Health-related quality of life in patients with peripheral arterial disease undergoing percutaneous transluminal angioplasty: a prospective one-year follow-up

Defining the relative utility of lumbar spine surgery: A systematic literature review of common surgical procedures and their impact on health states

Degenerative lumbar spondylosis is a common indication for patients undergoing spine surgery. As healthcare costs rise, measuring quality of life (QOL) gains after surgical procedures is critical in assessing value. We set out to: 1) compare baseline and postoperative EuroQol-5D (EQ-5D) scores for lumbar spine surgery and common surgical procedures to obtain post-operative quality-adjusted life year (QALY) gain, and 2) establish the relative utility of lumbar spine surgery as compared to other commonly performed surgical procedures. A systematic literature review was conducted to identify all studies reporting preoperative/baseline and postoperative EQ-5D scores for common surgical procedures. For each study, the number of patients included and baseline/preoperative and follow-up mean EQ-5D scores were recorded, and mean QALY gained for each intervention was calculated. A total of 67 studies comprising 95,014 patients were identified. Patients with lumbar spondylosis had the worst reported QOL at baseline compared to other surgical cohorts. The greatest QALY gain was seen in patients undergoing hip arthroplasty (0.38), knee arthroplasty (0.35) and lumbar spine surgery (0.32), nearly 2.5-fold greater QALY gained than for all other procedures. The low preoperative QOL, coupled with the improvements offered with surgery, highlight the utility and value of lumbar spine surgery compared to other common surgical procedures.

How To Assess a Claudication and When To Intervene

PURPOSE OF THE REVIEW

Peripheral artery disease (PAD) affects close to 200 million people worldwide. Claudication is the most common presenting symptom for patients with PAD. This review summarizes the current diagnostic and treatment options for patients with claudication. Comprehensive history and physical examination in order to differentiate between claudication secondary to vascular disease vs. neurogenic causes is paramount for initial diagnosis. Ankle-brachial index is the most commonly used test for screening and diagnostic purposes. Treatment consists of four different approaches, which are best utilized in combination: non-pharmacological treatment for claudication improvement, pharmacological treatment for claudication improvement, pharmacological treatment for secondary risk reduction, and interventional treatment for claudication improvement.

RECENT FINDINGS

Cilostazol is the only Food and Drug Administration (FDA)-approved agent for symptomatic treatment of claudication. Supervised exercise programs provide the maximum benefit for claudication improvement, but home-based exercise programs are an alternative. High-intensity statins and an antiplatelet agent should be prescribed to all patients with PAD. Angiotensin-converting-enzyme inhibitors can provide additional risk reduction, especially in patients with diabetes or hypertension. Rivaroxaban of low dosage (2.5 mg twice daily) in combination with aspirin further decreases cardiovascular risk, but this reduction comes at the cost of higher bleeding risk. Peripheral artery disease (PAD) is a form of atherosclerotic disease that affects hundreds of millions of people worldwide-one of its most common manifestations is intermittent claudication (IC), which results from insufficient blood flow to meet the metabolic demands of an affected extremity. This paper reviews the current literature regarding the workup, diagnosis, diagnostic modalities, treatment options, and management of intermittent claudication.

Comparison of three generic quality-of-life metrics in peripheral arterial disease patients undergoing conservative and invasive treatments

PURPOSE

To determine the effect of revascularisation for peripheral arterial disease (PAD) on QoL in the first and second year following diagnosis, to compare the effect depicted by Short Form Six Dimensions (SF-6D) and EuroQoL five Dimensions (EQ-5D) utilities, and Visual Analogue Scale (VAS) scores and to analyse heterogeneity in treatment response.

METHODS

Longitudinal data from 229 PAD patients were obtained in an observational study in southern Netherlands. Utility scores were calculated with the international (SF-6D) and Dutch (EQ-5D) tariffs. We analysed treatment effect at years 1 and 2 through propensity score-matched ANCOVAs. Thereby, we estimated the marginal means (EMMs) of revascularisation and conservative treatment, and identified covariates of revascularisation effect.

RESULTS

A year after diagnosis, 70 patients had been revascularised; the EMMs of revascularisation were 0.038, 0.077 and 0.019 for SF-6D, EQ-5D and VAS, respectively (always in this order). For conservative treatment these were - 0.017, 0.038 and 0.021. At 2-year follow-up, the EMMs of revascularisation were 0.015, 0.077 and 0.027, for conservative treatment these were - 0.020, 0.013 and - 0.004. Baseline QoL (and rest pain in year 2) were covariates of treatment effect.

CONCLUSIONS

We measured positive effects of revascularisation and conservative treatment on QoL a year after diagnosis, the effect of revascularisation was sustained over 2 years. The magnitude of effect varied between the metrics and was largest for the EQ-5D, which may be most suitable for QoL measurement in PAD patients. Baseline QoL influenced revascularisation effect, in clinical practice this may inform expected QoL gain in individual patients.

