to prevent recurrence, and extensive patient education. By implementing these new systems into the health care system, data for amputation incidence hopefully will be reduced in the future.

Rehabilitation of below-knee amputees: factors influencing outcome and costs in three programmes

The components of three different rehabilitation programmes were analysed to determine the factors that influence functional outcomes and prosthetic costs. Age and additional health problems showed little relationship to inpatient activity level while the physical health status score had a significant relationship. The level of expectation in the rehabilitation programmes for walking independently with canes or without aids at discharge was shown to have a strong influence on the activity level attained and the length of rehabilitation stay. The style of socket did not appear to affect fitting success but had some effect on the efficiency of the prosthetic fitting process and the length of stay.

Costs and benefits of prosthetic vascular surgery

For a variety of reasons, primary amputation is often advised in the elderly individual with a severely ischemic leg. Reinforcing this recommendation is the perception that reconstructive arterial surgery in this group is far more expensive than the primary amputation. Living more than only one more year after amputation, professional nursing care cost approaches $100,000. In two recent studies, the cost for patients undergoing primary below the knee amputations plus rehabilitation was almost identical to the mean patient cost for arterial reconstruction. In addition, under the prospective payment systems, substantial financial loss accrues to hospitals caring for these patients.

The medical and economic impact of severely injured lower extremities

Modern methods of open fracture management, skeletal fixation, and soft-tissue and bone reconstruction have dramatically improved the potential for limb salvage. The absence of adequate objective parameters on which to base the decision for salvage results in delayed amputations in many cases. The present study was undertaken to review the medical and economic impact of delayed versus primary amputations following severe open fractures of the tibia. From January 1980 to August 1986, 263 patients with grade III open tibia fractures were treated at a major trauma center: 43 ultimately had amputations. This group included 38 males and five females with an average age of 31 years (range, 15-73). All patients were taken to the operating suite for consideration of limb salvage procedures including debridement, fasciotomy, revascularization, or rigid fixation. The standard subjective criteria including color, consistency, bleeding, and contractility were used to determine muscle viability at the time of debridement. If substantial muscle mass was found to be nonviable then amputation was considered. Fourteen (32.6%) of the patients had primary amputations. They averaged 22.3 days hospitalization, 1.6 surgical procedures to the involved lower extremity, and $28,964 hospital costs (range, $5,344-$81,282). The 29 patients with delayed amputations had an average of 53.4 days hospitalization, 6.9 surgical procedures, and $53,462 hospital costs (range, $14,574-$102,434). Six (20.7%) of the delayed amputation patients developed sepsis secondary to their involved lower extremity and died; no patient in the primary amputation group developed sepsis or died.(ABSTRACT TRUNCATED AT 250 WORDS)

Cost of treating advanced leg ischemia. Bypass graft vs primary amputation

We compared the hospital costs of 94 patients undergoing femoropopliteal bypass grafts with those of 53 patients undergoing primary amputation. The total cost of uncomplicated bypass surgery averaged +20,300, compared with +14,000 for uncomplicated below-knee amputation. However, including the cost of prosthesis and rehabilitation, the total cost of primary amputation was +20,400, equivalent to that of the bypass operation. Complications requiring revision of a bypass graft increased hospitalization by 4.5 days with the total cost rising to +28,700; complications that ended with major amputation added 15 hospitalization days and had an average cost of +42,200. In contrast, complicated below-knee amputation cost +40,600 and added 12.5 hospitalization days. There is therefore no cost-benefit in primary amputation when compared with arterial reconstruction, and cost should not be used to deny a patient the opportunity for limb salvage.

The costs of surgery for limb-threatening ischemia

The clinical courses of 106 patients with limb-threatening ischemia were traced for as long as 5 years to determine the cost of their care. Seventy-eight patients initially treated with vascular reconstruction accrued an average of $40,769 +/- $3726 in costs over a mean follow-up period of 805 +/- 57 days, during which they had an average of 2.4 +/- 0.2 hospitalizations or 67 +/- 6 inpatient days. Twenty-eight high-risk patients treated with primary amputation accrued $40,563 +/- $4729 in costs over a mean follow-up period of 663 +/- 97 days, during which they had an average of 2.2 +/- 0.3 hospitalizations or 85 +/- 10 inpatient days. Successful revascularization resulted in lower costs ($28,374) than did primary amputation ($40,563) or failed reconstruction ($56,809). Patients with ischemic tissue loss accrued costs more rapidly than did patients with rest pain only. The high cost of providing care for these patients and the advent of diagnosis related group reimbursement mandate that proposed treatment protocols be evaluated not only for their effectiveness but also for their cost-effectiveness.

Cost effectiveness of early digit amputation in the patient with diabetes

Osteomyelitis in the digit of the diabetic patient is best managed by antibiotics and amputation. Antibiotics alone are not effective or cost-effective as demonstrated in a retrospective study of 22 such patients diagnosed clinically and confirmed roentgenographically. Definitive operation allows the patient to return to work within two weeks of amputation.

Therapeutic and economic impact of a modern amputation program

The experience with 142 below-knee amputations for vascular occlusive disease and/or diabetes mellitus in 133 patients has been reviewed. The program utilized Xenon(133) skin bloodflow measurement for the selection of amputation level, emphasized the use of the long posterior skin flap as an important part of surgical technique, and employed immediate postoperative prosthesis with accelerated rehabilitation for postoperative management. The results of this program yielded a 0% postoperative mortality, 89% amputation healing, and 100% prosthesis rehabilitation of all unilateral below-knee amputees, and 93% rehabilitation of all bilateral below-knee amputees. The average time interval between amputation and fitting of a permanent prosthesis was 32 days. The use of Xenon(133) clearance as a measurement of capillary skin bloodflow for purposes of amputation level selection continues to be valid. All amputations with flows in excess of 2.6 ml/100 g tissue/min healed primarily, including the last 58 consecutive amputations. The total amputation of the 172 hospital V.A. system was surveyed and a cost analysis, based upon duration of postamputation hospitalization, comparing immediate postoperative prosthesis with conventional techniques, was performed. The savings to the system, taking into account start-up and maintenance costs for a program which employs immediate postoperative prosthesis, was projected to be $80,000,000 over five years. We conclude that a modern amputation program employing Xenon(133) clearance for amputation level selection and immediate postoperative prosthesis with accelerated rehabilitation is well justified based upon reduced morbidity, negligable mortality, and optimum patient prosthetic rehabilitation at a marked reduction in overall cost.

Revascularization or amputation

The factors which determine the choice, revascularization or amputation of an ischaemic leg are very numerous, variable and sometimes also related. They are concerned with the extent and course of the gangrene, the general condition of the patient and the risk of operation, the technical operability in terms of arterial reconstruction, the skill and judgement of the vascular surgeon, the motivation and life expectancy of the patient, as well as the facilities at the limb-fitting centre. In principle, arterial reconstruction should be the primary consideration in all patients with severe ischaemia of a leg, and threatened with loss of the limb. This implies the need for evaluation by a vascular surgeon. If arterial reconstruction is impossible or undesirable and if lumbar sympathectomy is not indicated either, then if amputation is necessary it must be decided, when is it necessary, and whether a below-knee or an above-knee amputation is possible. The patient with severe arterial circulatory disorders is best served when the vascular surgeon who is responsible for the arterial reconstruction, also assumes responsibility for determining the timing and the level of an amputation, and in some hospitals even for doing the amputation. In other words, the same doctor, preferably the vascular surgeon, has to be responsible for the selection of the patients and the judgement whether the patient is a candidate for revascularization or amputation.