RESUMO
OBJECTIVE: The objective of this study is to systemically review the literature on Anterior Saphenous Vein (ASV) reflux treatment and insurance impediments to treatment coverage. METHODS: A literature search was performed using a PRISMA framework. In addition, a cross-sectional analysis of insurance policies for ASV treatment was evaluated. RESULTS: Published evidence and treatment considerations in the literature for ASV treatment are discussed. In 155 of 226 (68.6%) insurance policies reviewed coverage of ASV ablation was allowed while 62/226 (27.4%) did not specify coverage and 9/226 (4.0%) specified ASV treatment was not covered. Of the 155 that provide ASV coverage, 98 (62.2%) provide coverage with criteria such as requiring prior treatment of the great saphenous vein. CONCLUSIONS: Vein treatment experts should continue to advocate to insurance carriers to update their varicose vein treatment policies to reflect the substantial clinical evidence so that patients with ASV reflux can be appropriately treated.
Assuntos
Veia Safena , Varizes , Humanos , Veia Safena/cirurgia , Varizes/terapia , Varizes/economia , Cobertura do Seguro/economia , Insuficiência Venosa/terapia , Insuficiência Venosa/economia , Sociedades Médicas , Estados UnidosRESUMO
OBJECTIVE: Superficial venous incompetence (SVI) is a common disease that causes significant quality of life (QoL) impairment. There is a need for more health economic evaluations of SVI treatment. The aim of this study was to perform a cost effectiveness analysis in patients with great saphenous vein (GSV) incompetence comparing radiofrequency ablation (RFA), high ligation and stripping (HL/S), and no treatment or conservative treatment with one year follow up. METHODS: Randomised controlled trial economic analysis from an ongoing trial; 143 patients (156 limbs) with GSV incompetence (CEAP clinical class 2 - 6) were included. Treatment was performed with RFA or HL/S. Follow up was performed up to one year using duplex ultrasound, revised venous clinical severity score (r-VCSS), Aberdeen Varicose Vein Questionnaire (AVVQ), and EuroQol-5D-3L (EQ-5D-3L). RESULTS: Seventy-eight limbs were treated with RFA and HL/S respectively. No treatment or conservative treatment was assumed to have zero in treatment cost and no treatment benefit. In the RFA group, one limb had reflux in the GSV after one month and three limbs after one year. In HL/S, two limbs had remaining reflux in the treated area at one month and one year. Both disease severity (r-VCSS, p = .004) and QoL (AVVQ, p = .021 and EQ-5D-3L, p = .028) were significantly improved over time. The QALY gain was 0.21 for RFA and 0.17 for HL/S. The cost per patient was calculated as 1 292 for RFA and 2 303 for HL/S. The cost per QALY (compared with no treatment or conservative treatment) was 6 155 for RFA and 13 549 for HL/S. With added cost for days absent from work the cost per QALY was 7 358 for RFA and 24 197 for HL/S. The cost per QALY for both methods was well below the threshold suggested by Swedish National Board of Health. CONCLUSION: RFA is more cost effective than HL/S and no treatment or conservative treatment at one year follow up.
Assuntos
Análise Custo-Benefício , Qualidade de Vida , Ablação por Radiofrequência , Veia Safena , Insuficiência Venosa , Humanos , Ligadura/economia , Veia Safena/cirurgia , Veia Safena/diagnóstico por imagem , Insuficiência Venosa/cirurgia , Insuficiência Venosa/economia , Insuficiência Venosa/diagnóstico por imagem , Feminino , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento , Ablação por Radiofrequência/economia , Ablação por Radiofrequência/efeitos adversos , Anos de Vida Ajustados por Qualidade de Vida , Fatores de Tempo , Procedimentos Cirúrgicos Vasculares/economia , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Procedimentos Cirúrgicos Vasculares/métodos , Idoso , Ablação por Cateter/economia , Ablação por Cateter/efeitos adversos , Ablação por Cateter/métodos , Adulto , Custos de Cuidados de Saúde , Varizes/cirurgia , Varizes/economia , Varizes/diagnóstico por imagem , Análise de Custo-EfetividadeRESUMO
OBJECTIVE: To analyze the effectiveness and cost effectiveness of technologies for treatment of varicose veins over 5 years-conservative care, surgery (high ligation and stripping), ultrasound-guided foam sclerotherapy (UGFS), endovenous laser ablation (EVLA), and radiofrequency ablation (RFA), mechanochemical ablation (MOCA), and cyanoacrylate glue occlusion (CAE). METHODS: A systematic review was updated and used to construct a Markov decision model. Outcomes were reintervention on the truncal vein, retreatment of residual varicosities and quality-adjusted life years (QALY) and costs over 5 years. RESULTS: UGFS has a significantly greater reintervention rate than other procedures; there is no significant difference between the other procedures. The cost per QALY of EVLA vs UGFS in our base-case model is £16,966 ($23,700) per QALY, which is considered cost effective in the UK. RFA, MOCA, and CAE have greater procedure costs than EVLA with no evidence of greater benefit for patients. CONCLUSIONS: EVLA is the most cost-effective therapeutic option, with RFA a close second, in adult patients requiring treatment in the upper leg for incompetence of the GSV. MOCA, UGFS, CAE, conservative care, and high ligation and stripping are not cost effective at current prices in the UK National Health Service. MOCA and CAE seem to be promising, but further evidence on the effectiveness, reinterventions, and health-related quality of life is needed, as well as how cost effectiveness may vary across settings and reimbursement systems.
