Femoropopliteal Atherectomy In The OBL Is Not Cost-effective For Medicare
Katherine M. Sanders, MD, Starley Shade, PhD, MPH, Emanuel A. Jaramillo, MD, Michael S. Conte, MD, Warren J. Gasper, MD, Peter A. Schneider, MD, James C. Iannuzzi, MD, MPH.
UCSF, San Francisco, CA, USA.
Objective: Recent analyses have shown that Medicare spending on atherectomy far exceeds that of other peripheral vascular interventions (PVI) despite an absence of evidence supporting this approach. Few studies have examined the cost-effectiveness of atherectomy and those available are limited by potential conflicts of interest. This study integrates real world data to investigate the cost-effectiveness of atherectomy compared to plain balloon angioplasty (PBA) in patients with intermittent claudication (IC).Methods:A decision tree model (Figure 1) was developed using the base case of a 65-year-old cohort with lifestyle-limiting IC and atherosclerotic disease in the femoropopliteal segment amenable to endovascular intervention. Treatment arms included PBA and atherectomy. Costs were estimated using Medicare reimbursement in the office-based lab (OBL) setting and reflected the payor perspective. Effectiveness was estimated using quality-adjusted life years (QALYs). Cost effectiveness is measured by the incremental cost effectiveness ratio (ICER) and was estimated over a 1-year time horizon. Event probabilities and utility values were obtained from the literature. The willingness to pay (WTP) threshold was set at $100,000 per QALY. Sensitivity analyses were performed to account for parameter uncertainty. Results:Pursuing a primary strategy of atherectomy resulted in an ICER of $354,644 per QALY gained compared to a primary strategy of PBA. While atherectomy resulted in an incremental effectiveness of 0.013 QALY (0.757 vs. 0.744 for atherectomy and PBA, respectively), the incremental cost was $4,561 (expected costs $11,800 in atherectomy arm vs. $7,239 in PBA arm). On one-way sensitivity analysis of all variables in the model, the ICER ranged from $243,057 to $903,284 and failed to meet the WTP threshold across the range of currently available estimates for each variable. Reimbursement for atherectomy in the OBL setting would need to be reduced to by 31% to achieve cost-effectiveness at a $100,000 WTP threshold.Conclusions: Atherectomy offers a negligible incremental benefit over PBA, but at dramatically increased cost. At current Medicare reimbursement levels, atherectomy as a first-choice intervention for IC in the OBL setting does not meet generally acceptable cost-effectiveness thresholds. Further study is needed to identify the most cost-effective strategies for patients with lifestyle-limiting claudication. 
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