The burden of critical limb ischemia: a review of recent literature

Peripheral arterial disease is a chronic vascular disease characterized by impaired circulation to the lower extremities. Its most severe stage, known as critical limb ischemia (CLI), puts patients at an increased risk of cardiovascular events, amputation, and death. The objective of this literature review is to describe the burden of disease across a comprehensive set of domains—epidemiologic, clinical, humanistic, and economic—focusing on key studies published in the last decade. CLI prevalence in the United States is estimated to be approximately 2 million and is likely to rise in the coming years given trends in important risk factors such as age, diabetes, and smoking. Hospitalization for CLI patients is common and up to 60% are readmitted within 6 months. Amputation rates are unacceptably high with a disproportionate risk for certain demographic and socioeconomic groups. In addition to limb loss, CLI patients also have reduced life expectancy with mortality typically exceeding 50% by 5 years. Given the poor clinical prognosis, it is unsurprising that the quality of life burden associated with CLI is significant. Studies assessing quality of life in CLI patients have used a variety of generic and disease-specific measures and all document a substantial impact of the disease on the patient’s physical, social, and emotional health status compared to population norms. Finally, the poor clinical outcomes and increased medical resource use lead to a considerable economic burden for national health care systems. However, published cost studies are not comprehensive and, therefore, likely underestimate the true economic impact of CLI. Our summary documents a sobering assessment of CLI burden—a poor clinical prognosis translating into diminished quality of life and high costs for millions of patients. Continued prevention efforts and improved treatment strategies are the key to ameliorating the substantial morbidity and mortality associated with this disease.

Psychosocial consequences in men taking part in a national screening program for abdominal aortic aneurysm

Screening for abdominal aortic aneurysm (AAA) has proven to reduce AAA-related mortality, but how the knowledge of having an untreated AAA affects health and daily life requires further clarification. The aim was to investigate the psychosocial consequences and sense of coherence (SOC) in 65-year-old men diagnosed with AAA and participating in a national screening program during a 6-month follow-up compared with men with no AAA. The single-center cohort study included 52 men with AAA and 118 men without AAA. A questionnaire including the Short Form 36 Health Survey, Hospital Anxiety and Depression Scale, SOC, questions concerning stress, and questions related to AAA were answered at baseline and after 6 months. Men with AAA reported more problems with physical functioning, pain, and general health than men with a normal aorta at baseline. After 6 months, men with AAA still reported more problems with physical functioning and stress in relation to disease than men with normal aortic diameter. No differences were observed between groups in SOC, anxiety, and depression. A significantly higher satisfaction with information from the physician and desire to learn about the AAA diagnosis was reported at baseline compared with that at follow-up. Having knowledge about the AAA diagnosis may moderately impact physical health and perceived stress, and in combination with the increased prevalence of other cardiovascular diseases, may lead to impaired perceived health for men diagnosed with AAA.

An integrative review of health-related quality of life in patients with critical limb ischaemia

AIMS AND OBJECTIVES

To examine the domains and the domain-specific characteristics within a peripheral arterial disease health-related quality of life framework for their usefulness in defining critical limb ischaemia health-related quality of life.

BACKGROUND

Critical Limb Ischaemia presents a highly individualised set of personal and health circumstances. Treatment options include conservative management, revascularisation or amputation. However, the links between treatment decisions and quality of life require further investigation.

DESIGN

The framework for this integrative review was the peripheral arterial disease-specific health-related quality of life domains identified by Treat-Jacobson et al.

RESULTS

The literature expanded and refined Treat-Jacobson's framework by modifying the characteristics to better describe health-related quality of life in critical limb ischaemia.

CONCLUSIONS

Given that critical limb ischaemia is a highly individualised situation with powerful health-related quality of life implications, further research focusing on patient and family-centred decision-making relating to therapeutic options and advanced care planning is required.

RELEVANCE TO CLINICAL PRACTICE

A critical limb ischaemia-specific, health-related quality of life tool is required to capture both the unique characteristics of this disorder, and the outcomes for active or conservative care among this complex group of patients.

Patient-reported outcome measures in vascular surgery

Patient-reported outcomes (PROs) after vascular surgery are becoming increasingly important in the current era of health care reform. Although a number of general quality of life instruments exist, vascular disease-specific instruments may provide more targeted data on how patients feel after specific interventions. Here we provide a review of both generic and disease-specific instruments focused on arterial conditions, including peripheral arterial disease, carotid arterial disease, and aortic disease, which have been described in the literature. While many different tools currently exist, there is a paucity of well-validated, specific instruments that accurately reflect functional and objective measures of patients' arterial disease burden. A full understanding of the existing tools available to assess patients' perceived lifestyle impact of their disease and its treatments is essential for both research and clinical purposes, and to highlight the need for additional work on this topic.

Review: Quality of life in lower limb peripheral vascular surgery

PURPOSE

Vascular intervention studies generally consider patency and limb salvage as primary outcomes. However, quality of life is increasingly considered an important patient-oriented outcome measurement of vascular interventions. Existing literature was analyzed to determine the effect of different treatments on quality of life for patients suffering from either claudication or critical limb ischemia.