Assuntos
Técnicas de Apoio para a Decisão , Custos de Cuidados de Saúde , Varizes/economia , Varizes/terapia , Tomada de Decisão Clínica , Análise Custo-Benefício , Humanos , Cadeias de Markov , Modelos Econômicos , Qualidade de Vida , Anos de Vida Ajustados por Qualidade de Vida , Fatores de Tempo , Resultado do Tratamento , Varizes/diagnósticoRESUMO
Varicose veins afflict more than one in five Americans, and although varicose veins may be an asymptomatic cosmetic concern in some, many others experience symptoms of pain, aching, heaviness, itching, and swelling. More advanced venous disease can result from untreated venous insufficiency. The complications of chronic venous disease, including bleeding, thrombosis, and ulceration, are seen in up to 2 million Americans annually. Numerous reports have documented venous disease adversely affects quality of life and that treatment of venous disease can improve quality of life. It has previously been documented that private insurers, and Centers for Medicare & Medicaid Services subcontractors for that matter, have disparate policies that in many instances are self-serving, contain mistakes, use outdated evidence, and disregard evidence-based guidelines. The two leading venous medical societies, the American Venous Forum and the American Venous and Lymphatic Society, have come together to review the varicose vein coverage policies of seven major U.S. private medical insurance carriers whose policies cover more than 150 million Americans. The authors reviewed the policies for venous disease and, if significant gaps or inconsistencies are found, we hope to point them out, and, finally, to propose a thoughtful and reasonable policy based on the best available evidence.
Assuntos
Definição da Elegibilidade , Medicina Baseada em Evidências , Cobertura do Seguro , Reembolso de Seguro de Saúde , Programas de Assistência Gerenciada , Formulação de Políticas , Varizes/terapia , Doença Crônica , Tomada de Decisão Clínica , Definição da Elegibilidade/economia , Medicina Baseada em Evidências/economia , Humanos , Cobertura do Seguro/economia , Reembolso de Seguro de Saúde/economia , Programas de Assistência Gerenciada/economia , Estados Unidos , Varizes/diagnóstico por imagem , Varizes/economiaRESUMO
OBJECTIVE: To measure patient preferences for attributes associated with thermal ablation and nonthermal, nontumescent varicose vein treatments. METHODS: Data were collected from an electronic patient preference survey taken by 70 adult participants (aged 20 years or older) at three Center for Vein Restoration clinics in New Jersey from July 19, 2019, through August 13, 2019. Survey participation was voluntary and anonymous (participation rate of 80.5% [70/87]). Patients were shown 10 consecutive screens that displayed three hypothetical treatment scenarios with different combinations of six attributes of interest and a none option. Choice-based conjoint analysis estimated the relative importance of different aspects of care, trade-offs between these aspects, and total satisfaction that respondents derived from different healthcare procedures. Market simulation analysis compared clusters of attributes mimicking thermal ablation and nonthermal, nontumescent treatments. RESULTS: Of the six attributes studied, out-of-pocket (OOP) expenditures were the most important to patients (37.2%), followed by postoperative discomfort (17.1%), risk of adverse events (16.3%), time to return to normal activity (11.0%), number of injections (10.0%), and number of visits (8.4%). Patients were willing to pay the most to avoid postoperative discomfort ($68.9) and risk of adverse events ($65.8). The market simulation analysis found that, regardless of the level of OOP spending, 60% to 80% of respondents favored attribute combinations corresponding with nonthermal, nontumescent procedures over thermal ablation, and that less than 1% of participants would forgo either treatment under no cost sharing. CONCLUSIONS: Patients are highly sensitive to OOP costs for minimally invasive varicose vein treatments. Market simulation analysis favored nonthermal, nontumescent procedures over thermal ablation.
