H.J.P Fokkenrood

Innovative strategies for
intermittent claudication

towards a stepped care approach and new outcome measures



 Recently governments, nongovernmental organizations, and the private sector were called to assess the social and economic consequences of peripheral arterial disease (PAD) and to explore the best strategies for optimum treatment and prevention of this disease (1). Although treatment strategies for PAD are well described in international guidelines (2-4) and advocate a multimodal approach, including medication, lifestyle changes and symptomatic treatment, mentioning supervised exercise therapy (SET) as the primary treatment option (3), the actual availability of these SET programs worldwide is limited (5-9). In contrast, The Netherlands have a high availability of SET programs (10). However, a proven effective SET program (performed by physiotherapists trained at improving cardiorespiratory health status as well as life style factors and medication compliance) is in many cases not fully reimbursed.


 This reimbursement issue originates from a contradictory policy in the Dutch healthcare system. In the Netherlands, healthcare insurance companies have an obligation to accept everyone for a basic healthcare insurance. The Dutch government determines coverage of the standard insurance. In case of patients suffering from intermittent claudication (IC) the government decided not to cover the first 20 treatment sessions of a SET program, which have to be paid by the patient (either directly or through additional insurance). From the 21st session onwards all additional treatment sessions given in one year are covered by the basic health care insurance. Medication (prescribed by a physician) and invasive vascular interventions are both included in the standard package and fully reimbursed. As a consequence SET is largely underutilized. Patients may receive a proven insufficient and less cost-effective "go home and walk" advice (11-14) or a vascular intervention as an alternative first-line treatment strategy (5), which are contradictory to contemporary guidelines.


 The advocated treatment strategy in above-mentioned guidelines, could be incorporated into a so-called "stepped care" model (SCM) (5, 15, 16). This theoretical approach strives to initially refer all IC patients to a SET program and restrict revascularization for only those, who are not responding to SET. Several cost-effectiveness analyses have been performed supporting such a SET first treatment strategy (13, 16-20). However no study was performed to investigate the overall economic consequences of a SCM implementation nationwide. We decided to perform a cost-analysis in case of SCM implementation in the Dutch healthcare system. Costs of IC treatment were calculated and compared to estimated costs associated with three hypothetical scenarios of nationwide SCM implementation.