Total variable cost of care for
patients with CLI:
Is Endo or Open more cost-effective ?
TM Sullivan
Minneapolis, MN
Disclosures
WL Gore & Associates
Meeting organizer (SOAR)
CR Bard
Chair, CEC
Bolster trial
Veryan
National PI, MIMICS trial (SFA stent)
Allina Health
Employed physician
BASIL
Balloon Angioplasty in Severe
Ischemia of the Leg
Lancet 2005;366:1925-34
Critical limb ischemia:
Rest pain
Ulceration
Gangrene
Randomized, multi-center trial (UK)
comparing endovascular and surgical therapies
BASIL
Based on intent-to-treat:
OR associated with lower re-intervention rate
18% vs 26%
Based on first invention received:
The difference increases, favoring OR
17% vs 28%
Utilization of hospital resources @ 12 months
Based on intention-to-treat
Average cost, first 12 months (British pound sterling)
Surgery: 23,3222
PTA: 17, 419
BEST CLI
ClinicalTrials.gov
Primary Outcome Measures:
Time to Major Adverse Limb Event or Death
With or Without available SSGSV
Secondary Outcome Measures:
Treatment Associated Costs (up to 50 months)
With or Without available SSGSV
Definitions
Total cost (TC)
Total economic cost of production
Variable costs
Vary according to the quantity of goods produced
Devices, LOS, patient care labor / support
Variable direct: Direct pt. care departments
Allocated on a cost to charge ratio
Variable indirect: Housekeeping, nutrition, etc.
Costs attributed to pt care dept (eg, Sq feet for
housekeeping)
Allocated on a cost to charge ratio
Fixed costs
Independent of the quantity of goods produced
Lights, utilities, etc
7
Cost definitions
Total Costs
$
Variable Costs
Fixed costs
# of Units
8
Open bypass and endovascular ( EVT ) procedures based on volume
and percent involving amputation, 2001 to 2010.
Grant H. Skrepnek , David G. Armstrong , Joseph L. Mills
Open bypass and endovascular procedures among diabetic foot ulcer cases in the United States from 2001 to 2010
Journal of Vascular Surgery, Volume 60, Issue 5, 2014, 1255 - 1265
http://dx.doi.org/10.1016/j.jvs.2014.04.071
PVI vs LEB for infrageniculate disease in
patients with CLI
Hicks et al, Vasc Med 2017;22:28
Johns Hopkins
VQI Data
2566 patients;
500 LEB, 2066 PVI
Outcome measures @ 1 year:
Primary patency
Major amputation
Mortality
PVI vs LEB for infrageniculate disease
in patients with CLI
No difference in:
Major amputation
Mortality
Superior primary patency: PVI
The details…
38% of bypasses to DP or plantar vessel
0% of PVI procedures involved DP / plantar
Median # of vessels treated in PVI group: 1
PTA alone in 85%
”Majority” of bypasses with autogenous vein
? SSGSV
? Spliced vein
? Cephalic vein
Very likely that many of these LEB patients had no
endo solution
Determining cost of care:
Chronic Critical Limb Ischemia (CLI)
Patients identified from a prospective database
6 surgeons
5 Radiologists
One institution
Calendar year 2011, 2012
N = 217
Endovascular = 118
Open surgical = 76
Open + endo = 23
Index
hospitalization
All inpatient costs
for one year
Determining cost of care:
Chronic Critical Limb Ischemia (CLI)
What was captured:
All inpatient costs, subsequent hospitalizations related
to CLI
Reintervention
Amputations
Debridements
What was not captured:
Outpatient visits
Imaging
Wound care center
Treatment in other healthcare systems
Average Total Cost: 12 months
(Fixed + Variable)
Average Total 12 Month Cost (Fixed + Variable)
$60,000.00
$50,000.00
$46,578.82
$48,972.69
$40,000.00
$30,000.00
$25,556.35
P<0.001
$20,000.00
$10,000.00
$-
Endovascular
Open
Endovascular/Open
Average Variable Cost of Care
12 months
Average Variable 12 Month Cost
$35,000.00
$32,617.59
$29,446.89
$30,000.00
$25,000.00
P<0.001
$20,000.00
$16,534.30
$15,000.00
$10,000.00
$5,000.00
$-
Endovascular
Open
Endovascular/Open
Supply Cost: Initial Hospitalization
Average Supply Cost for Initial Hospitalization
$5,670.45
$6,000.00
$5,000.00
$4,000.00
$3,302.76
$2,670.19
$3,000.00
$2,000.00
$1,000.00
$-
Endovascular
Open
Endovascular/Open
Average Cost LOS: Initial
Hospitalization
Average LOS Cost for Initial Hospitalization
$9,000.00
$8,079.38
$8,000.00
$7,000.00
$6,576.84
$6,000.00
$5,000.00
P<0.001
$4,451.15
$4,000.00
$3,000.00
$2,000.00
$1,000.00
$-
Endovascular
Open
Endovascular/Open
Supply Cost by Treating Physician
Median Initial Varible Supply Costs by Surgeon
$8,000.00
$7,000.00
$6,000.00
$5,000.00
$4,000.00
$3,000.00
$2,000.00
$1,000.00
$Endo
Open
Both
A
$1,934.26
$1,760.93
$6,793.03
B
$2,347.19
$1,336.04
$4,247.09
C
$2,195.90
$$-
D
$$2,296.69
$4,519.22
E
$2,246.94
$2,749.67
$6,709.52
F
$2,217.55
$418.18
$6,646.08
G
$1,405.86
$1,475.97
$1,889.54
Cost of CLI: 12 months
Endovascular
$3M
Open
$ 3.5M
Combined
$ 1.1M
TOTAL
$ 7.6M
$35,000 per patient (N = 217)
VS Dashboard Overview
CLI Volumes
CLI Median LOS
CLI Average Total Cost
CLI Fem-tib bypass
Total Variable Cost
CLI Endovascular
Total Variable Cost
Why is this important ?
ACO era (capitated payment)
System’s bottom line = reduce variable cost of care
Total cost of care: enables bidding on contracts
What is the cost of caring for CLI in a given
population ?
Reducing variability of care = physician involvement
How do we reduce cost ?
For endovascular procedures:
Supply cost
For open surgical procedures
LOS
Reducing variability in practice
There is a financial incentive for physicians on
production-based compensation towards Endo
Physician involvement is key
Conclusions
The cost of caring for patients with CLI is substantial
Open surgical repair: LOS drives initial cost
Endovascular therapy: Device cost drives intial cost
At one year, endovascular therapy is less expensive
Need for reintervention ~ 20% for both groups
At two years, surgical bypass becomes less expensive
Fewer hospitalizations for re-intervention