Assuntos
Técnicas de Ablação , Anestesia , Procedimentos Endovasculares , Preferência do Paciente , Varizes/terapia , Técnicas de Ablação/efeitos adversos , Técnicas de Ablação/economia , Adulto , Idoso , Idoso de 80 Anos ou mais , Anestesia/efeitos adversos , Anestesia/economia , Comportamento de Escolha , Estudos Transversais , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/economia , Feminino , Estado Funcional , Custos de Cuidados de Saúde , Pesquisas sobre Atenção à Saúde , Gastos em Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Preferência do Paciente/economia , Complicações Pós-Operatórias/etiologia , Recuperação de Função Fisiológica , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , Varizes/economia , Adulto JovemRESUMO
BACKGROUND: Use of new technology can lead to changes in the treatment course for patients and in treatment costs for the health service. The aim of this study was to compare sickness absence and time to resumption of daily activities, as well as treatment costs, for two surgical treatments for varicose veins: endovenous steam ablation and vein stripping. MATERIAL AND METHOD: This prospective observational study included 46 patients treated with steam ablation and 37 treated with vein stripping in the period 2015-2016. The two groups were matched with respect to age, sex, occupational status and classification. After treatment, patients were interviewed every other week until daily activities had been resumed. Detailed information on expenditure related to personnel, equipment, premises and materials was used to calculate the cost of treatment. RESULTS: Patients treated with steam ablation resumed daily activities after a median of 0 (interquartile range 0-2) days versus 4 (2-7) days for vein stripping (p < 0.001), and sporting activities after 4 (2-9) days versus 11 (3-19) days (p < 0.004). For patients in employment, sickness absence after steam ablation was 2 (2-5) days versus 14 (6-21) for patients treated with vein stripping (p < 0.001). The estimated treatment cost for steam ablation was NOK 5 973, compared with NOK 10 109 for vein stripping. INTERPRETATION: Steam ablation led to shorter convalescence and sickness absence for the patient, and lower costs for the hospital. Reduced sickness absence also implies lower costs for society.
Assuntos
Veia Safena/cirurgia , Vapor , Varizes/cirurgia , Procedimentos Cirúrgicos Vasculares/métodos , Atividades Cotidianas , Adulto , Ablação por Cateter/métodos , Convalescença , Emprego , Feminino , Custos de Cuidados de Saúde , Humanos , Terapia a Laser/métodos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Recuperação de Função Fisiológica , Volta ao Esporte , Retorno ao Trabalho , Autorrelato , Licença Médica/economia , Licença Médica/estatística & dados numéricos , Varizes/economia , Varizes/reabilitaçãoRESUMO
Health insurers may use financial incentives to encourage their enrollees to choose preferred providers for medical treatment. Empirical evidence whether differences in cost-sharing rates across providers affects patient choice behavior is, especially from Europe, limited. This paper examines the effect of a differential deductible to steer patient provider choice in a Dutch regional market for varicose veins treatment. Using individual patients' choice data and information about their out-of-pocket payments covering the year of the experiment and 1 year before, we estimate a conditional logit model that explicitly controls for pre-existing patient preferences. Our results suggest that in this natural experiment designating preferred providers and waiving the deductible for enrollees using these providers significantly influenced patient choice. The average cross-price elasticity of demand is found to be 0.02, indicating that patient responsiveness to the cost-sharing differential itself was low. Unlike fixed cost-sharing differences, the deductible exemption was conditional on the patient's other medical expenses occurring in the policy year. The differential deductible did, therefore, not result in a financial benefit for patients with annual costs exceeding their total deductible.
Assuntos
Comportamento do Consumidor/estatística & dados numéricos , Dedutíveis e Cosseguros/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Comportamento de Escolha , Comportamento do Consumidor/economia , Feminino , Gastos em Saúde/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Teóricos , Países Baixos , Organizações de Prestadores Preferenciais/economia , Organizações de Prestadores Preferenciais/organização & administração , Organizações de Prestadores Preferenciais/estatística & dados numéricos , Varizes/economia , Varizes/terapia , Adulto JovemRESUMO
OBJECTIVES: To analyze the cost-effectiveness of current technologies (conservative care [CONS], high-ligation surgery [HL/S], ultrasound-guided foam sclerotherapy [UGFS], endovenous laser ablation [EVLA], and radiofrequency ablation [RFA]) and emerging technologies (mechanochemical ablation [MOCA] and cyanoacrylate glue occlusion [CAE]) for treatment of varicose veins over 5 years. METHODS: A Markov decision model was constructed. Effectiveness was measured by re-intervention on the truncal vein, re-treatment of residual varicosities, and quality-adjusted life-years (QALYs) over 5 years. Model inputs were estimated from systematic review, the UK National Health Service unit costs, and manufacturers' list prices. Univariate and probabilistic sensitivity analyses were undertaken. RESULTS: CONS has the lowest overall cost and quality of life per person over 5 years; HL/S, EVLA, RFA, and MOCA have on average similar costs and effectiveness; and CAE has the highest overall cost but is no more effective than other therapies. The incremental cost per QALY of RFA versus CONS was £5,148/QALY. Time to return to work or normal activities was significantly longer after HL/S than after other procedures. CONCLUSIONS: At a threshold of £20,000/QALY, RFA was the treatment with highest median rank for net benefit, with MOCA second, EVLA third, HL/S fourth, CAE fifth, and CONS and UGFS sixth. Further evidence on effectiveness and health-related quality of life for MOCA and CAE is needed. At current prices, CAE is not a cost-effective option because it is costlier but has not been shown to be more effective than other options.
