Significant savings with a stepped care model for treatment of patients with intermittent claudication.

WHAT THIS PAPER ADDS The aim of this study was to perform a cost-analysis of a recommended but largely underutilized SET first treatment strategy in intermittent claudication (IC). Until now no study has been performed to investigate the overall economic consequences of a nationwide SET first approach (stepped care). As the study used a large database (3.4 million people), daily practice is reflected well in the results. Implementation of a stepped care treatment for patients with IC may lead to significant savings of healthcare resources. These findings may be generalizable to other European healthcare systems. Objectives: International guidelines recommend supervised exercise therapy (SET) as primary treatment for intermittent claudication (IC). The aim of this study was to calculate treatment costs in patients with IC and to estimate nationwide annual savings if a stepped care model (SCM, primary SET treatment followed by revascularization in case of SET failure) was followed. Methods: Invoice data of all patients with IC in 2009 were obtained from a Dutch health insurance company (3.4 millionmembers).Patientsweredividedintothreegroupsbasedoninitialtreatmentafterdiagnosis(t0).TheSETgroup receivedSETinitiatedatanytimebetween12monthsbeforeandupto3monthsaftert0.Theinterventiongroup(INT) underwentendovascularoropenrevascularizationbetweent0andtþ 3m onths.Thethirdgroup(REST)receivedneither SET nor any intervention. All peripheral arterial disease related invoices were recorded during 2 years and average costs per patient were calculated. Savings following use of a SCM were calculated for three scenarios. Results: Data on 4954 patients were analyzed. Initial treatment was SET (n ¼ 701, 14.1%), INT (n ¼ 1363, 27.5%), or REST (n ¼ 2890, 58.3%). Within 2 years from t0, invasive revascularization in the SET group was performed in 45 patients (6.4%). Additional interventions (primary at other location and/or re-interventions) were performed in 480 INT patients (35.2%). Some 431 REST patients received additional SET (n ¼ 299, 10.3%) or an intervention (n ¼ 132, 4.5%). Mean total IC related costs per patient were V2,191, V9851 and V824 for SET, INT, and REST, respectively. Based on a hypothetical worst, moderate, and best case scenario, some 3.8, 20.6, or 33.0 million euros would have been saved per annum if SCM was implemented in the Dutch healthcare system. Conclusion: Implementation of a SCM treatment for patients with IC may lead to significant savings of health care resources.