Aaron J Deutsch1, C Charles Jain2, Kimberly G Blumenthal3, Mark W Dickinson4, Anne M Neilan5. 1. Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA; Harvard-MIT Division of Health Sciences and Technology, Harvard Medical School, Boston, MA. 2. Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA. 3. Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, MA; Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA. 4. Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA; Department of Pediatrics, Massachusetts General Hospital, Boston, MA. 5. Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA; Department of Pediatrics, Massachusetts General Hospital, Boston, MA; Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA. Electronic address: aneilan@partners.org.
Abstract
BACKGROUND: Critical limb ischemia (CLI) is a feared complication of peripheral vascular disease that often requires surgical management and may require amputation of the affected limb. We developed a decision model to inform clinical management for a 63-year-old woman with CLI and multiple medical comorbidities, including advanced heart failure and diabetes. METHODS: We developed a Markov decision model to evaluate 4 strategies: amputation, surgical bypass, endovascular therapy (e.g. stent or revascularization), and medical management. We measured the impact of parameter uncertainty using 1-way, 2-way, and multiway sensitivity analyses. RESULTS: In the base case, endovascular therapy yielded similar discounted quality-adjusted life months (26.50 QALMs) compared with surgical bypass (26.34 QALMs). Both endovascular and surgical therapies were superior to amputation (18.83 QALMs) and medical management (11.08 QALMs). This finding was robust to a wide range of periprocedural mortality weights and was most sensitive to long-term mortality associated with endovascular and surgical therapies. Utility weights were not stratified by patient comorbidities; nonetheless, our conclusion was robust to a range of utility weight values. CONCLUSIONS: For a patient with CLI, endovascular therapy and surgical bypass provided comparable clinical outcomes. However, this finding was sensitive to long-term mortality rates associated with each procedure. Both endovascular and surgical therapies were superior to amputation or medical management in a range of scenarios.
BACKGROUND:Critical limb ischemia (CLI) is a feared complication of peripheral vascular disease that often requires surgical management and may require amputation of the affected limb. We developed a decision model to inform clinical management for a 63-year-old woman with CLI and multiple medical comorbidities, including advanced heart failure and diabetes. METHODS: We developed a Markov decision model to evaluate 4 strategies: amputation, surgical bypass, endovascular therapy (e.g. stent or revascularization), and medical management. We measured the impact of parameter uncertainty using 1-way, 2-way, and multiway sensitivity analyses. RESULTS: In the base case, endovascular therapy yielded similar discounted quality-adjusted life months (26.50 QALMs) compared with surgical bypass (26.34 QALMs). Both endovascular and surgical therapies were superior to amputation (18.83 QALMs) and medical management (11.08 QALMs). This finding was robust to a wide range of periprocedural mortality weights and was most sensitive to long-term mortality associated with endovascular and surgical therapies. Utility weights were not stratified by patient comorbidities; nonetheless, our conclusion was robust to a range of utility weight values. CONCLUSIONS: For a patient with CLI, endovascular therapy and surgical bypass provided comparable clinical outcomes. However, this finding was sensitive to long-term mortality rates associated with each procedure. Both endovascular and surgical therapies were superior to amputation or medical management in a range of scenarios.
Authors: Andrew W Bradbury; Donald J Adam; Jocelyn Bell; John F Forbes; F Gerry R Fowkes; Ian Gillespie; Charles Vaughan Ruckley; Gillian M Raab Journal: J Vasc Surg Date: 2010-05 Impact factor: 4.268
Authors: John F Forbes; Donald J Adam; Jocelyn Bell; F Gerry R Fowkes; Ian Gillespie; Gillian M Raab; Charles Vaughan Ruckley; Andrew W Bradbury Journal: J Vasc Surg Date: 2010-05 Impact factor: 4.268
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