Assuntos
Procedimentos Cirúrgicos Eletivos/economia , Varizes/complicações , Técnicas de Ablação/economia , Tratamento Conservador/economia , Análise Custo-Benefício , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Humanos , Terapia a Laser/economia , Cadeias de Markov , Escleroterapia/economia , Varizes/economia , Varizes/cirurgiaRESUMO
BACKGROUND: In mid-2007, endovenous ablation (EVA) of the great saphenous vein was introduced into the publicly funded health care system in Saskatchewan, Canada. We hypothesize that the introduction of EVA resulted in a decrease in use of high ligation and stripping (HL/S), decreased costs to the health care system, and increased demand of patients for great saphenous vein ablative procedures. METHODS: We retrospectively reviewed administrative data to capture cases of HL/S between 2003 and 2014 and cases of EVA of the great saphenous vein (endovenous laser treatment and radiofrequency ablation) between 2007 and 2014. Accounting for the change in practice pattern that occurred slowly between 2007 and 2009, we divided our patients into the pre-EVA era (2003-2006) and the post-EVA era (2010-2014). Procedure costs were determined with models used by our health region for this purpose. RESULTS: Utilization rates for great saphenous vein intervention remained similar in the pre-EVA (90 procedures per year) and post-EVA (92 procedures per year; P = .83) eras. Case costs of HL/S ($1965.12/case) were higher than those of EVA (endovenous laser treatment, $1295.08/case; radiofrequency ablation, $1410.54/case). The total annual costs of great saphenous vein intervention decreased from $176,861 in the pre-EVA era to $134,525 (P = .02). CONCLUSIONS: Introduction of publicly funded EVA has reduced rates of HL/S and reduced costs to our health system by approximately $42,000 per year, without increasing great saphenous vein intervention rates.
Assuntos
Ablação por Cateter/economia , Atenção à Saúde/economia , Procedimentos Endovasculares/economia , Custos de Cuidados de Saúde , Planejamento Hospitalar/economia , Terapia a Laser/economia , Avaliação de Processos em Cuidados de Saúde/economia , Saúde Pública/economia , Veia Safena/cirurgia , Varizes/economia , Varizes/cirurgia , Demandas Administrativas em Assistência à Saúde , Ablação por Cateter/efeitos adversos , Redução de Custos , Análise Custo-Benefício , Bases de Dados Factuais , Procedimentos Endovasculares/efeitos adversos , Necessidades e Demandas de Serviços de Saúde/economia , Humanos , Terapia a Laser/efeitos adversos , Avaliação das Necessidades/economia , Avaliação de Programas e Projetos de Saúde , Estudos Retrospectivos , Veia Safena/diagnóstico por imagem , Veia Safena/fisiopatologia , Saskatchewan , Fatores de Tempo , Resultado do Tratamento , Varizes/diagnóstico por imagem , Varizes/fisiopatologiaRESUMO
OBJECTIVE: This study aimed to investigate the current clinical practice and management strategies for varicose veins among Chinese physicians in general and in specific case vignettes. METHODS: A questionnaire survey was conducted among 726 Chinese physicians who were attending the vascular surgery academic conferences during August 2016 to May 2017 in China. Physicians were eligible if they were familiar with several currently used treatment techniques for varicose veins. RESULTS: A total of 681 physicians from 527 hospitals in 29 provinces across China completed the questionnaire. Of them, 80.0% were vascular surgeons, 13.1% were general surgeons, and 6.9% were interventional radiologists. More than half (67.0%) of them had >5 years of experience in management of varicose veins. A third of the participants performed routine venography for patients with suspected varicose veins. Moreover, 87.5% believed that the patient's medical insurance would influence their choice of treatment modalities. Only 38.5% of the participants' departments could perform day surgery for varicose veins. The most common average hospitalization time was 4 to 7 days, with an average cost of 4000 to 8000 yuan per leg. In the basic case (Clinical, Etiology, Anatomy, and Pathophysiology classification C2,SEpAsPr2,3), 63.8% preferred traditional surgery for great saphenous vein reflux, followed by endovenous laser ablation (24.3%), radiofrequency ablation (5.6%), and ultrasound-guided foam sclerotherapy (3.1%). Physicians in coastal China were more likely to choose endovenous thermal ablation than those from western China (P < .05). In modified case vignettes complicated with hyperpigmentation and lipodermatosclerosis or ulceration, more participants chose traditional surgery for great saphenous vein (73.2% vs 63.8% [P < .001]; 75.9% vs 63.8% [P < .001]) compared with the basic case. Moreover, 31.9% preferred continuation of compression therapy for patients with varicose veins and deep venous reflux, and 65.4% preferred correction of iliac vein compression before treatment of varicose veins. Distributions of management strategies were significantly different between the basic and modified case vignettes (all P < .01). CONCLUSIONS: Both traditional surgery and minimally invasive techniques are used for patients with varicose veins in China, but traditional surgery is the mainstay of treatment for varying degrees of varicose veins. Related clinical factors, duplex ultrasound scan findings, medical insurance, and economy may have influenced the physicians' choice of treatment modality for varicose veins.
