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A Decision and Cost-effectiveness Analysis

Maria G. M. Hunink, MD, PhD; John B. Wong, MD; Magruder C. Donaldson, MD; Michael F. Meyerovitz, MD; Jelle de Vries; Donald P. Harrington, MD

JAMA. 1995;274(2):165-171.

Abstract
Objective.
—To evaluate the relative benefits and cost-effectiveness of revascularization for femoropopliteal disease using percutaneous transluminal angioplasty or bypass surgery.

Design.
—Decision analysis using a multistate transition simulation model (Markov process) and cost-effectiveness analysis from the perspective of the health care system.

Setting.
—Based on mortality, morbidity, patency, and cost data from a literature review.

Patients.
—Hypothetical cohort of patients with chronic femoropopliteal disease who desire revascularization. Subgroup analysis for patients defined by age, sex, indication, lesion type, and graft type.

Interventions.
—Percutaneous transluminal angioplasty, bypass surgery, and a strategies combining the two treatments.

Main Outcome Measures.
—Five-year patency results, quality-adjusted life expectancy, lifetime costs, and incremental cost-effectiveness ratios.

Results.
—For 65-year-old men with disabling claudication and a femoropopliteal stenosis or occlusion and for 65-year-old men with chronic critical ischemia and a femoropopliteal stenosis, initial angioplasty increased quality-adjusted life expectancy by 2 to 13 months and resulted in decreased lifetime expenditures compared with bypass surgery. For patients with chronic critical ischemia and a femoropopliteal occlusion, initial bypass surgery increased quality-adjusted life expectancy by 1 to 4 months and resulted in decreased lifetime expenditures compared with angioplasty. Sensitivity analysis demonstrated that angioplasty would always be the preferred initial treatment if the angioplasty 5-year patency rate exceeds 30%.

Conclusion.
—Angioplasty is the preferred initial treatment in patients with disabling claudication and a femoropopliteal stenosis or occlusion and in those with chronic critical ischemia and a stenosis. Bypass surgery is the preferred initial treatment in patients with chronic critical ischemia and a femoropopliteal occlusion.

(JAMA. 1995;274:165-171)

Author Affiliations
From the Department of Health Sciences, University of Groningen, and Office for Medical Technology Assessment, University Hospital, Groningen, the Netherlands (Dr Hunink and Mr de Vries); the Department of Health Policy and Management, Harvard School of Public Health, Boston, Mass (Dr Hunink); the Division of Clinical Decision Making, Department of Medicine, New England Medical Center, Tufts University School of Medicine, Boston, Mass (Dr Wong); the Division of Vascular Surgery (Dr Donaldson) and the Department of Radiology (Dr Meyerovitz), Brigham and Women's Hospital, Harvard Medical School, Boston, Mass; and the Department of Radiology, State University of New York at Stony Brook (Dr Harrington).

Footnotes
Reprint requests to the Department of Health Sciences, Medical Decision Making, Faculty of Medicine, University of Groningen, Ant Deusinglaan 1, 9713 AV Groningen, the Netherlands (Dr Hunink).

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