Kosten und Kosteneffizienz bei der Behandlung der peripheren arteriellen Verschlusskrankheit – was ist gesichert?

Zusammenfassung

Hintergrund: Die vorliegende Übersicht hat das Ziel, die gesundheitspolitische Bedeutung der peripheren arteriellen Verschlusskrankheit (pAVK) bei Patienten mit intermittierender Claudicatio und kritischer Extremitätenischämie (CLI) herauszustellen und die Behandlung unter dem Gesichtspunkt der Kosteneffektivität zu bewerten. Methodik: Für die Literaturübersicht wurde die Datenbank Medline (PubMed) unter den Schlüsselwörtern „critical limb ischemia AND cost“, „critical limb ischemia AND economy“, „peripheral arterial disease AND cost“, „peripheral arterial disease AND economy“ durchsucht. Ergebnisse: In den Jahren 2005 bis 2009 stiegen in Deutschland die stationären Aufnahmen von Patienten mit pAVK überproportional um 20 % an auf 483 961 Krankenhausaufnahmen, verglichen mit einer allgemeinen Steigerung der Krankenhausaufnahmen um lediglich 8 %. Die durchschnittlichen stationären Behandlungskosten wurden dabei auf ca. € 5000 pro Patient geschätzt – eine eher konservative Schätzung. Für den Patienten mit intermittierender Claudicatio ist die ökonomische Datenlage eindeutig, das strukturierte Gehtraining ist die bei weitem kostengünstigste Behandlungsoption, gefolgt von PTA und mit großem Abstand dem peripheren Bypass. Letzterer ist nach den Leitlinien des UK folglich nur indiziert, wenn die PTA versagt oder technisch nicht möglich ist. Bei Patienten mit CLI ist die Situation nicht so klar. Zwar errechnet sich auch hier ein kurzfristiger ökonomischer Vorteil für die PTA, aber für die langfristige Bewertung beider Verfahren reichen die Daten nicht aus. Auch fließen in die Berechnung die Risikofaktoren des Patienten ein, dies wurde zwar kurzfristig demonstriert, langfristig aber nicht analysiert. Schlussfolgerung: Die Frage der größeren Kosteneffektivität von offener oder endovaskulärer Behandlung bei Patienten mit CLI ist unentschieden, zu heterogen sind die Studien und Vergleichskollektive. Weitere Untersuchungen sind dringend geboten, um die verschiedenen Behandlungsoptionen in Leitlinien und klinischen Ablaufpfaden in ihrer Abfolge besser zu strukturieren.

Abstract

Background: This overview comments on the health-care relevance of peripheral arterial occlusive disease (PAOD) in patients with intermittent claudication (IC) and critical limb ischaemia (CLI). We evaluated different treatment modalities in terms of cost-effectiveness. Method: For the literature review, the Medline database (PubMed) was searched under the key words “critical limb ischemia AND cost”, “critical limb ischemia AND economy”, “peripheral arterial disease AND cost”, “peripheral arterial disease AND economy”. Results: In the years 2005 to 2009, the hospitalisations of patients with PAOD rose disproportionately in Germany by 20 %, to 483,961 hospital admissions. By comparison, hospital admissions altogether increased by only 8 %. The average in-patient costs were estimated to be approximately € 5000 per PAOD-patient – a rather conservative estimate. For the patient with IC the economic data position is clear, supervised exercise training is by far the most cost-effective treatment option, followed by percutaneous transluminal angioplasty (PTA) and finally the peripheral bypass. In accordance with the guidelines of the UK, the latter is therefore indicated only if PTA fails or is technically not possible. In patients with CLI, the situation is not obvious. Indeed, a short-term economic advantage can be calculated for the PTA, the long-term comparison of both methods, however, is impossible due to insufficient data. In addition, the risk factors for the patient have to be included in the calculation. This was indeed demonstrated in the short-term, but could not be analysed in the long-term follow-up. Conclusion: The issue of greater cost-effectiveness of open or endovascular treatment in patients with CLI is uncertain, the studies and patient populations are too heterogeneous. Further studies are urgently needed to structure the sequence of the various treatment options in guidelines and clinical pathways.

Schlüsselwörter

periphere arterielle Verschlusskrankheit (pAVK) - kritische Extremitätenischämie - Behandlungsoptionen - Kosten - Leitlinien

Key words

peripheral arterial occlusion disease (PAOD) - critical limb ischaemia - treatment options - costs - guidelines

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