Assuntos
Prática Profissional/estatística & dados numéricos , Varizes/terapia , Procedimentos Cirúrgicos Vasculares/métodos , Procedimentos Cirúrgicos Ambulatórios/estatística & dados numéricos , Ablação por Cateter/estatística & dados numéricos , China , Competência Clínica , Gerenciamento Clínico , Pesquisas sobre Atenção à Saúde , Custos Hospitalares/estatística & dados numéricos , Humanos , Terapia a Laser/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Flebografia/estatística & dados numéricos , Escleroterapia/estatística & dados numéricos , Especialidades Cirúrgicas/estatística & dados numéricos , Inquéritos e Questionários , Varizes/diagnóstico por imagem , Varizes/economia , Procedimentos Cirúrgicos Vasculares/estatística & dados numéricosRESUMO
BACKGROUND: To evaluate the effect of ultrasound-guided foam sclerotherapy (UGFS) in a single session combined with great saphenous vein (GSV) high ligation for severe lower extremity varicosis classified as C4-C6, compared with GSV stripping plus multistab avulsion or transilluminated powered phlebectomy (TIPP). METHODS: From January 2012 to December 2014, 177 patients with primary GSV insufficiency, classified as C4-C6, were randomized into the UGFS group or the control group. The UGFS group was managed by GSV high ligation and foam sclerotherapy in one session under the surveillance of ultrasonography, whereas the control group received GSV high ligation and stripping combined with multistab avulsion or TIPP. The patients were followed up at 1, 6, and 12 months after treatment. Outcome assessments included reflux recurrence rate, procedure-related adverse events, hemodynamic parameters, revised Venous Clinical Severity Score (VCSS), and Aberdeen Varicose Vein Questionnaire (AVVQ) score. The medical cost and operating time of the 2 groups were also compared. RESULTS: In total, 73 patients received UGFS, whereas 90 patients underwent traditional surgery. Sixty-five patients in the UGFS group (89.0%) and 74 patients in the control group (82.2%) completed the follow-up. At the end of 12 months, the cumulative reflux recurrence rate was 13.8% in the UGFS group and 13.5% in the control group (P = 0.955). In the UGFS and control groups, minor complications (27.7% vs. 21.6%, P = 0.406) and major complications (3.1% vs. 2.7%, P = 0.895) were not significantly different. Compared with baseline values, obvious improvements of the venous filling index, VCSS, and AVVQ scores after treatment were confirmed in both groups (P < 0.001). The average operating and recovery times were much shorter (38.3 vs. 81.2 min, 5.4 vs. 9.6 days, P < 0.001, respectively), and the average hospital cost was much lower ($853 vs. $1,575, P < 0.001) in the UGFS group than in the control group. The patient satisfaction rate reached 92.3% in the UGFS group and 89.2% in the control group 12 months after operation (P = 0.270). CONCLUSIONS: Our outcomes indicated that UGFS combined with GSV high ligation was safe and effective for severe lower extremity varicosis.
