H.J.P Fokkenrood

Innovative strategies for
intermittent claudication

towards a stepped care approach and new outcome measures



Adherence to a SCM

 A total of 5824 patients with "PAD Fontaine 2" (IC) were identified of which 871 patients were excluded for reasons listed in figure 1, leaving 4954 IC patients for analysis. Fourteen percent received SET, whereas 28% was primarily treated with an invasive intervention (INT). The remaining 58% (n=2890) did not receive any of these two treatment regimens within three months after diagnosis (REST). Patient characteristics of the three groups are shown in table 1. Significant differences between groups were found with respect to age, gender and congestive heart failure. Patients in the INT group were younger, more often male and had less often congestive heart failure.


 Primary and secondary treatments are depicted in table 2 and 3. A total of 45 SET patients (6.4%) were secondarily treated with an endovascular (n=43) or open surgical (n=2) procedure (table 2). A total of 1055 endovascular (aortoiliac lesions: 696; femoro-popliteal lesions: 340) and 308 open surgical procedures were initially performed in 1363 INT subjects (table 2). In 480 of these patients (35.2%), an additional revascularization procedure (endovascular: n=464; open: n=16) was performed within 2 years. In the REST group, 299 patients (10.3%) were additionally treated with SET and 132 patients (144 interventions, 4.6%) with an endovascular revascularization.

Costs of IC treatment

 A wide range of costs was found regarding the physician based invoices. Bills ranged from a minimum of €99 and €2,515 to a maximum of €14,428 and €50,173 for the SET and INT group, respectively. Total costs ranged from a single visit at the patient outdoor clinic (€99) to a bilateral open surgical revascularization. Mean costs of SET declarations ranged from €28 to €7,187 in the SET group to a maximum of €12,886 in the REST group as related to the number of SET sessions (1 to 470 sessions; table 3). The MTC per patient in the SET group (€2,191) was almost five times lower compared a patient in the INT group (€9,851; table 4).

Cost-analysis of a hypothetical nationwide adherence to a SCM

 The effects on cost-savings of a SCM with and without sensitivity analysis (SA) are shown in table 5. In the 2009 situation (14% SCM), the costs were 17.3 million euros. In the hypothetical best-case scenario (80%-80%), 1573 of the 2064 eligible patients would receive SET and 491 a vascular intervention as initial treatment. Nationwide implementation of such an 80%-80% scenario SCM would result in a 33.0 million euros annual savings for the Dutch population (table 5). Implementation of the worst-case scenario (30%-25%) would still reduce the yearly costs of IC treatment with 3.9 million euros (table 5). In the sensitivity-analysis (SA), 2023 of 2890 patients remained in the REST group (30% non-PAD exclusion) leaving 4087 eligible IC patients for analysis. In the best-case scenario, 2868 of these patients would receive SET, 491 a vascular intervention and 728 a walking advice. Savings would still be reduced from 33.0 to 24.2 million with an 80%-80% SCM implementation after SA (table 5).