Exercise beats stenting, medical care for PAD costs

Proponents of supervised exercise as a treatment for peripheral artery disease (PAD) can flex their muscles a bit more with policy makers and payers after a cost-effectiveness analysis showed the approach to be a good value.

The CLEVER (Claudication: Exercise Versus Endoluminal Revascularization) trial compared three treatments for patients with moderate to severe aortoiliac PAD: supervised exercise, iliac stenting and optimal medical care. Patients were followed for 18 months.

Results showed that patients in the exercise and stenting groups had improved walking performance and quality of life (QOL) at six and 18 months compared with optimal medical care. The economic study, led by Matthew R. Reynolds, of the Harvard Clinical Research Institute in Boston, assessed the relative cost-effectiveness of the three strategies over a five-year time frame.

The cost analysis included 98 patients with complete clinical and economic follow-up data at six months. In their base case, the researchers assumed the utility differences between groups would diminish over time and equalize at five years.

Their analysis showed that the mean encounter cost for the stenting group totaled $9,211 with a mean hospital stay of 0.8 days. Mean total costs for supervised exercise was $4,447 with almost half attributed to the time (lost wages) spent by patients. They converted all costs to 2011 U.S. dollars.

Cumulative 18-month costs reached $5,179 for optimal medical care, $9,804 for supervised exercise and $14,590 for stenting. Under the base case model and adjusted for baseline differences, quality-adjusted life years (QALYs) through 18 months were 1.05, 1.14 and 1.16, respectively.

Over five years, the incremental cost-effectiveness ratios (ICERs) for exercise vs. medical care and stenting vs. medical care were $24,070 per QUAL gained and $41,376 per QALY gained, respectively. Compared with supervised exercise, the ICER for stenting at five years totaled $122,600 per QALY gained. In sensitivity analyses, assuming better stent durability than in the base case model improved the ICER for stenting while assuming lower facility costs for exercise improved its ICER.

“[T]he cost-effectiveness of ST [stenting] relative to SE [exercise] was uncertain and would most likely represent high value only if the treatment effect of ST were more durable than that of SE,” Reynolds et al wrote.

Based on longer-term QOL benefits projected in the economic analysis, they saw the incremental costs of stenting and supervised exercise to be reasonable and economically attractive from a societal perspective. In the short-term, exercise may provide a better value, they suggested.

Excluding patient costs in the exercise program—that is, taking on the payer or health system perspective— gave exercise a cost advantage over optimal medical therapy.

Reynolds et al noted Medicare covers rehabilitation costs for a number of cardiovascular procedures but not for supervised exercise for PAD claudication. Even when assuming facility costs for supervised exercise that were 50 percent higher than some of the reimbursed cardiac rehabilitation costs, exercise proved to be more cost effective than optimal medical management for PAD.

Stenting is widely available as a treatment for PAD claudication. “Given the increased expense and marginal benefits of ST relative to SE, there would appear to be no rational justification for covering ST but not SE for the treatment of claudication,” they argued.