Assuntos
Polietilenoglicóis/administração & dosagem , Veia Safena/cirurgia , Soluções Esclerosantes/administração & dosagem , Escleroterapia/métodos , Ultrassonografia de Intervenção , Varizes/terapia , Procedimentos Cirúrgicos Vasculares/métodos , Adulto , Idoso , China , Terapia Combinada , Análise Custo-Benefício , Feminino , Hemodinâmica , Custos Hospitalares , Humanos , Tempo de Internação , Ligadura , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Satisfação do Paciente , Polidocanol , Polietilenoglicóis/efeitos adversos , Polietilenoglicóis/economia , Estudos Prospectivos , Recidiva , Retratamento , Veia Safena/diagnóstico por imagem , Veia Safena/fisiopatologia , Soluções Esclerosantes/efeitos adversos , Soluções Esclerosantes/economia , Escleroterapia/efeitos adversos , Escleroterapia/economia , Índice de Gravidade de Doença , Inquéritos e Questionários , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia de Intervenção/economia , Varizes/diagnóstico por imagem , Varizes/economia , Varizes/fisiopatologia , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Procedimentos Cirúrgicos Vasculares/economiaRESUMO
The basis of surgery of great saphenous vein insufficiency is the concept of "privat circulation" coined by Trendelenburg in 1891. It was only logical that the dissection of the insuffcient vein or it's partial or complete resection could bring about healing. Over the years varicose vein stripping was modified to finally result in the highly effectiv concept of crossectomy and stripping. For decades this was the Goldstandard in surgery of varicose vein insufficiency. All the other minimally invasive therapeutic techniques which have been developed in the last decades had to compete with crossectomy and stripping. Thanks to progress in technical development the classic stripping procedure has been replaced by highly effectiv, minimally invasiv procedures, at least in the western industrialisied countries. For a minority of patients with specific anatomical pathologies as well as countries with limited health resources vein stripping remains a surgical standard procedure.
Assuntos
Varizes/cirurgia , Insuficiência Venosa/cirurgia , Procedimentos Cirúrgicos Ambulatórios/métodos , Doença Crônica , Análise Custo-Benefício , Endoscopia/métodos , Humanos , Perna (Membro)/irrigação sanguínea , Procedimentos Cirúrgicos Minimamente Invasivos/economia , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Complicações Pós-Operatórias/etiologia , Recidiva , Resultado do Tratamento , Varizes/classificação , Varizes/economia , Veias/cirurgia , Insuficiência Venosa/classificação , Insuficiência Venosa/economiaRESUMO
Varicose veins affect one-quarter to one-third of Western adult populations and consume an increasing amount of health care resources. Much of this increased utilization has been driven by the advent of minimally invasive technology including endovenous thermal ablation, foam sclerotherapy, and more recently mechanicochemical and cyanoacrylate glue ablation. This has largely been driven by patient and physician preferences in the absence of robust evidence that one therapy is truly superior to another. This partially arises from misunderstandings about appropriate outcomes measures and what truly constitutes effective treatment of varicose veins. Technical outcomes, such as saphenous closure rates, have frequently been used as surrogates for effective treatment but are poorly correlated with symptom improvement, quality of life, and risk of recurrence. Although there does appear to be a trend towards higher recurrence with ultrasound-guided foam sclerotherapy, the data are occasionally conflicting and there does not appear to be substantial differences between the various modalities. Similarly, there do not appear to be major differences in late quality of life measures between these treatment options. As long-term differences in recurrence and quality of life are small, overall cost effectiveness is driven primarily by initial treatment costs and ultrasound-guided foam sclerotherapy is the most cost-effective strategy in many models. However, there continues to be substantial uncertainty surrounding cost estimates and other factors of importance to the patient may ultimately drive treatment decisions. The benefits of some adjuncts to the treatment of axial superficial reflux, such as the concurrent versus staged management of tributary varicosities, remain ill-defined while that of others, such as routine post-procedural ultrasound surveillance and compression, need critical re-evaluation.
Assuntos
Procedimentos Endovasculares , Hipertermia Induzida , Qualidade de Vida , Escleroterapia , Varizes , Adulto , Custos e Análise de Custo , Procedimentos Endovasculares/economia , Procedimentos Endovasculares/métodos , Feminino , Humanos , Hipertermia Induzida/economia , Hipertermia Induzida/métodos , Masculino , Recidiva , Fatores de Risco , Escleroterapia/economia , Escleroterapia/métodos , Varizes/economia , Varizes/terapiaRESUMO
BACKGROUND: This registry study evaluated low-cost outpatient surgery (mini-S) for venous insufficiency as an alternative to stripping. METHODS: This 20-year follow-up is focused on the recurrence of varices and on the long-term efficacy of the mini-S (group 1) in comparison with controls (2, stripping), sclerotherapy (3) or a combination of mini-S+sclerotherapy (4). Costs were compared. RESULTS: At 20-years of follow-up, considering recurrence/development of new varicose veins, 24.05% of the limbs treated with mini-S developed new varices in comparison with 64.4% in group 2, 24.1% in group 3 and 15.4% in group 4 (P<0.05). New surgical procedures were needed in 18.9% of mini-S patients vs. 58.5% in group 2, 21.9% in group 3 and 19.7% in group 4 (P<0.05 between group 2 and the other groups). Sclerotherapy (in the years following the initial treatment) was used in 37.9% of mini-S patients in comparison with 67.7% of subjects in group 2 patients, 33.1% in group 3 and 22.8% in group 4 (P<0.05 between outpatient treatment and group 2). The superficial venous system was incompetent in 21% of mini-S patients in comparison with 38.8% in group 2 (P<0.05), 20.7% in group 3 and 17.9% of group 4. At 20 years edema was present in 10.5% of limbs in group 2 in comparison with a <3% (range 2.2-2.1%) in the other groups. Edema was more significant after stripping. Ambulatory venous pressure measurements in subgroups was lower in groups 1, 3 and 4 with a lower refilling time (P<0.05). The cost of in-hospital, daily surgical treatments were 1978 (covered by the heathcare provider). The cost of mini-S was on average 488 per limb (covered by patients). CONCLUSIONS: Outpatients procedures, in particular the mini-S management plan, were cheaper than stripping and more effective at 20-years follow-up. They could be a model for emerging contries with restricted budgets for vein surgery. Also being cheaper more people may have benefits from treatment when/where hospital procedures are not covered by an healthcare provider.
