H.J.P Fokkenrood

Innovative strategies for
intermittent claudication

towards a stepped care approach and new outcome measures



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) would have been followed.

Invoice data of all patients with IC in 2009 were obtained from a Dutch health insurance company (3.4 million members). Patients were divided into three groups based on initial treatment as followed after diagnosis (t0). The SET group received SET initiated at any time between 12 months before and up to 3 months after t0. The intervention group (INT) underwent endovascular or open revascularization between t0 and t+3 months. The third group (REST) received neither SET nor an intervention. All peripheral arterial occlusive disease (PAOD) related invoices were recorded during 2 years and average costs per patient were calculated. Savings following use of a SCM were calculated for 3 scenarios.

Data on 4954 patients were analysed. Initial treatment was SET (n=701, 14.1%), INT (n=1363, 27.5%) or REST (n=2890, 58.3%). Within two 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=299, 10.3%) or an intervention (n=132, 4.5%). Mean total IC related costs per patient were €2191, €9851 and €824 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 health care system.

Implementation of a SCM treatment for patients with IC may lead to significant savings of health care resources.