BASIC METHODS

A review of the literature was undertaken in the Medline library. A search was performed on quality of life in peripheral arterial disease. Results were stratified according to treatment groups.

PRINCIPAL FINDINGS

Twenty-one articles described quality of life in approximately 4600 patients suffering from peripheral arterial disease. Invasive treatment generally results in better quality of life scores (at a maximum of 2 years of follow-up), compared with non-invasive treatment. In patients with critical limb ischemia, successful revascularization improves quality of life scores. Only one study reported long-term results.

CONCLUSIONS

Increase in quality of life scores can be found for any intervention performed for peripheral arterial disease. However, there is scarce information on long-term quality of life after vascular intervention.

Cost-effectiveness analysis of orbital atherectomy plus balloon angioplasty vs balloon angioplasty alone in subjects with calcified femoropopliteal lesions

Introduction

As cost considerations become increasingly critical when selecting optimal endovascular treatment strategies, a cost-benefit analysis was conducted comparing the Diamondback 360°® Orbital Atherectomy System (OAS) (Cardiovascular Systems, Inc., St Paul, MN, USA) and balloon angioplasty (BA) vs BA alone for treatment of calcified femoropopliteal lesions.

Patients and methods

The clinical outcomes from COMPLIANCE 360°, a prospective, multicenter, randomized study comparing OAS+BA vs BA alone for treatment of calcified femoropopliteal lesions, were correlated with cost data and previously published quality of life data. Site of service, hospital charges, and associated medical resource utilization were obtained from Uniform Billing statements for index treatments and associated revascularizations out to 1 year. Hospital costs were estimated using hospital-specific, procedure-specific cost-to-charge ratios. Length of stay and procedural data were collected from participating study sites.

Results

Twenty-five subjects with 38 lesions and 25 subjects with 27 lesions were randomized to the OAS+BA and BA-alone groups, respectively. Mean hospital charges (US$51,755 vs US$39,922) and estimated hospital costs (US$15,100 vs US$11,016) were higher for OAS+BA compared with BA alone (not statistically significant). Stent utilization was statistically significantly higher with BA-alone treatment for all subjects (1.1 vs 0.1, P=0.001) and in the subset of subjects with one lesion (1.0 vs 0.1, P<0.00001). There was a significant difference in cost for single-lesion versus multiple-lesion treatment. Using costs and quality-adjusted life years (QALYs) for the single-lesion cohort, the 1-year incremental cost of OAS+BA vs BA alone was US$549, and incremental QALY was 0.16. This results in an incremental cost-effectiveness ratio of US$3,441, well below the US$50,000 threshold.

Conclusion

One-year index procedure cost and cost-effectiveness were comparable for OAS+BA vs BA alone. This study provides compelling cost-effectiveness data for using atherectomy for treatment of calcified femoropopliteal lesions, a longstanding challenge for peripheral artery disease interventionalists.

A systematic literature review of cardiovascular event utilities

Cardiovascular disease (CVD) results in half of the non-communicable disease-related deaths worldwide. Rising treatment costs have increased the need for cost-utility models designed to compare the value of new and existing therapies. Cost-utility models require utilities, values representing the strength of preferences for various health states. This systematic literature review aimed to identify and evaluate utilities reported for stroke, myocardial infarction (MI) and angina. In total, 83 unique studies were identified that reported utilities for these events. Approximately two-thirds reported utility values for stroke, and most used the EuroQoL five dimension to derive utilities. Utility values were lower in patients who experienced cardiovascular (CV) events than in patients who did not. The utility estimates for each condition varied greatly, likely due to differences in assessment methodologies and patient populations. This variability must be considered when choosing values for cost-utility models. Comparisons among reported utilities are further complicated by inconsistent CV event definitions.

Assessment of functional status and quality of life in claudication

BACKGROUND

Treadmill walking is commonly used to evaluate walking impairment and efficacy of treatment for intermittent claudication (IC) in clinical and research settings. Although this is an important measure, it does not provide information about how patients perceive the effects of their treatments on more global measures of health-related quality of life (HRQOL).

METHODS

PubMed/Medline was searched to find publications about the most commonly used questionnaires to assess functional status and/or general and disease-specific HRQOL in patients with peripheral artery disease (PAD) who experience IC. Inclusion criteria for questionnaires were based on existence of a body of literature in symptomatic PAD.

RESULTS

Six general questionnaires and seven disease-specific questionnaires are included, with details about the number of domains covered and how each tool is scored. The Medical Outcomes Study Short Form 36-item questionnaire and Walking Impairment Questionnaire are currently the most used general and disease-specific questionnaires at baseline and after treatment for IC, respectively.

CONCLUSIONS

The use of tools that assess functional status and HRQOL has importance in both the clinical and research areas to assess treatment efficacy from the patient's perspective. Therefore, assessing HRQOL in addition to treadmill-measured walking ability provides insight as to the effects of treatments on patient outcomes and may help guide therapy.