Assuntos
Custos e Análise de Custo , Pacientes Ambulatoriais , Escleroterapia/economia , Varizes/economia , Varizes/terapia , Adulto , Índice de Massa Corporal , Estudos de Casos e Controles , Feminino , Seguimentos , Humanos , Itália , Ligadura/economia , Masculino , Pessoa de Meia-Idade , Recidiva , Sistema de Registros , Veia Safena , Escleroterapia/métodos , Resultado do Tratamento , Varizes/diagnóstico por imagem , Varizes/cirurgiaRESUMO
In market-based health care systems, channeling patients to designated preferred providers can increase payer's bargaining clout, other things being equal. In the unique setting of the new Dutch health care system with regulated competition, this paper evaluates the impact of a 1-year natural experiment with patient channeling on providers' market shares. In 2009 a large regional Dutch health insurer designated preferred providers for two different procedures (cataract surgery and varicose veins treatment) and gave its enrollees a positive financial incentive for choosing them. That is, patients were exempted from paying their deductible when they went to a preferred provider. Using claims data over the period 2007-2009, we apply a difference-in-difference approach to study the impact of this channeling strategy on the allocation of patients across individual providers. Our estimation results show that, in the year of the experiment, preferred providers of varicose veins treatment on average experienced a significant increase in patient volume relative to non-preferred providers. However, for cataract surgery no significant effect is found. Possible explanations for the observed difference between both procedures may be the insurer's selection of preferred providers and the design of the channeling incentive resulting in different expected financial benefits for both patient groups.
Assuntos
Dedutíveis e Cosseguros/estatística & dados numéricos , Organizações de Prestadores Preferenciais/estatística & dados numéricos , Extração de Catarata/economia , Extração de Catarata/estatística & dados numéricos , Dedutíveis e Cosseguros/economia , Humanos , Revisão da Utilização de Seguros , Países Baixos , Varizes/economia , Varizes/terapiaRESUMO
OBJECTIVES: To conduct economic evaluations of radiofrequency ablation, ultrasound-guided foam sclerotherapy and surgery for great saphenous vein ablation. METHOD: A cost-utility and cohort analysis from societal perspective was performed to estimate incremental cost-effectiveness ratio. Transitional probabilities were from meta-analysis. Direct medical, direct non-medical, indirect costs, and utility were from standard Thai costings and cohort. Probabilistic sensitivity analysis was performed to assess parameter uncertainties. RESULTS: Seventy-seven patients (31 radiofrequency ablation, 19 ultrasound-guided foam sclerotherapy, and 27 surgeries) were enrolled from October 2011 to February 2013. Compared with surgery, radiofrequency ablation costed 12,935 and 20,872 Baht higher, whereas ultrasound-guided foam sclerotherapy costed 6159 lower and 1558 Bath higher for outpatient and inpatient, respectively. At one year, radiofrequency ablation had slightly lower quality-adjusted life-year, whereas ultrasound-guided foam sclerotherapy yielded additional 0.025 quality-adjusted life-year gained. Because of costing lower and greater quality-adjusted life-year than other compared alternatives, outpatient ultrasound-guided foam sclerotherapy was an option being dominant. Probabilistic sensitivity analysis resulted that at the Thai ceiling threshold of 160,000 Baht/quality-adjusted life-year gained, ultrasound-guided foam sclerotherapy had chances of 0.71 to be cost-effective. CONCLUSIONS: Ultrasound-guided foam sclerotherapy seems to be cost-effective for treating great saphenous vein reflux compared to surgery in Thailand at one-year results.
Assuntos
Ablação por Cateter/economia , Veia Safena/cirurgia , Escleroterapia/economia , Varizes , Adulto , Idoso , Ablação por Cateter/métodos , Custos e Análise de Custo , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Escleroterapia/métodos , Tailândia , Varizes/economia , Varizes/terapiaRESUMO
Laser ablation involves the delivery of laser light through a glass fibre placed into the lumen of a refluxing vein. This energy is converted into heat inducing a permanent, non-thrombotic occlusion. This highly effective and safe approach has significant advantages over traditional surgical treatment and has driven the endovenous revolution in the management of varicose veins. This chapter will explore the mechanism of action, present the evidence of laser' clinical and cost effectiveness, and analyse specific and generic aspects of laser ablation technique.
Assuntos
Procedimentos Endovasculares/métodos , Terapia a Laser/métodos , Veia Safena/cirurgia , Varizes/cirurgia , Anestesia , Análise Custo-Benefício , Procedimentos Endovasculares/economia , Humanos , Terapia a Laser/economia , Lasers , Luz , Reprodutibilidade dos Testes , Escleroterapia/métodos , Varizes/economiaRESUMO
OBJECTIVE: The aim was to investigate the cost-effectiveness of interventional treatment for varicose veins (VV) in the UK NHS, and to inform the national clinical guideline on VV, published by the National Institute of Health and Care Excellence. DESIGN: An economic analysis was constructed to compare the cost-effectiveness of surgery, endothermal ablation (ETA), ultrasound-guided foam sclerotherapy (UGFS), and compression stockings (CS). The analysis was based on a Markov decision model, which was developed in consultation with members of the NICE guideline development group (GDG). METHODS: The model had a 5-year time horizon, and took the perspective of the UK National Health Service. Clinical inputs were based on a network meta-analysis (NMA), informed by a systematic review of the clinical literature. Outcomes were expressed as costs and quality-adjusted life years (QALYs). RESULTS: All interventional treatments were found to be cost-effective compared with CS at a cost-effectiveness threshold of £20,000 per QALY gained. ETA was found to be the most cost-effective strategy overall, with an incremental cost-effectiveness ratio of £3,161 per QALY gained compared with UGFS. Surgery and CS were dominated by ETA. CONCLUSIONS: Interventional treatment for VV is cost-effective in the UK NHS. Specifically, based on current data, ETA is the most cost-effective treatment in people for whom it is suitable. The results of this research were used to inform recommendations within the NICE guideline on VV.
Assuntos
Técnicas de Ablação/economia , Custos de Cuidados de Saúde , Escleroterapia/economia , Meias de Compressão/economia , Ultrassonografia de Intervenção/economia , Varizes/economia , Varizes/terapia , Procedimentos Cirúrgicos Vasculares/economia , Técnicas de Ablação/efeitos adversos , Redução de Custos , Análise Custo-Benefício , Humanos , Cadeias de Markov , Modelos Econômicos , Anos de Vida Ajustados por Qualidade de Vida , Escleroterapia/efeitos adversos , Medicina Estatal/economia , Meias de Compressão/efeitos adversos , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia de Intervenção/efeitos adversos , Reino Unido , Varizes/complicações , Varizes/diagnóstico , Procedimentos Cirúrgicos Vasculares/efeitos adversosRESUMO
The aim is to present our experience and observations regarding varicose vein treatment by means of ultrasound guided foam sclerotherapy (UGFS). The study included 81 patients, 54 with insufficient main stem superficial veins in one limb and 27 with both limbs affected. Great saphenous vein insufficiency was diagnosed in 68, small saphenous insufficiency in 18, anterior accessory saphenous vein insufficiency in 11, and Giacomini vein insufficiency in 3 limbs. Seven limbs had combined insufficiency of great saphenous vein and small saphenous vein, and 1 limb had combined insufficiency of Giacomini vein and small saphenous vein. UGFS was employed to treat main stem vein reflux and their tributaries. Within a month after treatment, all main stem veins were occluded and only small corrections were performed occasionally to treat residual varices. Regarding side effects, skin darkening and hard lumps at the sites of varicose veins were most commonly observed. We also recorded several episodes of thrombophlebitis. Few patients experienced dry cough, visual disturbances and headache following the treatment. After six months, repeat UGFS of main stem veins had to be performed in few patients. Very few patients expressed dissatisfaction a year after treatment, mainly because of residual skin darkening. In conclusion, UGFS proved to be the simplest, quickest and cheapest method of varicose vein treatment. According to our experience, it yielded satisfactory functional and cosmetic results. Side effects do occur, but are acceptable, in particular at long term.